‘Fatigue, difficulty concentrating, insomnia, and anxiety or depression were the most common PCS symptoms. Baseline risk factors for reporting PCS included screening for common mental disorders, direct contact with COVID-19 patients, pre-existing respiratory illnesses, female sex and older age.’

‘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)

‘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).

❦ ‘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 ➤

‘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.’ ✾

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

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

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

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

❦ “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.”

❦ “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.”

❦ “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.”

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

❦ “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.”

❦ “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.”

❦ “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.”

❦ “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.”

❦ “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.”

❦ “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 .”

❦ “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.”

❦ “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.”

❦ “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.”

❦ “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…”

❦ — “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.

❦ “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.. .”

❦ “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.”

❦ “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 ➤

❦ “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.”

❦ “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.”

❦ “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.

❦ 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.”

❦ “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.”

❦ “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.”

❦ “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.”

❦ “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.”

❦ “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 .

❦ “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.”

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

❦ “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.”