— “What?! Binned by a cold?” NHS (England) Staff Sickness Absence Rates per Month (per 100k) by Staff Group and Condition 2019–2026.

‘Breathing, speaking, coughing, and sneezing produce infectious aerosols in clinical environments. Coughing produces more aerosols than endotracheal intubation.’

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 (2026).

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

‘This study included 5248 healthcare workers. While 33.6% reported prolonged COVID-19 symptoms consistent with PCS, only 7.4% reported a formal diagnosis of PCS. Fatigue, difficulty concentrating, insomnia, and anxiety or depression were the most common PCS [Post-COVID-19 Syndrome] 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.’

❦ “Every single case in which a person with COVID-19 infects another person in a healthcare setting – patient, relative, or hospital staff member – is a significant failure of hospital procedures. Every single instance .”

‘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 ➤

❦ “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.”

‘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.’ ✾

❦ “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.”

❦ “I think a big problem is that many people’s conceptions of morality do not extend to invisible viral transmission and indirect chains of harm. Punching someone in the face and bloodying their nose is unconscionable. Killing a hundred people in a chain of negligent transmission? No biggie.” © 2023 Blake Murdoch ➤

❦ 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.”

❦ I keep saying that someday I’ll write a book about the struggle to bring an engineering perspective to infection prevention and control in healthcare. For now... just an essay. Is there anything worse than knowing that there are oceans full of icebergs ahead; how easy it is to engineer systems to detect and steer around them; but not being able to get the owners of the liners (or anyone in command) to listen as you blindly head straight for them? I’ve been advocating for engineering solutions and standards for air, water and surfaces in healthcare facilities to lower disease transmission for over 30 years. The irony of being accused by out-of-touch ID/PH/IPAC/Epi * of epistemic trespassing before and during the pandemic is gobsmacking. * ID = Infectious Diseases / PH = Public Health / IPAC = Infection Prevention and Control / Epi = Epidemiology. I started with single patient rooms. In pre-pandemic Canada, we had the highest HAI* rate in OECD * – one in ten inpatients – and the lowest beds and lowest single rooms per capita. * HAI = Hospital-Acquired Infection, also known as a nosocomial infection, is an infection that patients get in healthcare facilities while receiving treatment for other medical or surgical conditions. * OECD = Organisation for Economic Co-operation and Development. We also had sicker patients. Studies now show that single-patient rooms cut infection rates in half. Ten years ago, Canada began moving to primarily single-patient rooms for new hospital builds – although not a hundred percent as hospitals won’t give up preferential private-room billing to insurance companies. In 2007, we formed a small group of volunteers to create a Canadian National Standard for Plume Evacuation – source control to prevent airborne transmission of disease in ORs * . * OR = Operating Room. Despite nurses’ complaints, we couldn’t get support – until doctors started getting genital warts in their noses. We helped ISO * develop a similar global standard which was published in 2014. * ISO = International Organization for Standardization. Because laser and electrocautery smoke is clearly visible, and there are now national and international standards, the practice of source control in ORs is now well-accepted. Unlike smoke, our breath is not visible – and there are no national or international standards yet for pathogen-free air. However, the principle of air extraction would work in ICUs * and patient rooms just as well as ORs. * ICU = Intensive Care Unit. Copper was registered as an antimicrobial in 2008, 50 years after silver. Over the past ten years, countless studies have shown efficacy, persistence, durability and the safety of copper surfaces – but the ID community pushes back with objective conclusions like “... Too good to be true”. While ID/IPAC has no budget of their own to implement engineering measures in hospitals, in Canada they can (and most often do) scuttle initiatives in Engineering and Facilities Management, and in Environmental Services departments, to introduce new technologies and materials to combat HAIs. In 2011, I pursued the concept of combining continuous and high-frequency bioburden reduction of surfaces to prevent fomite transmission. Copper could provide ‘continuous’ reduction on high-touch surfaces, while UV * (if automated) could provide ‘high-frequency’ reduction on all surfaces. * UV = Ultraviolet (UV) radiation. In 2014 we launched AutoUV – built-in fixtures that detected occupancy, monitored whether doors were open or closed, and dosed rooms every four hours and after every exit. As expected, it works. It can’t not work. And after seven years in the field, it’s been shown to be extremely safe. Bathrooms can be the source of half of disease spread in hospitals. C diff * can be colonized in air after every toilet flush. Aerosols drift for minutes to hours. Intestinal and respiratory diseases are often spread through toilet aerosolization. * C. diff , also known as Clostridioides difficile or C. difficile , is a gram-positive bacterium that can cause diarrhoea and colitis. AutoUV? Bathroom source-control. Today, there are thousands of units in use across Canada – and the Ontario Ministry of Health has made AutoUV a standard-of-care for new hospital builds. MOHLTC * now mandates and funds AutoUV. * MOHLTC = Ontario Ministry of Health and Long Term Care. Hooray. But IPAC stubbornly pushes back against the use of AutoUV. In other ironic news, Health Canada is cutting off use of open-air UV in healthcare, including Upper Air UV – in the middle of an airborne pandemic – due to a flood of household UV devices that are being sold retail and online that don’t work, don’t have safety certificates, or produce [dangerous] ozone. In 2014 I co-founded CHAIR – the Coalition for Healthcare-Acquired Infection Reduction – a group of scientists, engineers, ID doctors and industry partners working together to engineer air, water and surfaces in order to lower HAIs. We naively thought that we could achieve an 80 percent decrease in preventable, environmental HAIs with new technologies and materials. We knew legacy industry players in chemical disinfection would be a challenge. We had no idea that the biggest battle would come from the ID/IPAC community itself. I watched in horror at the denial of airborne transmission of 2003 SARS at a plenary session in Toronto in May 2014. Playing to the crowd in a purposeful, dismissive and comedic way, the speaker claimed that “SARS is not airborne . The droplets fall to the floor within six feet.” Dr Yu, of Hong Kong Public Health, had only just re-analyzed and re-published the Amoy Gardens study six months earlier on the 10-year anniversary reaffirming airborne transmission of [the original 2002-2004] SARS. When I challenged the speaker, he exclaimed: — “Oh, don’t worry. I know him. He's changed his mind.” In 2014, an ID doc from PHO * presented at a Toronto IPAC Education Day. * PHO = Public Health Ontario. He claimed that Ebola was definitely not airborne . When challenged with a study showing transmission between caged and separated laboratory primates, he replied: — “Well, monkeys have long arms. Besides, they can spit.” In a follow-up from me: “There’s airborne transmission of PRRV * in hogs between factory farms kilometers away, and documented in Veterinary journals...” * PRRV = Porcine reproductive and respiratory syndrome virus. — “I don’t read those journals.” — “Would you like me to send you some articles?” — “Don’t bother.” They don’t want to know. Hospitals are a global network of MDRO * incubators. * MDRO = A multidrug-resistant organism (MDRO) is a germ that is resistant to multiple types of antibiotics, making it difficult to treat and cure infections. CDI * and MRSA * initially tend to spread in hospitals before seeding community-acquired versions. Sinks and drains are known sources of contamination, especially via the aerosol route. Pathogens are getting more virulent – including MDRO/CPE/CRE/CPOs and C auris. * CDI = Clostridioides difficile infection (CDI or C-diff), also known as Clostridium difficile infection, is a symptomatic infection due to the spore-forming bacterium Clostridioides difficile. * MRSA = Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections. Water contamination and aerosolization, and bacterial, fungal and biofilm reservoir control = Engineering. Progressive examples: ➲ In Calgary Health Region: UV all incoming water? No Legionella. Self-disinfecting sinks? Electrocatalytically-split H2O into OH-, O-, O3 and H2OH = Disinfectant. ➲ In Ontario, the Ministry of Health now funds and mandates self-disinfecting sink and drain technologies. However, IPAC/ID continue to push back against new technologies. So why write this essay? Because the current struggle to recognize airborne transmission, and the engineered solutions, is part of an epic struggle. We’ve seen how much resistance there has been in almost two years. The entrenchment started a century ago, as most of us know. But the struggle has been about much more than “airborne” . It’s a struggle for epistemic control; for critical thinking; for evaluation to first principles; the applied use of deductive reasoning; politics; economics; tension between careerism, and the Precautionary Principle. Many in ID/PH have fought against engineering measures, but now are giving up on fighting the virus at all. It’s important to not give into the temptation of accepting that “We just have to live with it,” or that “It’s endemic now” – or “It's mild” . No . Not acceptable. COVID-19 is airborne. It’s very manageable. Wear an N95 [FFP2 respirator] in occupied spaces until case counts are near zero. Make indoor air safe – ventilate, filter it, and use UV. Set national and international standards for safe indoor air. Set a goal of elimination – first regional, then national, and then global. ❂ © 2021 Barry Hunt . ➲

‘The arrival of the Omicron variant marked a major shift, introducing numerous extra mutations in the spike gene compared with earlier variants. Before Omicron, natural infection provided strong and durable protection against reinfection, with minimal waning over time. However, during the Omicron era, protection was robust only for those recently infected, declining rapidly over time and diminishing within a year.’