📖 Guidance for Healthcare Employers and Workers on the use of Fluid Resistant Surgical Masks (FRSM) and respirators (FFP3 etc) to comply with the requirements of COSHH (2002) (England) (Updated 2025)

The British Occupational Hygiene Society ~ COSHH and Healthcare Respiratory Protection • 20 October 2025

‘FRSMs [Surgical Masks] have never been considered either adequate or suitable equipment for protection against inhalable or respirable risks under COSHH.’

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‘Healthcare workers and employers will rightly focus on the safe and effective provision of patient care for patients.

This is the central concern of the Health and Social Care Act, which creates the architecture for IPC [Infection Prevention and Control].

The central aim of this Act is to ensure that the environment is managed effectively to prevent the transmission of infections and that healthcare workers do not inadvertently act as agents for transmission, either because of insufficient hygiene precautions, or because they are themselves infected and could therefore infect others.

Biological hazards can be transmitted via an oral/faecal route, or bloodborne routes, by droplet, fluid splashes, airborne particles or any combination.

COSHH requires all possible routes of exposure to be controlled.

FRSMs [Surgical Masks] have never been considered either adequate or suitable equipment for protection against inhalable or respirable risks under COSHH.

The only respiratory protective equipment [RPE] designated as such for the protection against biological agents is the FFP3 or another respirator type with the same assigned protection factor (APF) (e.g. reusable ‘elastomeric’ respirators, or powered hoods with the appropriate filter).

Failure to comply with COSHH and control standards for RPE is a criminal offence.

This relates to:

(a) the employer’s duty to provide suitable RPE and ensure that it is properly used, inspected and maintained;

and (b) the employee’s duty to wear the RPE as instructed by the employer and to take reasonable care of it.’

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‘COSHH and Healthcare Respiratory Protection: Guidance for Healthcare Employers and Workers on the use of Fluid Resistant Surgical Masks (Type IIR) and respirators (FFP3 etc) to comply with the requirements of the Control of Substances Hazardous to Health Regulations (COSHH) (2002) (England) (Updated 2025).’

[Abridged] ‘COSHH and Healthcare Respiratory Protection’

‘Respiratory infections have long been a recognised hazard of working within healthcare settings.

The principal concern of healthcare legislation and healthcare employers has been the protection of patients who are likely to be vulnerable to such infections, with precautions designed accordingly.’

Page 1

‘Equipment designed to protect the wearer against infection by inhalable pathogens is “respiratory protective equipment” (RPE), a type of personal protective equipment (PPE) designed to reduce (or eliminate) the risk of inhalation of infected particles.

Examples of RPE include FFP3, FFP2 (and N95 [and N99/N100]) respirators which work by the wearer of a respirator drawing in air through filters designed to remove infected particles from the air.’

Page 1

‘If any control, whether through segregation, barrier controls, [or] ventilation, leaves any risk of exposure of an individual worker to a respiratory hazard, then so far as it is reasonably practicable, RPE must be provided and worn in line with health and safety regulations.’

Page 2

‘Training on duties in relation to respiratory protection and the management of RPE has not been widespread through the health service.

There has also been some confusion in Government bodies as to who has regulatory oversight of RPE in the health service as well as the applicable science.

In 2024, the World Health Organisation (WHO), recognising a global need for greater clarity, reviewed the approach to respiratory infection and control.

The new approach recommended by WHO has not been incorporated into UK IPC guidance but is entirely consistent with UK Health and Safety Law.’

Page 3

‘Healthcare workers and employers will rightly focus on the safe and effective provision of patient care for patients.

This is the central concern of the Health and Social Care Act, which creates the architecture for IPC.

The central aim of this Act is to ensure that the environment is managed effectively to prevent the transmission of infections and that healthcare workers do not inadvertently act as agents for transmission, either because of insufficient hygiene precautions, or because they are themselves infected and could therefore infect others.’

Page 3

‘The overriding legal duty is to protect the health and safety of employees, as well as others for whom an undertaking will impact (including patients, service users, contractors and visitors).

Considerations should not be driven by whether someone has a patient-facing or clinical function, is an employee, is in one healthcare setting or another, but should be focused on the risk to that person of exposure to substances hazardous to their health’

Page 4

‘Patients and service users may be vulnerable to biological hazards that would not be a concern for a healthy person exposed to an infectious agent.

For this reason, quite rightly, there is a great emphasis placed on ensuring that healthcare workers do not become the inadvertent agents of the spread of pathogens.’

Page 5

‘Every effort should be made to exclude the pathogen from the place of work.

If this is not possible, engineered controls, not dependent on individuals for their effectiveness, should be deployed, e.g. negative pressure treatment areas or highly effective ventilation.’

Page 6

‘Biological hazards can be transmitted via an oral/faecal route, or bloodborne routes, by droplet, fluid splashes, airborne particles or any combination.

COSHH requires all possible routes of exposure to be controlled.’

Page 6

‘FRSMs [Fluid Repellent Surgical Masks] are, unhelpfully, described as Personal Protective Equipment in the NIPCM.

This is incorrect both in law and in practical terms.

This incorrect designation of FRSMs as PPE or RPE is commonplace within NHS literature and perpetuates a dangerous and illegal inaccuracy.

The only respiratory protective equipment designated as such for the protection against biological agents is the FFP3 or another respirator type with the same assigned protection factor (APF) (e.g. reusable ‘elastomeric’ respirators, or powered hoods with the appropriate filter).’

Page 7

‘FRSMs, as barriers, belong elsewhere in the hierarchy of controls when dealing with respiratory risk, because they do not provide adequate control to prevent the inhalation of infectious particles.

They are not designed to do so and to provide them for that purpose would be in breach of COSHH.’

Page 8

‘[FRSMs’ / Surgical Masks’] effective performance in reducing infection by pathogens such as influenza, even in vitro testing by HSE, will seldom achieve beyond 40%.

Providing an employee with a device that only protects them to that level for a hazardous pathogen would be insufficient and there would be a requirement, in the absence of other highly effective controls, to also provide recognised RPE in order to be legally compliant.’

Page 9

‘FFP3s are made of complex filtering material designed to remove 99% of inhalable and respirable particles.

Of course, they only work as a filter if they are tightly fitted to the face, otherwise they cannot provide that extremely fine filtering as contaminated air will leak into the breathing space through gaps in the face seal.’

Page 9

‘Where there is a risk of exposure of a worker to a significant respiratory hazard which cannot be controlled by other means, including the use of medical devices such as FRSMs, then adequate and suitable RPE must be provided.

Adequate RPE for biological agents is RPE designed to reduce exposure risk to as low as it is reasonably practicable to do so.

Thus, if there is a transmission route involving inhalable respiratory particles such as aerosols, even if a contact transmission route is predominant, then that risk has to be reduced by the use of an FFP3 or equivalent.’

Page 10

‘If RPE fails to achieve the levels of protection it is designed to achieve in healthcare settings, then this is an indication of the failure of the employer to ensure that RPE has been correctly managed to ensure that it achieves its designed protective capability.

This is undoubtedly a breach of Health and Safety law.’

Page 10

‘FRSMs have never been considered either adequate or suitable equipment for protection against inhalable or respirable risks under COSHH.’

Page 10

❦ ‘Guidance for Healthcare Employers and Workers on the use of Fluid Resistant Surgical Masks (Type IIR) and respirators (FFP3 etc) to comply with the requirements of the Control of Substances Hazardous to Health Regulations (COSHH) (2002) (England)’

By The British Occupational Hygiene Society (Updated by BOHS: 2025 / Accessed: 20 Oct 2025)

[Full document] ‘COSHH and Healthcare Respiratory Protection’

Introduction

[Long document ahead: feel free to scroll fast past this...]

Respiratory infections have long been a recognised hazard of working within healthcare settings. The principal concern of healthcare legislation and healthcare employers has been the protection of patients who are likely to be vulnerable to such infections, with precautions designed accordingly.

Prior to the COVID-19 pandemic, regulators regarded instances of harm to healthcare workers from pathogens spread by the respiratory route of transmission (such as influenza, SARS coronaviruses, Respiratory Syncytial Virus [RSV] etc.) as having been relatively rare. This perspective requires revision as a result of the acute and long-term impact of COVID-19 on healthcare workers.

As a consequence of this, healthcare workers and their employers had a great degree of familiarity with medical devices designed to protect patients against respiratory infection by healthcare workers and, indeed, protective equipment designed to protect against contact, ingestion and bloodborne routes. However, awareness of controls to prevent respiratory infection of healthcare workers via the inhalation route has not been as widespread.

Medical devices designed to prevent the wearer from passing on infections to others are typically described as “source control,” because they restrict the source of infection by creating a barrier between the infected wearer and the sterile environment. These devices, like surgical masks, are not personally protective, but interrupt the transmission of infection by reducing the risk that an infected person will pass the infection by creating a barrier to reduce the number of particles, droplets and splashes they might release from their mouth and nose.

The COVID-19 pandemic was, understandably for many, the first time that they were required to deploy or use apparatus designed to protect healthcare workers themselves against inhalation of pathogens. Equipment designed to protect the wearer against infection by inhalable pathogens is “respiratory protective equipment” (RPE), a type of personal protective equipment (PPE) designed to reduce (or eliminate) the risk of inhalation of infected particles. Examples of RPE include FFP3, FFP2 (and N95) respirators which work by the wearer of a respirator drawing in air through filters designed to remove infected particles from the air, and powered filtering respirators which deliver filtered air to the wearer’s breathing zone via a hood.

Understandable confusion has developed between surgical masks (source control) and respirators (wearer personal protection). Both have a role in the reduction of infection prevention and control (IPC), both are worn on the face, both are termed as “PPE” in the National Infection Prevention and Control Manual (NIPCM) and both were recommended by Government and Healthcare Bodies for the control of transmission of COVID-19 at various times and in various places during the pandemic. However, each has a very different function and their use is directed as part of two different systems of legal obligations.

• Surgical masks are devices for use in furtherance of patient safety, as outlined by the Health and Social Care Act 2008. Failure to follow these duties may result in regulatory intervention against a healthcare provider by the Care Quality Commission in England and disciplinary action against a healthcare worker in breach.

• RPE is used to protect workers against infection in furtherance of duties under the Health and Safety at Work Act etc 1974. Breach of duties by an employer is a criminal offence, enforceable by the Health and Safety Executive. It is also a criminal offence for a worker not to comply with these duties and could also result in disciplinary action against a healthcare worker in breach.

The purpose of this guidance note is to ensure that employers and healthcare workers can have a clear understanding of the differences between medical devices used as source control, particularly surgical masks, and RPE, particularly filtering facepiece respirators used as wearer personal protection.

This guidance does not express opinions as to the suitability of each type of device to control specific risks arising from specific pathogens. However, it is a legal requirement in either case that, when determining the suitability of a device to provide control, reference is made to the manufacturer’s instructions. In addition, when using each type of device, scientific and technical guidance produced by the relevant regulator must be followed.

In practice this means that, when using surgical masks as source control (to protect the sterile environment), the Infection Prevention and Control Manual should be followed, as well as any technical and scientific guidance. When using RPE to protect the safety of the wearer, the HSE’s guidance should be followed, as well as any specific technical and scientific guidance.

The IPC regulatory regime is open to clinical interpretation and a wider range of professional discretion using dynamic risk assessment. However, once it has been determined that other methods cannot completely protect a worker against a substance hazardous to health, necessitating the use of RPE, the COSHH Regulations and accompanying official guidance and codes of practice should be followed.

The hierarchy of controls including segregation, ventilation etc is not, however, to be taken as being an order of priority or preference. If any control, whether through segregation, barrier controls, ventilation, leaves any risk of exposure of an individual worker to a respiratory hazard, then so far as it is reasonably practicable, RPE must be provided and worn in line with health and safety regulations. This is not a consideration that is made after the implementation of other controls and where there is evidence of actual control failure, but a decision that needs to be made at the stage of an initial risk assessment and the identification of practicable controls.

Thus, while good general ventilation and source controls such as masks may reduce respirable risk, these measures may not reduce the risk to individuals of inhaling hazardous infectious pathogens, e.g. at close quarters or where the infection is transmitted to some degree by smaller airborne droplets known as aerosols. Such a residual risk of infection, while reduced by other interventions higher up the hierarchy of controls, would require the use of RPE as part of the system of controls to meet the expected threshold under COSHH.

When considering the relative merits of surgical masks and RPE, the primary purpose of either type of device must not be overlooked. Surgical masks aim to contribute to a reduction in overall infections for patients and workers. Failures in adherence and the effectiveness of the device in achieving this is a regulatory performance issue.

Respirators protect the wearer against respiratory exposure to infective agents.

Training on duties in relation to respiratory protection and the management of RPE has not been widespread through the health service. There has also been some confusion in Government bodies as to who has regulatory oversight of RPE in the health service as well as the applicable science.

In 2024, the World Health Organisation (WHO), recognising a global need for greater clarity, reviewed the approach to respiratory infection and control. The new approach recommended by WHO has not been incorporated into UK IPC guidance but is entirely consistent with UK Health and Safety Law.

This guide aims to help employers and worker representatives with a clear statement to outline the differences between medical devices used in IPC (such as the Type IIR mask) on the one hand and RPE on the other. It aims to outline how compliance with IPC measures may not automatically equate to COSHH compliance. Similarly, compliance with COSHH may not necessarily meet IPC standards.

Legal Duties

Healthcare workers and employers will rightly focus on the safe and effective provision of patient care for patients. This is the central concern of the Health and Social Care Act, which creates the architecture for IPC. The central aim of this Act is to ensure that the environment is managed effectively to prevent the transmission of infections and that healthcare workers do not inadvertently act as agents for transmission, either because of insufficient hygiene precautions, or because they are themselves infected and could therefore infect others.

The Act sets out principled requirements for bodies inspectable by the Care Quality Commission Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance - GOV.UK.

The Code states:

“However, the code is not mandatory so registered providers do not by law have to comply with the code. A registered provider may be able to demonstrate that it meets the regulations in a different way (equivalent or better) from that described in this document.”

It further states:

“The code does not replace the requirement to comply with any other legislation that applies to health and social care services; for example, the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health Regulations 2002.”

All healthcare governance bodies, with responsibilities for guiding employees and patients, as well as employing organisations have legal duties under Health and Safety law. This arises, among other legal duties, in section 2 (1) of the Health and Safety at Work Act.

(1) It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.

Section 3(1) extends the duty to third parties.

Therefore, the following considerations should be kept in mind when formulating guidance, rules, training, protocols and procedures which have an impact on health and safety (as they relate to the use of surgical masks and respirators):

1) The overriding legal duty is to protect the health and safety of employees, as well as others for whom an undertaking will impact (including patients, service users, contractors and visitors);

2) Considerations should not be driven by whether someone has a patient-facing or clinical function, is an employee, is in one healthcare setting or another, but should be focused on the risk to that person of exposure to substances hazardous to their health;

3) Guidance which may be evidence-based in relation to the reduction of infectious risk, which uses administrative methods or medical devices to reduce risk, is a useful element of the hierarchy of controls. However, if there is a residual risk of workers being exposed to hazardous substances, then so far as reasonably practicable, approved RPE must be provided to eliminate that risk.

4) Terminologies, such as “PPE ensemble” and the casual description of medical devices, or fluid resistant surgical masks as “PPE”, should be avoided. Only equipment designed and tested as personal protective equipment, in line with the appropriate standards and which has been determined to adequately control the exposure and which is suitable for the wearer and their work, will be compliant with legal duties.

COSHH vs IPC

Keeping infectious agents out of healthcare areas is difficult. The historic challenges of controlling healthcare acquired infections have led to the current complex infrastructure to help ensure patient safety. Patients and service users may be vulnerable to biological hazards that would not be a concern for a healthy person exposed to an infectious agent.

For this reason, quite rightly, there is a great emphasis placed on ensuring that healthcare workers do not become the inadvertent agents of the spread of pathogens.

The governance and infrastructure of healthcare institutions in the UK is framed by this focus when it comes to IPC. In many contexts, by maintaining good IPC standards, for example sterile environments, good hygiene and the use of bespoke medical devices, healthcare workers will also be protected from exposure.

However, there should not be an automatic assumption that maintaining acceptable and practicable standards of IPC will meet the threshold for protecting workers from exposure as required by COSHH. Equally, standard PPE measures for the control of exposures to workers, such as the use of respirators with exhalation valves, which may compromise the health and safety of others, may need to be re-thought.

The inter-relationship between IPC practices and COSHH practices may seem confusing.

When considered in the context of other concepts, such as the hierarchy of controls, this confusion can escalate further. The use of the same terminology which means different things in two different regulatory systems can be even more confusing.

To explain further, consider this:

1) To prevent the transmission of a pathogen which may be very hazardous to a patient, but not unduly hazardous to a worker, there may be a range of options. It may be accepted that the nature of work that a person does, brings a high probability of infection because of the patients cared for or the role undertaken. If the worker is infected: they may be sent home; deployed away from dealing with certain high-risk patients; be provided with source control equipment (such as surgical masks); or may be immunised so that an infection does not develop in them that can be transmitted further. All of these approaches may be entirely lawful when considering the practicability of preventing exposure to infection.

However, all of these IPC measures still allow the healthcare worker to be infected. The exposure is entirely lawful in IPC terms and can be defensible in COSHH terms if the benefit of completely preventing exposure of the healthcare worker is greatly outweighed by the sacrifice the healthcare provider would have to make to protect the worker.

2) To prevent a pathogen which is directly hazardous to the worker as well as to patients, a different approach may be required. If exposing the worker to a pathogen may have serious and irreversible impact on their health, then the options outlined above would not be lawful.

Every effort should be made to exclude the pathogen from the place of work. If this is not possible, engineered controls, not dependent on individuals for their effectiveness, should be deployed, e.g. negative pressure treatment areas or highly effective ventilation. It would be relatively unusual for a designed solution such as this to work on its own, since compliance by healthcare workers with protocols, such as who is allowed into such a controlled area, need to be in place.

These “administrative controls” rely on compliance and people management.

Finally, however, there will be circumstances where a worker cannot benefit from the protection of the engineered control because, for example, they are providing close quarter care. In these instances, rather than controlling the environment or access to the environment, the focus on controlling the risk must be on protecting the person.

PPE is highly dependent on its correct selection, its correct use and management.

Importantly, the PPE must be suitable to meet the needs of the person, e.g. a person’s physical characteristics such as size and shape (also face size and shape with regard to face seal of FFPs) and the type of work that they do. The suitability of PPE requires a thorough risk assessment (as outlined in HSE guidance, for example), careful consideration, planning and analysis. What works for one person may not work for another. As well as being suitable, PPE needs to adequately protect the wearer so far as is reasonably practicable from the risk of hazardous exposure. This means that the device itself should be designed to be capable of providing a specified degree of protection (as defined in applicable UK designated standards).

It is therefore paramount that all the factors of how PPE may be compromised are considered and appropriately managed. In some ways, this is common sense. A firefighter may attend a fire and may be exposed to flames, fumes, oxygen deprivation, toxic dust, falling debris, heat exhaustion and a range of other risks.

When determining the appropriate PPE, all the potential risks need to be protected against so far as reasonably practicable. If the respirator protects against toxic dust but does not protect against oxygen deprivation, the hazard is not controlled.

The same applies to the control of infectious pathogens. Biological hazards can be transmitted via an oral/faecal route, or bloodborne routes, by droplet, fluid splashes, airborne particles or any combination.

COSHH requires all possible routes of exposure to be controlled. Thus, for infectious diseases, all possible routes of transmission need to be considered unless the level of risk being protected against is marginal compared to the sacrifice required to achieve adequate control. Thus, while a face visor may protect the mucosa from splashes and therefore control a deposition route to infection, it will not control the risk of inhalation of airborne pathogens which may cause infection.

Even if the predominant route of infection is by fluid splashes, if there is another transmission route (e.g. inhalation) and the pathogen is hazardous to health via inhalation, then infection via the inhalation route must also be adequately controlled. That is the legal requirement of COSHH. By contrast, from an IPC point of view, it may be viewed that infection transmission can be most effectively reduced by focusing on the predominant mode of transmission and using other measures, such as the removal of infected staff from the roster.

These differing approaches represent a fundamental difference in the tolerance of risk of infection of individual healthcare workers. The former focuses on the reduction of the risk of exposure for each worker so far as reasonably practicable, whereas the latter looks at the impact in overall infection transmission within the healthcare setting, often with a priority on the extent of patient risk, balanced against operational delivery.

FRSM vs FFP3

The COVID-19 pandemic and the COVID-19 Inquiry has brought into sharp contrast fundamental misunderstandings about IPC measures and COSHH measures. This is typified by ongoing debates about the relative roles of Type IIR Fluid Resistant Surgical Masks (FRSMs) and Filtering Facepiece Respirators - level 3 (FFP3s). Both devices have roles within both the achievement of IPC and COSHH outcomes, but in quite different ways.

Sometimes the debate is unhelpfully abbreviated to “masks” vs “respirators”. Even this simplification is fraught with danger. Conflating all masks together (whether or not they are fluid resistant) would be problematic. Similarly, conflating FFP1 (low level protection), FFP2/N95 (higher level protection) and FFP3 (or N99, the US equivalent of FFP3) is not helpful. Each provides a different level of filtration and consequent protection.

In WHO documentation, NHS research material and submissions to the COVID-19 Inquiry, evidence about the effectiveness of masks vs respirators which conflates these devices and equipment has caused confusion which undermines legal compliance.

FRSMs are, unhelpfully, described as Personal Protective Equipment in the NIPCM. This is incorrect both in law and in practical terms. This incorrect designation of FRSMs as PPE or RPE is commonplace within NHS literature and perpetuates a dangerous and illegal inaccuracy.

The only respiratory protective equipment designated as such for the protection against biological agents is the FFP3 or another respirator type with the same assigned protection factor (APF) (e.g. reusable ‘elastomeric’ respirators or powered hoods with the appropriate filter).

This is because, while both are worn about the face and both have a role in the prevention of infection, they are very different things. In very simple terms, these are the distinctions.

• FFP3s are designed and tested to filter respirable and inhaled particles (including viral and other pathogens). The whole device aims to protect the wearer from anything but the smallest level of exposure, provided it is selected and used correctly.

• FRSMs are designed and tested to create a barrier to exhaled bacteria in droplets and to be made of material which resists pressurised artificial blood. The effect is to reduce the risk of the wearer’s exhaled breath contaminating a sterile environment with bacteria. It also creates a barrier for the wearer against splash contamination by liquids around the nose and mouth, if worn correctly.

(From a technical and legal perspective, the differences are summarised below in Annex I.)

The differences between the underpinning design and operation of FRSM and FFP3 (a barrier and a filter; exhalation and inhalation; droplets containing bacteria and respirable viral particles such as aerosols; protecting others and protecting the wearer) must make it clear that these are two very different types of devices designed for two very different purposes.

In terms of IPC, the premise of an FRSM is that the wearer may be infected with a pathogen transmitted by larger droplets and that the barrier can protect against those droplets having an uninterrupted trajectory into a sterile environment or onto a patient.

They may also present a barrier to splashes and droplets that have a trajectory towards the wearer’s mouth and nose. In that respect, they operate almost the same as a visor barrier or screen. They can provide a vital break in human-human transmission probability, especially where there is a significant role for pathogen transmission by direct deposition of fluids in splashes or droplets.

This is a barrier method of protection, but anything that can circumvent the barrier, such as a particle suspended in the air, can compromise its role as a protective device. Inhaled respirable particles are therefore inherently capable of getting drawn in through the gaps between the mask and the wearer.

FRSMs are not tightly fitted to the face (and are not designed to be) because the fluid resistant material would also make breathing very difficult. The reason for the general requirement of fit testing of RPE is that leakages due to poor seals defeat the very fine filtration design.

FRSMs, as barriers, belong elsewhere in the hierarchy of controls when dealing with respiratory risk, because they do not provide adequate control to prevent the inhalation of infectious particles. They are not designed to do so and to provide them for that purpose would be in breach of COSHH. That does not mean that high mask adherence cannot reduce the risk of transmission of a pathogen which has a deposition transmission route.

However, their effective performance in reducing infection by pathogens such as influenza, even in vitro testing by HSE, will seldom achieve beyond 40%. Providing an employee with a device that only protects them to that level for a hazardous pathogen would be insufficient and there would be a requirement, in the absence of other highly effective controls, to also provide recognised RPE in order to be legally compliant.

FFP3s are made of complex filtering material designed to remove 99% of inhalable and respirable particles. Of course, they only work as a filter if they are tightly fitted to the face, otherwise they cannot provide that extremely fine filtering as contaminated air will leak into the breathing space through gaps in the face seal.

Many FFP3s are fitted with exhalation valves. This makes them largely unsuited to protecting the sterile environment against the risks posed by the wearer if they are infected with a pathogen which could be transmitted by fluids, direct deposition or condensates of respirable particles. Therefore, while valved FFPs protect the wearer from respiratory risk, they may not provide an effective IPC control, if the wearer is infected. Not all FFP3s will meet the impermeability standards for Type IIR FRSMs either, potentially presenting a risk for a fluid-based infection. If there is a risk of wicking of infectious fluid, then an FFP respirator with fluid resistant properties would be appropriate.

The very limited availability of unvalved FFP3 respirators, with fluid resistant properties, capable of achieving an effective fit to faces of healthcare workers during the pandemic reflected a failure to have a secure supply or stockpile of adequate (i.e. designed to achieve the right level of protection) and suitable (i.e. fits the person and works in the context of their activity) RPE. In the context of the pandemic, this lack of availability meant that it may not have in all circumstances been reasonably practicable to meet the standards expected in COSHH while those shortages persisted.

FFP3 respirators with certified fluid resistance (Type IIR), which are designed in vitro to filter 99% of respirable particles, were certified as an alternative to FRSMs to provide IPC control in the same way as FRSMs.

The preponderance of citations in NHS literature (as to the relative effectiveness of masks against respirators in the control of infection) are derived from overseas studies and almost exclusively consider comparisons with N95 filtering facepieces. N95 respirators are equivalent to FFP2 respirators in the UK, which would not be deemed to provide adequate control of respirable particles under UK law.

Clinical studies almost never record the extent to which face fit requirement for N95s has been implemented, meaning the deployment of respirators may not meet the UK’s standards for testing suitability of the equipment to the wearer.

The apparent lack of technical understanding of these fundamental RPE principles by reviewing authors means studies such as The role of respirators and surgical masks in mitigating the transmission of SARS-CoV-2 in healthcare settings need to be read with caution, especially when considering the appropriateness of equipment for the purposes of respiratory protection.

These studies have been cited by bodies such as the UK Health Security Agency to provide only limited evidence that N95s were more effective in controlling infection transmission and/or wearer protection. However, few (if any) conclusions can be drawn from them about FFP3 performance within UK healthcare settings.

In determining the question of duties, the matter is clearer. Where there is a risk of exposure of a worker to a significant respiratory hazard which cannot be controlled by other means, including the use of medical devices such as FRSMs, then adequate and suitable RPE must be provided.

Adequate RPE for biological agents is RPE designed to reduce exposure risk to as low as it is reasonably practicable to do so. Thus, if there is a transmission route involving inhalable respiratory particles such as aerosols, even if a contact transmission route is predominant, then that risk has to be reduced by the use of an FFP3 or equivalent.

That is one leg of the legal duty on employers.

However, the RPE also needs to be selected so as to be capable of delivering the designed protection, i.e. that it is suitable. This means that the device fits the intended wearer, and that it can be worn without disturbance in the working conditions the wearer is likely to encounter. That is the second leg of the duty of the employers.

Thus, if an employer provides RPE but it does not fit (the intended wearer(s)) or is not appropriate for the working conditions within which it is used, the employer cannot abandon the use of RPE in favour of another control, such as barrier, if it is known that it would not provide as effective a control as suitable RPE.

In order for RPE to become licensed for use, it needs to meet a range of stringent tests, which consider and address the potential for failure in a range of workplace environments.

If RPE fails to achieve the levels of protection it is designed to achieve in healthcare settings, then this is an indication of the failure of the employer to ensure that RPE has been correctly managed to ensure that it achieves its designed protective capability.

‘If RPE fails to achieve the levels of protection it is designed to achieve in healthcare settings, then this is an indication of the failure of the employer to ensure that RPE has been correctly managed to ensure that it achieves its designed protective capability.

This is undoubtedly a breach of Health and Safety law.’

This is undoubtedly a breach of Health and Safety law. Such a breach must be remedied by finding adequate and suitable alternative RPE with the required Assigned Protection Factor such as powered filtering respirators (as well as instituting other measures from the hierarchy of controls to reduce residual risk). Such other measures may include using barrier (engineering) controls, such as FRSMs. However, FRSMs have never been considered either adequate or suitable equipment for protection against inhalable or respirable risks under COSHH. [End of document]

‘FRSMs have never been considered either adequate or suitable equipment for protection against inhalable or respirable risks under COSHH.’

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📖 (Accessed: 20 Oct 2025 ~ British Occupational Hygiene Society / Occupational & Environmental Medicine) COSHH and Healthcare Respiratory Protection: Guidance for Healthcare Employers and Workers on the use of Fluid Resistant Surgical Masks (Type IIR) and respirators (FFP3 etc) to comply with the requirements of the Control of Substances Hazardous to Health Regulations (COSHH) (2002) (England) (Updated 2025) ➤ [PDF]

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On Omicron JN.1: 📖 A letter to Amanda Pritchard, Chief Executive Officer of NHS England, from the British Medical Association (BMA)

by Professor Phil Banfield (BMA) & Dr. Barry Jones (CAPA) • 22 December 2023

‘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 British Medical Association (22 Dec 2023)

📖 COVID JN.1 variant: Royal College of Nursing (RCN) seeks assurance on new PPE advice

by Royal College of Nursing (RCN) (UK) • 21 December 2023

‘The RCN is urging healthcare employers to assess the risk posed by COVID-19 and put appropriate safeguards in place for patients and staff. WHO [has] 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; and to improve ventilation in health facilities.’ ✾ ❦ 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 equipmen t 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 healthcare 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).

📖 Post-acute COVID-19 complications in UK doctors: results of a cross-sectional survey

by Bland et al / Occupational Medicine • 11 December 2023

❦ ‘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 ➤

Who’s clapping now? On abandonment, and bureaucratic cowardice

by Dr. Kelly Fearnley, NHS (England) • 4 July 2023

‘Healthcare workers must be provided with respiratory protection and the air quality in hospitals be monitored and improved through the installation of ventilation systems and air filter units.’ ✾

📖 Upgrading PPE for staff working on COVID-19 wards cut hospital-acquired infections dramatically

by University of Cambridge / Cambridge University Hospitals (CUH) NHS Foundation Trust • 29 June 2021

‘When Addenbrooke’s Hospital in Cambridge upgraded its face masks for staff working on COVID-19 wards to Filtering Face Piece 3 (FFP3) respirators, it saw a dramatic fall – up to 100% – in hospital-acquired SARS-CoV-2 infections among these staff.’

On the ‘Alpha’ Variant of Concern (VOC): 📖 A letter to Sarah Albon, UK Health and Safety Executive (HSE), from the Royal College of Nursing (RCN) and the British Medical Association (BMA)

by The Royal College of Nursing (RCN/UK) and The British Medical Association (BMA) • 21 January 2021

‘Our very serious concerns relate to the risk of aerosol/airborne infection; RCN and BMA members working in all settings are raising concerns that they are not adequately protected. Our members are concerned that fluid-repellent surgical face masks [FRSM] and face coverings, as currently advised in most general healthcare settings, do not protect against smaller more infective aerosols. ’

Solutions in... NHS Estates Bulletins

📖 NHS Estates Technical Bulletin ~ Application of HEPA filter devices for air cleaning in healthcare spaces: guidance and standards

by NHS England • 4 December 2023

‘This document aims to serve as interim guidance and a 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 emergence of SARS-CoV-2 as a highly contagious virus has demanded new and innovative solutions to safeguard patients, staff, and visitors.’

📖 NHS Estates Technical Bulletin ~ Application of ultraviolet (UVC) devices for air cleaning in occupied healthcare spaces: guidance and standards

by NHS England • 4 December 2023

✻ Accessed: 4 Dec 2023. ➲ Date published: 9 May 2023 . ➲ Date last updated : 2 Oct 2023 . ➲ Please note: This NHS Estates page is currently being updated and re-formatted as of 08 Jan 2026 . It will be completed by 16 Jan 2026 . ❦ 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 NHSEstates Technical Bulletin (NETB 2023/01B):applicationof 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.

More on... COSHH

'The Approved List of biological agents'. Advisory Committee on Dangerous Pathogens / UKHSA.

On Biosafety Levels, Hazard Groups, SARS-CoV-2, the UKHSA, Notifiable Organisms and Notifiable Diseases

by United Kingdom Health Security Agency (UKHSA) / Health & Safety Executive (HSE) / Control of Substances Hazardous to Health Regulations (COSHH) / C19.Life • 23 October 2025

The Health and Safety Executive (HSE) has designated SARS-CoV-2, the virus that causes COVID-19, a Hazard Group 3 (HG3) pathogen that can cause severe human disease. The United Kingdom’s Health Security Agency (UKHSA) classifies SARS-CoV-2 as a notifiable organism, and COVID-19 as a notifiable disease (2025).

From... The UKHSA

“How does Covid being a notifiable disease interact with the UK government discouraging testing?

How does this work? How does it work with NHS Trusts telling their staff not to test?”

Tern, a Priest (28 Aug 2023)

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📖 UKHSA Advisory Board: Preparedness for infectious disease threats ~ Airborne (droplet or aerosol) transmission

by UK Health Security Agency (UKHSA) • 4 December 2023

✻ 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.’ ❂ ➲ [ Note ] : The accepted scientific definition of ‘airborne 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 .

📖 Health & Safety At Work Act 1974

by UK Health Security Agency (UKHSA) / Compact Law • 4 December 2023

✻ 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.

✾

“If we didn’t do any testing, we would have very few cases.”

Donald John Trump (15 May 2020)

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More... Healthcare Worker insights

❦ Some thoughts and essays by Dr. Lisa Iannattone

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 19 April 2025

“There’s nothing radical about clean air and compassion.”

❦ Some thoughts and essays by Dr. Noor Bari

by Dr. Noor Bari, Emergency Medicine • 18 April 2025

“We are drunk-driving in healthcare... with a pathogen that has a 10% fatality rate in that setting.”

On volunteering for infection, and spinning the evolutionary wheel

by Dr. Noor Bari, Emergency Medicine ❂ NextStrain.org • 29 October 2024

❦ “If you are letting yourself get infected and taking no precautions against passing it on, you are not a passive bystander for your next infection. You’ve participated in creating it.”

On hospitals and drunk-driving

by Dr. Noor Bari, Emergency Medicine • 30 August 2023

❦ “It’s not like I’ve never seen people die of causes that are a result of their lifestyle... but it’s awful seeing people die as a result of other people’s lifestyles... and now that includes their healthcare provider! It feels very similar to watching people die from another person’s drunk-driving... That’s the closest similar situation I can think of. We are drunk-driving in healthcare... with a pathogen that has a 10% fatality rate in that setting.”

On immune systems, and chewing on the leftovers

by Dr. Noor Bari, Emergency Medicine • 27 August 2023

❦ “If y’all are busy weakening your immune systems with one virus, let me assure you that there are packs of other pathogens out there waiting to chew on the leftovers.”

On “mildness”, transmissibility, healthcare and mortality

by Dr. Noor Bari, Emergency Medicine • 11 August 2023

❦ “Anything that is more transmissible will kill in two ways. Infecting more people. Worsening pressure on healthcare.”

Ever since my last infection, I...

by Dr. Noor Bari, Emergency Medicine • 8 August 2023

❦ “In real life, no-one… and I mean no-one… is actually living a normal life if they have abandoned C-19 precautions. Either they are suffering the effects of illness themselves, are caring for someone that is sick, grieving, or all of the above. It’s not all people of one race/genotype either. It’s across a broad spectrum of people. It’s not even segregated by money. People with money that did not take it seriously enough to seek treatment have also fallen foul of problems. At this point in my social world the denial is being peeled away… and people are opening up about issues. However many still feel unable to prevent further problems. I’m seeing everything from acute COVID deaths to long COVID deaths. Every kind of autoimmune disease seems to be on the cards, colitis, hearing loss, joint problems… One common thread… people either have not made the connection to C-19, or think they are the odd one out. That they have somehow personally failed to be tough enough to weather the SARS storm. One can only congratulate the ghouls that have allowed that feeling to spread. I mean no-one I know… So all these people that I see on-and-off are living in their own quiet bubble of difficulty… and no-one is brave enough to tackle anything because no-one wants to be different… or perceived as a failure… or in many cases, they don’t know what to do anyway… This is a massive failure of public health. The anti-maskers are out on social media, loud and proud; public health departments barely whisper some diluted numbers once a week. Literally, things tick along “normally” in the conversation until you hit that bump. Ever since my last infection I _____. Fill in the blank. It’s often something that sounds really minor… but those that have read the data know what it really means. Quit the gym. Food is bland. Ringing in ears. Headaches. Joint pain. Stomach upset. Dizzy. Heart races. Tired. Stopped driving or stopped driving long distances. Quit the booze. Rashes. Keep getting xyz infections. Just going to tack on here that the first sentence contains an omission. “Real life” = People I know in real life. My real-life home village is sick or grieving or caring. Pretty much every household.”

On off-ramping, and respirators in healthcare

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 7 July 2023

❦ “The truth is that SARS2 is so contagious, so virulent, and reinfects so easily that there is no off-ramp for masking in healthcare. At least not without better vaccines and therapeutics that actually stop transmission and prevent Long Covid, Cardiovascular Covid and Neurocovid.”

On airborne disease control and safer indoor-air infrastructure vs. lockdowns

by Dr. Noor Bari, Emergency Medicine • 16 June 2023

❦ “Dear economy enthusiasts... The only humane way to avoid locking down for airborne disease control ever again is to set up safer indoor-air infrastructure... globally. Everyone that is slowing down this process is asking for another lockdown. Or mass murder. More likely another lockdown though because in the end, if bird flu takes off or MERS has an interesting offspring... the public will not stomach as much death as the anti-lockdown and dirty-air proponents would like.”

On healthcare workers, Dr. Semmelweis, clean hands, and dirty air

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 8 June 2023

❦ “Whenever I hear someone ask if we’re expected to continue masking in healthcare settings forever, I immediately think of Semmelweis – the man who discovered that healthcare workers’ dirty hands were causing fever and death in patients. The result of his discovery wasn’t the widespread implementation of hand hygiene though... Instead he was shunned, ostracized, lost his job and eventually institutionalized. It took around fifty years before the life-saving value of hand-washing was fully recognized in healthcare. Fifty years. It turns out that doctors didn’t take kindly to the idea that their own hands were unhygienic – and the source of disease and death for some of their patients. Despite the evidence, the denial was rampant and it was strong. The majority consensus was that Semmelweis was a crank... The resistance to the idea that the air we exhale while caring for patients can be unhygienic, and a source of illness and death for some, feels exactly the same to me. Despite the evidence, the denial is strong. Many prefer to cling to the status quo they knew before the pandemic. But that status quo was when we didn’t know better, and when we didn’t have such a virulent and dangerous new airborne pathogen in permanent circulation. Now that we do, and now that we know better, we should be willing to do better. So if the air we breathe can be unhygienic, and cause illness and death in our patients, and we know there’s a simple, effective solution – filtering it through a respirator – then it seems logical that this would become the new standard in our clinics, hospitals and long-term care facilities. Permanently. But as with Semmelweis’ experience, I expect that suggestion to get a lot of pushback, and for it to take a very long time for the medical field to accept that the old status quo is gone, and that masking in healthcare is the new normal. I just hope it won’t take another fifty years.”

On “personal risk assessment” and group leadership

by Dr. Noor Bari, Emergency Medicine • 27 May 2023

❦ “There is no such thing as “personal risk assessment” for the vast majority of people. A tiny number of dominant personalities in your life (and it could be you) have decided what to do, and the rest will follow. Even those that are making the decisions are not making a personal risk assessment. They are making a group risk assessment and taking their whole family/community with them. People may not even realise this – that they have made the decision on behalf of their entire household/class/company... but they have... If there is no responsible public health leadership, someone else is leading... because that is how we work, by and large, as a species. Someone is in charge... someone is always in charge, and unfortunately... misinformation is rife.”

On life and death in the 2020 red-zone

by Dr. Noor Bari, Emergency Medicine • 26 May 2023

❦ “No-one said life was gonna be easy. No-one said living through a pandemic was going to be easy. It’s all about what you think is important and worth fighting for. I chose health, lives, and sticking together. I chose to try to solve problems, not hide them. You can rewrite history. You can say that the mass overseas graves didn’t matter. You can say that we didn’t need to lock down in Australia in 2020 (when we had no PPE, no vaccines, and no therapeutics). I know different. I was there. Shed enough tears, attended enough zoom funerals… I know it wasn’t easy. I saw the tears when I said that a family on the breadline needed to isolate. I saw the heartbreak as I led a person away from their family, across the red line into the “red zone”. Even as I walked away from my family every day into the red zone, I felt your effort with me. When I said goodbye to my kid every day, and isolated away from my family to protect them from any accidental breaches... I know you all sacrificed too... ...and I was so grateful, and so proud... I wasn’t the one saving lives, you all were. You saved my life... I’m sure of it. We didn’t have enough PPE... Don’t ever forget that, and don’t let those bombastic characters writing rubbish articles about lockdown ever take that away from you.”

On radical normality and compassion

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 26 May 2023

❦ “Yesterday someone confronted me about my social media content – saying that while I’m not wrong, I’m too radical. They asked me: — “OK. What happens once everyone agrees (that Covid reinfections are problematic ) – then what?” Then we clean the air. HEPA filters are not radical. I don’t know what they expected as an answer. We regulate water safety and food safety in an effort to decrease population rates of waterborne and foodborne illnesses. Having clean air standards to lower the rates of respiratory illnesses isn’t radical. It’s also not radical to suggest we keep masking in healthcare and in essential indoor spaces so that the disabled, the high-risk, the elderly and their families can safely enjoy community life again. Wearing a respirator is not hard. Wearing 4-inch heels is hard, and I do that all the time for no good reason other than vanity. Accessibility is not radical. Advocating in favor of a public health response to an on-going threat is not extremism. SARS-CoV-2 is the Number One infectious-disease killer in Canada, and our excess deaths are still high. It’s not radical to think we should do something about it... It’s also not radical to advocate for the bare minimum in terms of public health education campaigns on Long Covid / Post-Covid Syndrome, and airborne transmission. Empowering people through education is not radical. It’s just wild for me that someone would think my Covid public health advocacy is radical when, in reality, they agree that we should clean the air, mask in healthcare and other essential places, and educate the public. Did they think I was going to answer with “lockdowns” ? Or is the radical part that I care enough to advocate out loud? Even when it’s not popular? Even when there’s an increasingly intense push to frame Covid health advocates as radicals and extremists? Or maybe I’m a radical because I don’t value brunch or maskless grocery shopping enough to risk Long Covid, or to betray my values? Is it radical that my physical health and my integrity are important enough to me that I’m at peace with my decision not to conform to societal expectations? If you’ve misclassified people you actually don’t disagree with as “radicals” in your mind, you should take half a second to examine how and why that happened, and re-examine your assumptions. There’s nothing radical about clean air and compassion. We don’t lack scientific consensus. The pandemic is complicated because we lack values consensus .”

On harmful choices vs. harming the vulnerable

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 20 May 2023

❦ “I’m a little confused at the “making people feel bad about how their choices harm others is bad advocacy” takes. Didn’t we do that with smoking? Wasn’t the “second-hand smoke kills” education campaign exactly that? Isn’t “if you drive drunk, you could kill someone” exactly that? Since when is it controversial to point out how our choices could harm other people? Some people seem to think that advocacy should never make anyone feel uncomfortable… Do they really not realize that they’re out here shaming the oppressed for making their oppressors feel bad? We’ve created a system of structural violence against the immunocompromised, disabled, and clinically vulnerable. One that now extends to healthcare. We deserve to feel ashamed about it and we should always feel uncomfortable with perpetuating structural violence against others.”

On SARS-CoV-2 and HIV

by Dr. Noor Bari, Emergency Medicine • 20 February 2023

❦ “I’m vaguely following the chatter on the comparisons of COVID with HIV. I’ve never been a fan of this, because there are so many unanswered questions. One thing I am sure of. Research shows the immune system does get damaged. It does. Which bits? How much? Recovery? What opportunistic infections? Impact on global disease patterns? Impact on animal disease patterns (ecology and food-chain threats)? All questions that will be answered over time. No-one should be surprised by this. It should not be even vaguely controversial. Plenty of viruses damage the immune system . We will find out exactly the extent of the nature of COVID on this aspect of health. Another thing I can say with some certainty. Your chances of recovery from a depressed post-viral immune system will not be improved by further [SARS-CoV-2] infections. I can see a lot of people directly comparing COVID with HIV. Rest assured. I am concerned. I just don’t find that particular comparison helpful. As many have already pointed out, there are significant differences too. You don’t walk into the supermarket and catch a new strain of HIV starting a whole new acute infection every 6-8 months, for example. But there are also signs that some immune cells are recovering many months after infection too – then again, there are probably reservoirs in the body that could potentially continue to mutate, and then cause other pathology down the line – as some animal coronaviruses do. I think COVID is quite an interesting and horrible disease. I expect we will see what repeated infections really do as time goes on. Excess deaths are already through the roof. One last attempt to clarify. Trying to make COVID into either a cold, or HIV, and ending up with “half-way between” – when in reality COVID is doing 100% COVID, which is turning out to be really, really bad in its own right… and it’s airborne… and we are catching it all the time. That’s the part I find frustrating with this comparison. SARS is a dangerous, dangerous disease. It always has been. Both of them [SARS-1 and SARS-2] . Yes, there are threads of similarities, and we can use our wealth of knowledge to extrapolate possible outcomes, and test treatments… But SARS is not half-way to anything. It is, in itself, a giant problem.”

On going back to normal

by Dr. Noor Bari, Emergency Medicine • 22 January 2023

❦ “No. We haven’t gone back to normal. We have gone forward into abnormal. Really abnormal. Kill your elders abnormal. Douse the kids in viruses abnormal. Ignore and kill disabled people abnormal. Please go back to normal... because I don’t believe for a second that when you wake up and look in the mirror, that this is what you ever wanted to see looking back at you. It’s not too late.”

On high stakes, uncertainty, and following the crowd

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 13 January 2023

❦ “The way I see it, if somehow all the data on the cumulative risk of death, hospitalisation, disability, heart attacks, strokes, etc. with repeat Covid infections turns out to be wrong, I will have worn a mask for longer than I needed to and missed a few social events. I’m OK with that. Whereas if I decided to follow the crowd instead of the available science, and the available data turns out to be right about the risks of cumulative Covid infections, then I’d be facing high odds of poor health, disability, and premature death. Those are very high stakes. When the stakes are high, you can’t afford to be wrong. So seeing ‘experts’ wave around the absence of certainty as their justification for choosing the high-stakes position, when the high-stakes position is the one that requires the most certainty… it’s just so absurd. On the other hand, I can pull up multiple scientific studies on how Covid (and the loss of parents/primary/secondary caregivers) harms children…”

Why me?

by Dr. Noor Bari, Emergency Medicine • 4 January 2023

❦ — “How was your New Year?” — “S’ok...” Sad face... young adult person... “I got sick... kind of like a cold...” (But face says, “It ruined my New Year.”) So much is left unsaid. So many assumptions that everyone else is having fun – why not me? Guilt about being a let-down. (‘Am I not strong enough? My immunity not good enough?’) Others move on to chat about dining out at restaurants... This young person turns away, and continues to work. Isolated in her thoughts... How desperately I wanted to go over to her and say, “You are not alone...” But I’m a stranger, just passing... I think about how people in power are misleading and hurting young people. It’s deplorable.

On lung and liver fibrosis: A message for 2023

by Dr. Noor Bari, Emergency Medicine • 30 December 2022

❦ “COVID-19 causes lung fibrosis. It affects the immune system, and it causes liver fibrosis . COVID-19 causes brain inflammation and heart inflammation, strokes, heart attacks and large blood clots. COVID-19 causes diabetes . COVID-19 can cause kidney failure. I could go on... and on. Bone necrosis, joint pain, hair and teeth falling out. Do you normally expect a cold to make your teeth fall out ? Look up ‘lung fibrosis’ and ‘liver fibrosis’. Google them, and read about the complications. Read how patients that have these progressive diseases die. (Apologies to patients that already know.) Time and again, these patients have said to me (particularly when I was a young medical student): “Don’t do what I did.” “Don’t smoke.” “Alcohol is...” “I wish I had never...” “Save yourself...” Of those dying of infectious causes of lung and liver fibrosis: “Why me...?” “I wish I could have avoided that infection...” Stop. Stop as many COVID infections as you can. Stop now. Now is your chance to avoid treading these terrible paths. Once COVID has weakened your organs and immune system, every other pathogen – and even some environmental/commensal bugs – can move in... You will feel nothing wrong, nothing wrong, nothing wrong... then... the cascade of deterioration will snowball. Stop now while you are still in the “I feel nothing wrong” phase. There may well already be stuff wrong, but it’s better to try to stay in this phase than accelerate towards death any faster than is avoidable. No, not everyone will get every effect to the same extent, but macrophages do get activated by COVID (as well as other immune pathways and cells). Some of the inflammation in the body has been observed for months. That is a recipe for damage and fibrosis. I wrote this after hearing – again and again – “I have a cough, it just won’t budge, and it’s not COVID”. I don’t know what's causing all the coughing. Could be anything... but this is one of the ways I would expect widespread prevalence of lung damage to present. It’s also one of the ways I would expect chronic infections with slow-growing pathogens (like TB or atypical pneumonias) to present... Chronic coughs can also have other malignant or serious causes. These should be assessed and monitored by a GP if it’s not budging. Please... try to look after yourselves.. .”

On pregnancy, and avoiding pathogenic diseases

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 4 December 2022

❦ “I’m so pro-mask and anti-infection that I started masking in 2019. Why? Because I was pregnant and working in healthcare. And in the before-times, it was normal to try your best to avoid contracting pathogens in pregnancy. We didn’t worry about the (illegitimately-termed) “generational immunity debt”. I was doing it wrong – intermittent masking with leaky, blue surgical masks, haha – but I was masking every day because I was pregnant during RSV/flu season, and I was acutely aware that both of those viruses (and several others) could put both myself and the baby at risk. Pregnancy is a state of relative immunosuppression, and there’s research associating fever, regardless of the pathogen, to neurodevelopmental disorders. Pathogens are always unwelcome, but especially so in pregnancy. I picked up the idea of masking while pregnant as a med student during my pediatrics rotation. One of my attendings (supervising physician) was pregnant, and she masked to protect herself. It really bothered me. Not the mask. It bothered me that she and her baby had to be in harm’s way at all. Where I live, women that work in childcare get preventative leave during pregnancy because of the risk of contracting viral illnesses. Not doctors, though. So here was this pediatrician working specifically with young children who have viral illnesses, while she was pregnant. It seemed so unfair. It left me upset. But she was doing what she could to protect herself. Gloves. Scrubs. Hand hygiene. And a mask all day. With every patient. Even with us. So years later, when I was pregnant, I masked at work, too. I actively tried to avoid viral illness. After all, if I had a job in childcare, I’d be on preventative leave, right? So why would I expose my pregnant self to viruses in a healthcare setting, when doctors were taking women in other high-infectious-risk environments off work entirely? So anyway, imagine my utter shock when 2020 rolled around, and the “experts” started telling the population that masks don’t work. Remember that? — “Masks only protect others and not the wearer,” they said. That was the first lie in what we now know would be a long stream of lies. It was with that first lie that I understood that I needed to rely on myself, and not just the official messaging. That to keep my newborn safe, I would have to diligently double-check what we were being told. I knew I needed to find the truth-tellers among the “experts”. And this is not just about masks. Maybe the decision to mask in pregnancy wasn’t common pre-2020 – but looking out for each other absolutely was. In dermatology, we’d try to do the fever-plus-rash consults (and any other virus-risky consults) for pregnant colleagues. Why? Because why take unnecessary risks? Pathogens in pregnancy are bad. We’d often worry about the risk of the rash-plus-fever consult being measles or varicella. — “But aren’t you vaccinated?” Yes, and why take the risk? That was the mindset before the “vax-and-relax” lie. We got vaccinated against influenza in pregnancy as recommended, because we didn’t want to catch it – not so that we could go out and expose ourselves to it. We didn’t “vax and relax”. We “vaxxed and continued to actively avoid” . It was an easier task with the flu than it is with Covid, given how much less contagious flu is. With Covid, individual effort is insufficient. For it to be avoidable with small individual efforts, there needs to be not much of it circulating. Which would require a big Public Health project. So the deciders decided that that was not going to happen. We were going to live with infinite, forever Covid. But that would endanger so many people. So that’s when the “pandemic of the unvaccinated” lie was born. And the “Omicron is mild” lie. And the “Long Covid is rare” lie. Honestly, there are just so many lies that I can’t keep them all straight. We’re just constantly being “nudged” with nonsense messaging to get us to accept unmitigated exposure to SARS and other pathogens as normal. And it’s working. People seem even less cautious than they were before. We had crushed RSV and the flu, emptied pediatric hospitals, and had negative pediatric excess mortality. And we took zero lessons from that time forward with us. We figured out how to dramatically lower infant/childhood morbidity/mortality, and they made sure we unlearned it ASAP. They didn’t marvel at that achievement, and strive to do the non-disruptive stuff like cleaning the air and normalizing masks during the winter viral season. Instead, the “let a SARS virus mass-infect kids”, and the lies to normalize all the suffering that we’re seeing just keep on coming. See, that’s the problem with siding with the disinformers. Maybe you let the lies go because you agreed that kids shouldn’t have to wear masks for the benefit of “the vulnerable”. But now the disinformers are saying that society shouldn’t have to mask up for the safety of your kids, either. Siding with people that openly devalue the lives and right to safety of other human beings, because you are not personally in the devalued group, rarely ever goes well. And that’s the point of this essay. We’ve slowly and tragically slid down a slippery slope. This is nothing like 2019. In 2019 we would have cared that pediatric ICUs were overflowing, and worn masks to flatten the curve for kids. We’ve fallen so far since 2019. And with each passing day that our society can be convinced not to wear a mask to work – or in the mall, or on the bus – to prevent others from dying, or to keep babies out of the ICU, we slip a little further down the slope. And the scary thought is that this is very unlikely to be rock bottom. We still have further to fall.”

On lymphopenia, and viral infections

by Dr. Noor Bari, Emergency Medicine • 30 November 2022

❦ “Lymphopenia is present during and after some viral infections, and this also varies between individuals. It is very transient in most cases, and by that I mean a couple of weeks. The viruses that cause longer derangement are already known to be associated with long-term immune system derangement – including secondary infections, immune amnesia and cancers. COVID-19 lymphopenia has been recorded present for months. COVID-19 has been found to destroy (engulf in syncytia), directly infect, stimulate, and suppress a lot of white-cell function. Reinfections are frequent. Secondary infections/reactivations observed. It’s a huge worry. As a general rule, efforts are made to control/treat viruses that cause prolonged immune system derangement. COVID-19 is wildly exceptional in that we are ignoring it, pretending the lymphocytes bounce back like after a cold, and are frequently infecting people with it. We are also losing naive lymphocytes in large numbers due to superantigen stimulation. This is very different to transient suppression of peripheral blood lymphocytes due to cytokines or migration. This is another example of people making assumptions (huge and wrong), based on entirely dissimilar pathogens. It’s very important to look at what happens in similar situations, such as post-other-super-antigen-carrying infections. (Nothing good.) I could have saved my energy today and just let everyone play with a super antigen and find out… but sadly, the people finding out the hardest lessons are not the people deciding to play with it. So… here we are…”

On protecting the vulnerable ad absurdum... Continuous “herd reinfection”, sickness, and death as Remedy

by Dr. Noor Bari, Emergency Medicine • 21 November 2022

❦ “This is quite possibly the most absurd thing you will read today. Let’s take this one step at a time. For the purposes of this short essay, I will be ‘vulnerable’.”

On post-COVID infections, immunodeficient patients, and multi-drug-resistant diseases

by Dr. Noor Bari, Emergency Medicine • 10 November 2022

❦ “This morning someone said to me: — “I just can’t shake this... first a chest infection, and now a urine infection...” Someone else I know (very close) has had three eye infections post-COVID. Another has had a deterioration in their fertility, as compared to their baseline pre- and post-COVID. Measured. It’s almost as if the stuff in the science papers is real. None of them have twigged that COVID might have toasted them yet either. They are all heading into this next wave with no idea how dangerous it might be to abuse their already struggling immune system like this. You know what’s coming next... Multi-drug-resistant bacteria. Many are already here, but this is going to get really out of control. Trying to treat infections in immunodeficient patients is a great way to make loads of drug-resistant bacteria and viruses.” ✾ 📖 (24 Sep 2025 ~ CIDRAP/University of Minnesota) Outpatient antibiotic use in COVID patients linked to 'downstream' antibiotic resistance ➤ 📖 (15 Jul 2025 ~ UKHSA: News story) UTIs [Urinary Tract Infections] cost NHS hospitals over £600m last year ➤ 📖 (26 Jun 2025 ~ Forbes) Cancer Patients Face Silent Crisis From Superbugs, New Research Shows ➤ 📖 (12 Dec 2024 ~ CIDRAP/University of Minnesota) Report describes spread of highly drug-resistant cholera strain ➤ 📖 (1 Nov 2024 ~ China CDC Weekly) Emergence of a New Sublineage of Candida auris Causing Nosocomial Transmissions - Beijing Municipality, China, March-September 2023 ➤ 📖 (17 May 2024 ~ CIDRAP/University of Minnesota) Global Meta-analysis estimates 43% rate of multidrug resistance in COVID patients ➤ 📖 (14 May 2024 ~ Journal of Infection) Global antimicrobial resistance and antibiotic use in COVID-19 patients within health facilities: A systematic review and meta-analysis of aggregated participant data ➤ 📖 (24 May 2023 ~ Current Microbiology) Interaction Between SARS-CoV-2 and Pathogenic Bacteria ➤ 📖 (18 Apr 2023 ~ BMC Infectious Diseases) Fungal infection profile in critically ill COVID-19 patients: a prospective study at a large teaching hospital in a middle-income country ➤ 📖 (29 Mar 2023 ~ Journal of Fungi) Fungal-Bacterial Co-Infections and Super-Infections among Hospitalized COVID-19 Patients: A Systematic Review ➤ 📖 (30 Sep 2021 ~ Business Insider) Drug-resistant infections in the US have risen sharply during the pandemic, and experts warn it's getting worse as COVID patients overwhelm hospital resources ➤

On youth and indestructibility

by Dr. Noor Bari, Emergency Medicine • 6 November 2022

❦ “During my young and ‘indestructible’ days, I did a lot of risky things. I now have a dodgy ankle, and various other aches and pains to remind me... Young people these days will also accumulate their scars of youth... but in my opinion, the COVID scars were unnecessary. We could have made it so much safer to travel and have fun by controlling disease properly. We gave up on them, our youth. We left them last for vaccines, and last for any consideration of their needs. They can’t even date properly without excess risk of long-term health problems because we can’t be bothered to do the work. Dating and finding a partner is a need , by the way. Sure, there are ways around this… but realistically, zero COVID would have been for them. The young. People think it’s to protect the old... but that’s only a small part of the story! Zero COVID would have given our kids safer schools. Parties would be safer. Sport would be safer, and they could excel without fear of COVID ruining their goals. We should have done it for the kids. See what I mean. We have misguided and abandoned them.”

On erectile dysfunction (ED), COVID, and the future of male youth

by Dr. Noor Bari, Emergency Medicine • 6 November 2022

❦ “What are we going to tell young men in twenty years’ time if they discover that they can’t ever have an erection in the usual manner due to repeated childhood COVID infections? Have we thought about using vaccines and therapeutics in children to prevent this? What about protecting children with NPIs ( non-pharmaceutical interventions )? We all worry about kids missing out on fun stuff in this pandemic. What about their sexual health later in life? Is this not fun? Is this not important? Is this not for them ? Let’s not be squeamish. Let’s think this through properly. Our youth are being repeatedly infected with a pathogen that we know affects sexual and reproductive health in a myriad of ways. Due to the fact that I will likely be dead by the time you figure this out, I’m going to take the liberty of saying a few things now. 1) This is unacceptable. 2) I told you so. 3) I’m sorry future adults, I really tried. I hope that solutions come your way.”

On immunological dysfunction and post-COVID infections

by Dr. Noor Bari, Emergency Medicine • 30 October 2022

❦ “COVID-19 is fighting back by generally depressing the whole adaptive immune system. We are showing narrow resilience to COVID reinfections due to adapting – but we are becoming more vulnerable in general to infections of all kinds. ❦ Worst case scenario A single infection causes on-going and progressive immunodeficiency . ❦ Best case scenario A single infection causes temporary immunosuppression , and we suppress COVID transmission enough to allow recovery. ❦ Most likely scenario, medium-term Immunosuppression that becomes continuous and possibly progressive due to reinfections. Reduced immune function after a viral infection is not unusual. Many viruses do this. The concerning issue is the length and breadth of the immune system dysfunction, coupled with emerging evidence of other pathogens taking advantage .” ✾ ❦ Immunosuppression ~ Suppression of the immune system and its ability to fight infection. ❦ Immunodeficiency ~ A state in which the immune system’s ability to fight infectious diseases and cancer is compromised, or entirely absent.

Back To The Future (Redux version)

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 22 October 2022

❦ Medical school lectures on respiratory pathogens in 2060: “Interestingly in the 1900s and early 2000s, doctors thought respiratory viruses were transmitted by fomites, not aerosols. They spent a tremendous amount of energy cleaning hands and surfaces instead of cleaning indoor air. Unsurprisingly, they were quite terrible at limiting the spread of respiratory viruses and had terrible epidemics each year leading to thousands of deaths, including many among infants and young children.” “Air hygiene has been one of the greatest public health advancements of the century.”

On skin cancer and time

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 20 October 2022

❦ “Something my skin cancer patients say to me all the time is “You know, my parents’ generation didn’t protect us from the sun when we were kids...” and it of course gets me wondering what today’s kids will one day tell their doctors about what our generation didn’t do for them.”

On your fireside ‘cardiovascular risk’ speech

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 4 October 2022

❦ “If you’re an MD [medical doctor] that spends time counseling patients to exercise and quit smoking in order to reduce their risk of a heart attack or stroke, and you haven’t yet added “Avoid Covid” to your ‘Cardiovascular risk factors’ counseling speech – you may want to re-evaluate that oversight.”

On “immunity debt”, and paying the interest

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 1 October 2022

❦ “Immunity debt” is making the rounds again. So here’s my reminder that while there are viruses that are more severe if caught as a teen or adult (like polio or chickenpox), that isn’t the case for respiratory viruses . There’s a mortality benefit from first RSV and flu infections being delayed. So no, your toddler doesn’t need to catch all the viruses before the age of two to “build their immune system”. In fact, it’s the opposite: infants and young toddlers are more at risk of hospitalization and death from many respiratory viruses at their age than older children. You know how we’re asked not to give kids honey until they’re one? Or how Health Canada has a whole list of unsafe foods for kids under five? “ For many pathogens, kids are more susceptible to severe outcomes when they’re very young. ” And there is benefit to delaying exposure. This new (and very politically convenient) idea that it’s always best to catch pathogens very early in life “to build your immune system” can actually be quite dangerous when you take the time to think it all the way through. Stop blindly promoting “immunity debt” pseudoscience. Three years ago, I never would have believed that I’d one day see scientists and MDs [medical doctors] promoting the idea that it’s good for infants and young toddlers to be exposed to dangerous respiratory viruses like flu and RSV, instead of trying to delay those first infections – and yet here we are.”

On repeat

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 24 September 2022

❦ “It’s interesting to see people treat the statement “Catching Covid repeatedly until it kills you” as hyperbole. Covid is a leading cause of death across all ages. If nothing changes, then losing people we care about to Covid will be as common as cancer, heart disease or dementia. We’ve all lost loved ones to cancer, heart disease or dementia – but not all in the same year. The losses occurred over many years. Since Covid is still a brand new “leading cause of death” we don’t feel the full impact of this reality yet, but give it a few years and we will. If Covid remains a Top 3 leading cause of death going forward then inevitably, given enough time, “Catching Covid repeatedly until it kills you” will prove to be a true statement for a lot of people. It’s not as controversial a statement as some people would like to believe.”

On emergencies, and doing things in the right order

by Dr. Noor Bari, Emergency Medicine • 28 July 2022

❦ “I graduated from UCL. It has changed a lot since I was there. The ability to prioritise actions in an emergency is my job. You have to do things in the right order, or none of it works. We need COVID control, so we can free up resources to do other work. I don’t just mean health resources either. Depletion of workers due to sick leave; long-term illness; carer duties; and death – with some jobs becoming frankly undesirable. The expected benefits of ventilation and masks in essential services would be to reduce Reff * and save lives. * Reff , or the effective transmission number , is a measure used to indicate how many people, on average, a single infected person will transmit a disease to. A Reff value above 1 suggests that the infection is spreading , while a value below 1 indicates that the outbreak is declining . How much… you have to do it to find out, because it hasn’t been done before. We have to build this plane while flying. No room for excess baggage. Small case studies (like individual schools, or wards in a hospital ) indicate the benefit might be quite a lot. Even if it’s not as much as hoped, it has to be done, because we are rapidly accumulating long-term sickness. We have to try everything to slow that process.”

On bat-like immune systems, and “living with the virus”

by Dr. Noor Bari, Emergency Medicine • 21 July 2022

❦ “So, we want to “live with the virus”. Is there any evidence of this occurring successfully anywhere? Yes! In bats... and it has taken 64 million years of evolution to get there. To “live with the virus”, bats have better host defences – they don’t overdo inflammation, and they can get rid of toxic compounds and deal with reactive oxygen species much better than humans. They literally live with the virus .

On sewage systems, typhoid, and clean air

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 11 July 2022

❦ “Engineers raised the entire city of Chicago in the 1850s so they could install a sewage system in response to repeated epidemics of typhoid and cholera, but please tell me again how you don’t believe engineers can retrofit buildings with proper ventilation and filtration in 2022.”

The Salmon Run

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 8 July 2022

❦ “It can be lonely to be the type of person that copes with uncertainty by running towards information instead of away from it.”

On stating the obvious, and the conspiracy of brick walls

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 12 June 2022

❦ “When a weird new health issue arises globally after the West’s co-ordinated decision to allow mass infection of their countries’ populations with a novel, extremely pathogenic virus, it’s the height of intellectual dishonesty not to consider that novel virus as the prime suspect. I can’t believe we’re instead in a place where people get ridiculed and called conspiracy theorists for pointing out that Covid is the prime suspect. “LOL everything is Covid with you people” is a deflection tactic meant to silence rational people just pointing out the obvious. “But everyone caught Covid, are we going to blame every new health signal on Covid now?” Blame? No. Thoroughly and transparently investigate whether Covid is the cause or a contributing factor in the new global health issue? Yes. That’s how the aftermath of mass infection works.”

Don’t bother. Really

by Dr. Noor Bari, Emergency Medicine • 9 April 2022

❦ “I think it would be good if people stop asking family members of vulnerable people when they will unmask and go on holiday… and what their off-ramp is. Like… is “off-ramp” code for bumping off the vulnerable person in the household? Exit strategy via coffin? The faster everyone accepts that some of us can’t even go to a dentist without a risk-benefit analysis, let alone a dinner party, the happier we will all be. Do I walk around asking you about your personal choice not to mask? What makes you think you can ask me why I do mask? I know that tone says you aren’t actually interested in the answer. Let it go. No, no… I don’t have to learn to “live my life again”. I am living my life the way I have always lived my life. With due respect for myself and others.”

On problematic sand-dunes and the human head

by Dr. Lisa Iannattone, Assistant Professor of Dermatology • 17 February 2022

❦ “If you still think alarmism is a big issue at this point, in 2022 when we’re five waves in with a true global death toll estimated to be between 14 and 23 million, then I regret to inform you that you’re part of the problem.”

Let’s play pretend

by Dr. Noor Bari, Emergency Medicine • 20 December 2021

❦ “Let’s play pretend. Pretend we have unlimited resources to staff the hospitals. Unlimited ICU beds. We let COVID-19 take its natural course. COVID-19 would average, what? Two or three infections per person, per year? Let’s be conservative. Let’s say you get COVID-19 once a year. So once a year, a certain proportion of all human beings, except those in countries with good COVID control will: die; have reproductive difficulties like erectile dysfunction; get heart failure; lose the pleasure of the smell and taste of food; have new autoimmune issues; develop new cognitive issues; have vascular problems like strokes; suffer other organ damage, like kidney failure; receive a new diagnosis of diabetes. Etc. Each of these has a percentage prevalence in cases. Some of those numbers are not small. Each time, there will be people that get one or more of these issues. Each of those conditions has their own associated increase in mortality. Then there is the drop in productivity and quality of life. How long do you think it would be before the majority of the population has something not quite right with them due to COVID-19? I don’t think it would take all that long. Ten years maybe? Twenty? How can it possibly be a sane public health strategy to have hospitalisation and ICU capacity preservation as the goal of a nation, when the obvious and massive loss of health (and life) due to circulating COVID can be predicted already? Some years, we will not have a great match between vaccines and circulating strains (such as Omicron); other years we will get it right (maybe if we are fast enough, and we aren’t yet). What does that mean? There will be multiple episodes in the future where vaccine-mediated cover and infection-mediated immunity will not be great. That means the organ damage will be somewhat more severe. Why are public health officials OK with this? Even if we can never get back to zero COVID, why are they OK with having a high frequency of infections per lifetime? Am I in an alternate universe where I can see these studies and they can’t? We have therapeutics coming in, so that will help, but they aren’t 100% magic bullets either. People need a combination of factors to bounce through a COVID infection without noticeable effects (although kidney damage can present late). That combination, to be maintained at all times for an individual is difficult, let alone a population. The strategy of “Living with COVID-19” is fatally flawed. That flaw is the fact that COVID-19 is a rapidly mutating virus that causes irreversible, or slowly reversible damage to the human body. We can’t actually withstand it for our usual natural lifetimes. The government must show the modelling for long-term health outcomes for their “living with the virus” plans. The economic impact of the same. All the colleges of medicine should submit their modelling on how COVID-19 is affecting human health. This is critically important work. How a biohazard was allowed into Australia and allowed to circulate – without modelling its overall impact on human health – is a matter that should be investigated thoroughly. It was a huge decision. There should have been expert discussion and documentation. No… Saying “We didn’t know” is not good enough. If you don’t know… Don’t play with SARS.”

📖 Guidance for Healthcare Employers and Workers on the use of Fluid Resistant Surgical Masks (FRSM) and respirators (FFP3 etc) to comply with the requirements of COSHH (2002) (England) (Updated 2025)

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