The title says two things. The first is that I, like everyone else, make mistakes [‘regerts’ rather than regrets]. The second is that I consider the work I have done to highlight errors in infection prevention and control (IPC) guidance and making healthcare ‘IPC-safe’* has been worthwhile. This is regardless of the responses so far from decision-makers which have been:
- late
- ignored
- ineffective
- patronising
- untruthful, and
- if I’m honest, at times, a little snippy.
However, ensuring we have evidence based, effective IPC is about people; the people who work in and use the NHS – all of us. And it’s also about all those HCWs who died or are debilitated (e.g., have Long Covid) owing to the ongoing denial of airborne transmission and the provision of ineffective protective equipment and unsafe environments.
For the length of the pandemic, which in my opinion is still ongoing, IPC / public health (PH) guidance writers have advocated an unevidenced and erroneous dominant mode of transmission – droplets. This error is in effect a biblical scale healthcare ‘Never Event’. And never, has there been such an error supported and sustained by people who are charged with the safety of others. Indeed, the denial of the pandemic mode of transmission errors is itself of pandemic proportions.
One of the key players is the World Health Organization (WHO) which now appears to be progressing through a Kubler Ross grieving process. At first the WHO denied airborne transmission happened, it got defensive at aerosol scientists who told them it did, and here we are at bargaining. The WHO’s bargaining proposal involves new definitions of airborne, accepting short-range aerosol transmission, combining it with old splashed on droplets – but without changing any requirements for personal protective equipment (PPE). Presumably, with this bargaining proposal, the WHO is looking to return itself to the reputable institution everyone needs it to be.
My assessment of their bargaining proposal is this – its unevidenced. For all those who shouted there is no evidence for airborne transmission when the pandemic broke, I am shouting back – there is no evidence for old droplets (new direct deposition); well, certainly not from the WHO. The standard of academic behaviour expected of everyone completing a Bachelor’s, Master’s, Doctorate, or an institution making recommendations for safe practice is the same – when you make a claim you must use supporting evidence – this includes the WHO.
Four years into the pandemic, the World Health Organisation have proposed new definitions for airborne transmission. The term proposed is ‘through the air’ and not the obvious ‘airborne’ transmission. The new WHO definition proposal is that through the air transmission results in infection via inhalation at any distance from a source, and direct deposition (semi-ballistic trajectory [on exhalation] entering to infect after landing on mucous membranes), i.e., sprayed on. This deposition only happens close to a source. There is much to welcome in this proposal, including the upfront acknowledgement of inhalation at short range. However, there is no change to PPE. So, to summarise the proposal (WHO bargaining position):
Before this proposal: Its spread by droplets unless aerosol generating procedures (AGPs), so you don’t need respiratory protection unless attending AGPs.
With this proposal: Its spread by aerosols and droplets regardless of AGPs and you still don’t need respiratory protection.
The WHO stated that it did not consider a change to PPE during this process. However, since evidence is presented for both through the air via inhalation, and through the air via ballistic trajectory then droplet deposition, there must have been some evidence searching (or perhaps, it was just a what-was-on-my-desk-selection). There also should have been some evaluation of where the evidence is strongest (inhalation or direct deposition). Notable by its absence in this World Health Organisation document is mention of AGPs. Its disappearance is without comment.
The how we got to this point of needing a change in nomenclature is mis-remembered by the WHO. In the report they claim the terms ‘airborne’ and ‘airborne transmission’ and ‘aerosol transmission’ were used differently by different scientists, and this caused confusion about how pathogens are transmitted (p2). This was not the case. The aerosol scientists provided the evidence for airborne transmission and the WHO ignored it – both the evidence and the scientists. On the 6th of July 2020, 239 scientists signed a letter asserting that SARS-CoV-2 was spread via short and medium range aerosols. COVID was airborne. Additionally, the WHO’s statements on transmission of COVID (March 2020, July 2020) confirmed transmission was predominantly by droplets and close contact, [the WHO admitted that transmission by aerosols at short-range could not be ruled out in July 2020]. To evidence their statements’ definitions the WHO cited their pandemic planning document of 2014, which contained no evidence for the definitions used and included the line, the ‘implications for IPC measures are not yet clear’ (pxvii).
On the 22nd December 2021, the WHO recommended HCWs use FFP2 or FFP3 masks. The next day, 23rd December 2021, the WHO finally acknowledged COVID was airborne. Of note, national guidance which had ‘followed the WHO’ up to this point did not change because WHO’s evidence was ‘limited’. Something of an anomaly here as the WHO had zero evidence for their definitions and just above zero for transmission being by droplets – which guidance writers had considered to be ‘evidence’.
The WHO may wish to present history as their continuous endeavours to reach a collective evidenced reasoning between professionals. However, having initially failed to defer to experts (a high-reliability characteristic), they rationalised the need for new definitions by blaming scientists for causing confusion – which is clearly unacceptable.
However, a more in-depth analysis of the World Health Organization’s evidence is needed. Join me in the 2nd part of this blog… Where I still have no regerts, to be published on Monday 10th June.
Dr. Evonne T Curran NursD. Rtd RN
*IPC Safe Guidance is evidenced-based and when followed minimises the risk of nosocomial transmission and infection.
IPC Safe Practice is achieved when IPC Safe Guidance is followed.
IPC Safe Environments are present when the environments enable safe practice.