Letters to the Infection Prevention and Control Team

Dear Infection Prevention and Control Team,

I’m writing to you today as I have some concerns about the recent changes to mask policies within the trust. However, please know that part of the reason I am spending the time to contact you is because I have hope that you will truly listen; the prevalence of HEPA filters and ventilation systems within the hospital means I trust that you understand the airborne nature of the current pandemic. This is an improvement upon many other NHS Trusts, though I still believe that current policies make the hospital unsafe. I believe that universal masking throughout the hospital would greatly improve the safety of everyone within it.

I am writing to you equally as a biochemist, a medical student, and a clinically vulnerable patient myself. I hope that you will take into consideration the following points when next reviewing the masking guidance within our hospitals.

The first point to make clear is that the Covid-19 pandemic is far from over and Covid-19 remains prevalent. It is important to realize that the official government testing figures are much lower than true values as testing is no longer encouraged; testing is no longer free and there is no way for the public to report private test results. These official government numbers are therefore not robust evidence on which to base policy. However, measures from alternative sources indicate that the virus remains prevalent. Before the ONS Survey was paused at the end of March, it showed that 1 in 40 people were infected with Covid-19 in England, with an increase upon the previous week (1). Equally, the ongoing ZOE Covid-19 Study has shown a persistence of over 1 million active infections at any given time for more than one year (2).

In addition, although I appreciate that masks remain within some clinical areas, evidence shows that this is inadequate for prevention of infection. Research shows that most healthcare-acquired COVID-19 infections in staff may not be from directly caring for COVID-19 patients (3). This is likely partly due to the high prevalence of asymptomatic Covid-19 infections, which cannot be ignored (4). Moreover, it should go without saying that patients, including those especially vulnerable to Covid-19, walk through many shared areas of the hospital where masks are currently optional. Patients walk through corridors; wait in shared waiting rooms and visit hospital shops. They should be able to do all this safely. The virus cannot differentiate between clinical and non-clinical areas and ultimately the effects of patient infection remain the same.

Equally, leaving masking to personal choice means an increased risk even for patients who choose to mask. This places an unfair burden on patients who wish to seek healthcare. Research shows that if rooms are poorly ventilated, as is often the case in the outpatient department for example, infectious Covid-19 particles can remain in the air even after the unmasked infected person has left (5,6). This means that even if the next patient chooses to mask, they are still at an increased risk of infection compared to if the previous occupier had also masked. Additionally, studies show that one-way masking is far less effective than two-way masking (7). This means that patients remain at high risk of infection even if they try to protect themselves. It should also be made clear that patients being able to ask their healthcare provider to mask is not acceptable. The onus of safety in healthcare should not be placed on the patient, and in many cases, patients do not feel comfortable requesting this. Personally, even with my medical background, I still struggle to find the confidence to ask for this as a patient.

Furthermore, other protective measures are inadequate to prevent spread of Covid-19. As Covid-19 is airborne, hand sanitisers, plastic screens, and social distancing do not provide adequate protection from the virus (6, 8, 9, 10). Also, guidelines that require staff to stay home when unwell are ineffective. One study showed that despite healthcare workers being asked to remain at home when unwell, nearly half went into work with symptomatic Covid-19 infections (11). I myself can attest that I have seen many symptomatic members of staff at the hospital, usually without masks on.

It is evident that the measures currently in place to prevent Covid-19 infection within healthcare are lacking throughout the country. Recent data shows that around 30% of patients in hospital with Covid-19 acquired it within the hospital when staying for other reasons (12). This is unacceptable and directly contradicts the core NHS value of commitment to safe and effective care. We also know that at least 14,000 patients have already died from hospital-acquired Covid-19, though the true number is likely much higher as less than half of trusts responded to this freedom of information request (13).

The effect of inadequate Covid-19 policies on patients is huge. Firstly, removing protections means that vulnerable patients are less likely to seek healthcare. Surveys by the group Clinically Vulnerable Families have found that 91% of clinically vulnerable people have or would delay/cancel medical appointments due to high COVID-19 risks caused by lack of mask mandates, lack of testing and high community levels (14). Equally, 54% of respondents had already delayed/cancelled appointments due to high COVID-19 risks (15). This is something I can personally identify with, as I try to minimise the time I spend in areas of the hospital without mask mandates when on placement and as a patient I have declined an operation (within a different trust) due to their poor Covid-19 infection control measures.

Moreover, the mortality rate for patients with hospital-acquired Covid-19 is substantially higher than for community-acquired infection. A systematic review found that patients infected with Covid-19 whilst in hospital are at a 30% greater risk of death compared to patients hospitalised with community-acquired Covid-19 (16). Also, a recent study in a London teaching hospital found that mortality rate of hospital-acquired Covid-19 was 13% (9% direct cause, 4% contributing factor; 17). Clearly, the human cost of this should be reason enough to establish substantial mitigation measures, but it should also be said that this results in longer hospital stays and thus an increased cost to the trust.

In addition, it is important not to rely solely on vaccines or previous infection to ensure that no serious harm comes to patients. This, of course, would never be the policy for control of other infectious diseases such as measles or polio. Also, what is clear is that vaccine efficacy is waning and is suboptimal against newer variants of Covid-19. A recent preprint suggests that the bivalent Covid-19 vaccine is unable to provide protection against infection for newer XBB variants (18). Additionally, a BMJ article shows that effectiveness of mRNA vaccines against moderate/severe Covid-19 wanes substantially within 4-5 months (19). However, currently only a small percentage of the population are eligible for booster doses, with even fewer electing to have them. Similarly, studies show that immunity from prior infection also wanes rapidly (20). We also know that vaccines provide little protection against Long Covid, which already affects nearly two million people in the UK (21, 22).

However, it is not just patients who are harmed by inadequate Covid-19 mitigation. Studies show that universal masking limits healthcare worker absences, and conversely that frequent Covid-19 infections increase burdens on the workforce by increasing staff absences (23, 24). In addition, two million days were lost to healthcare staff absence during just the first 18 months of the pandemic and staff absent with Long Covid are away for more than 80 days on average (25). It is no secret that short-staffing and worker retention is already an issue within the NHS, so why not implement policies proven to help with this problem?

Finally, if Covid-19 infection control is not enough to instigate universal masking, then effects on other diseases should be considered. Mask wearing has the ability to interrupt transmission of many pathogens with outbreak potential such as Influenza, RSV, Varicella Zoster Virus, Adenovirus, Mumps, Monkeypox, Group A Strep and more (26). All of these pathogens could cause serious morbidity to patients, both those on wards and those required to visit outpatients and A&E.

I believe it is worth remembering that changes to the standards of PPE in healthcare are frequent as we learn more about infectious disease. These changes are often met with some resistance, but ultimately following the science is the right choice for our patients. After Semmelweis proved that handwashing reduced mortality in childbirth, this measure remained controversial and for a time the Vienna hospital where he had worked abandoned mandatory handwashing (27). Similarly, prior to the AIDS pandemic in the early 1980’s, gloves were not commonly worn to prevent contact with infectious body fluids. When first introduced the healthcare community were sceptical and offered some resistance, but nowadays they are simply a part of universal precautions that we don’t think twice about (26). I’m sure that as an Infection Prevention and Control team, you would never consider making handwashing or gloves optional even if maternal morbidity or blood-borne illnesses decreased. In the same way, masks should form a part of standard infection control precautions.

I hope that this letter makes clear my concerns about the current reduction in masking policies throughout the trust. Many thanks for your time in reading this, and your consideration.

Yours faithfully,

Charlie Dennis

Sources

1. ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19/latestinsights
2. health-study.joinzoe.com/data#levels-over-time
3. Seidelman et al., 2020. Universal masking is an effective strategy to flatten the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) healthcare worker epidemiologic curve. Infection Control & Hospital Epidemiology, 41(12), pp.1466-1467
4. Kimball et al., 2020. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. MMWR. Morbidity and Mortality Weekly Report, 69(13), pp.377-381
5. Fiorillo et al., 2020. COVID-19 Surface Persistence: A Recent Data Summary and Its Importance for Medical and Dental Settings. International Journal of Environmental Research and Public Health, 17(9), p.3132
6. Lewis, D., 2021. Why indoor spaces are still prime COVID hotspots. Nature, 592(7852), pp.22-25
7. Bagheri et al., 2021. An upper bound on one-to-one exposure to infectious human respiratory particles. Proceedings of the National Academy of Sciences, 118(49)
8. Zhang et al., 2020. Identifying airborne transmission as the dominant route for the spread of COVID-19. Proceedings of the National Academy of Sciences, 117(26), pp.14857-14863
9. Wang et al., 2021. How effective is a mask in preventing COVID‐19 infection?. MEDICAL DEVICES & SENSORS, 4(1)
10. Greenhalgh et al., 2021. Rapid evidence review to inform safe return to campus in the context of coronavirus disease 2019 (COVID-19). Wellcome Open Research, 6, p.282
11. Linsenmeyer, K. et al. (2023) “Sickness presenteeism in healthcare workers during the coronavirus disease 2019 (covid-19) pandemic: An observational cohort study,” Infection Control & Hospital Epidemiology, pp. 1–4. Available at: https://doi.org/10.1017/ice.2023.47
12. england.nhs.uk/statistics/statistical-work-areas/covid-19-hospital-activity/
13. mirror.co.uk/news/uk-news/we-need-better-over-14000-28046576
14. Clinically Vulnerable Families [@cv_cev]. Available at: https://twitter.com/cv_cev/status/1618194848703737858
15. Clinically Vulnerable Families [@cv_cev]. Available at:  https://twitter.com/cv_cev/status/1541882988320915457
16. Ponsford MJ, Ward TJ, Stoneham SM, Dallimore CM, Sham D, Osman K, et al. A systematic review and meta-analysis of inpatient mortality associated with nosocomial and community COVID-19 exposes the vulnerability of immunosuppressed adults. Frontiers in Immunology. 2021;12. 
17. Hawkins LPA, Pallett SJC, Mazzella A, Anton-Vazquez V, Rosas L, Jawad SM, et al. Transmission Dynamics and associated mortality of nosocomial COVID-19 throughout 2021: A retrospective study at a large teaching hospital in London. Journal of Hospital Infection. 2023;133:62–9. 
18. Shrestha NK, Burke PC, Nowacki AS, Simon JF, Hagen A, Gordon SM. Effectiveness of the coronavirus disease 2019 (COVID-19) bivalent vaccine. 2022
19. Ferdinands JM, Rao S, Dixon BE, Mitchell PK, DeSilva MB, Irving SA, et al. Waning of vaccine effectiveness against moderate and severe COVID-19 among adults in the US from the Vision Network: Test Negative, case-control study. BMJ. 2022
20. Tan CY, Chiew CJ, Pang D, Lee VJ, Ong B, Lye DC, et al. Protective immunity of SARS-COV-2 infection and vaccines against medically attended symptomatic Omicron Ba.4, BA.5, and XBB Reinfections in Singapore: A national cohort study. The Lancet Infectious Diseases. 2023
21. Al-Aly Z, Bowe B, Xie Y. Long COVID after breakthrough SARS-COV-2 infection. Nature Medicine. 2022;28(7):1461–7.
22. Qasmieh SA, Robertson MKM, Teasdale CA, Kulkarni SG, Jones H, McNairy M, et al. The prevalence of SARS-COV-2 infection and long covid in US adults during the BA.5 Surge, June-July 2022. 2022
23. Temkin et al., 2021. Effect of a national policy of universal masking and uniform criteria for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) exposure on hospital staff infection and quarantine. Infection Control & Hospital Epidemiology, 43(6), pp.757-763
24. Khorasanee et al., 2021. The effects of COVID-19 on sickness of medical staff across departments: A single centre experience. Clinical Medicine, 21(2), pp.e150-e154
25. theguardian.com/society/2022/jan/24/long-covid-nearly-2m-days-lost-in-nhs-staff-absences-in-england
26. Kalu, I., Henderson, D., Weber, D., & Haessler, S. (2023). Back to the future: Redefining “universal precautions” to include masking for all patient encounters. Infection Control & Hospital Epidemiology, 1-2. doi:10.1017/ice.2023.2
27. nationalgeographic.co.uk/science-and-technology/2020/03/wash-your-hands-was-once-controversial-medical-advice

Dear Infection Prevention and Control Team,

Further to my last email, I feel it important to inform you that I recently tested positive for Covid-19 after successfully avoiding it for over 3 years. Given I had only been in two places for the last two weeks, BNHH and RHCH, I can only conclude that I caught it at a hospital within your trust despite wearing my fit tested FFP3 mask. This is yet more evidence to me that one-way masking will never be enough to protect patients and staff.

I have also learnt this week that the policy for returning to the hospital is a ‘minimum 5 days off and no need to test to return’. In truth, this horrifies me. I can find no robust evidence that the vast majority of people are no longer infectious by day 5, in fact all evidence points to the contrary. Studies show that between 17-80% of people continue to test positive on LFT by day 5, with higher powered studies indicating it is closer to 80% (1,2) To be allowing staff who are likely infectious back to work in a place without universal masking goes against the basic principles of infection control and prevention. Personally, I tested positive for 13 days, meaning I could have been working with patients without a mask for 8 days, whilst still likely infectious, according to current policy.

Additionally, it is notable that this policy also increases the risk of long-term symptoms in staff. Rest is known to reduce Long Covid risk, so encouraging staff back to work when they are still early in their acute phase could prove detrimental to their long-term health (3).

This Covid-19 infection means that I am now at substantially higher risk of brain damage, heart problems, blood clots, immune issues, further autoimmune diseases, cancer, Parkinson’s disease, and Alzheimer’s disease (4-13). There is no telling what other risks it may present decades from now. I must also now wait to find out if it has worsened my current illnesses, including a genetic disorder (Ehlers Danlos Syndrome) and autonomic dysfunction, which were previously well-managed. Emerging evidence suggests this is likely (14, 15, 16). If I am disabled further this could make completion of my medicine degree very difficult. This Covid-19 infection may also prematurely end my life, as is shown by ongoing excess deaths and increased rates of heart attacks and strokes in young people (17- 20).

To know that the situation I am in could have been prevented, with universal masks and two negative tests for returning staff, breaks my heart. Such simple measures that aren’t being taken may now have put me on a course for a very different life, and yet there is nothing stopping it from happening again. What happened to ‘first, do no harm’?

I acknowledge that current government guidance states that universal masking and LFT tests to return to work are no longer mandatory. However, it is also evident that these guidelines are unsupported by evidence. Given that these guidelines are not statutory, I implore you to please consider an evidence-based approach to airborne infection control.

Additionally, regardless of current guidelines, current policy could leave the trust open to negligence claims. Regulations 12 and 17 of the Health and Social Care Act 2008 state that healthcare providers should do “all that is reasonably practicable to mitigate risks”; “preventing, detecting and controlling the spread of infections” and “mitigate the risks relating to the health, safety and welfare of service users” (21, 22). Furthermore, Section 2 of the Health and Safety at Work Act 1974 states that “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” (23). Given that both universal masking and LFT testing to return to work have previously been part of policy, it is evident that these measures can be considered reasonably practicable.

To conclude, I am extremely concerned by the trust’s lack of airborne infection control policies, which are likely to have contributed to my infection with SARS-COV2, at one of the trust’s hospitals. This happened despite me wearing a high standard of PPE- a fit tested FFP3 mask and glasses. I am asking you to strongly consider reintroducing universal masking and negative LFT testing to return for staff, in order to both ensure the safety of the hospitals and avoid negligence claims.

I look forward to receiving your response.

Yours faithfully,

Charlie Dennis

1. Bouton TC, Atarere J, Turcinovic J, Seitz S, Sher-Jan C, Gilbert M, et al. Viral Dynamics of Omicron and delta severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) variants with implications for timing of release from isolation: A longitudinal cohort study. Clinical Infectious Diseases. 2022 Aug 2;76(3). doi:10.1093/cid/ciac510
2. Marquez C, Kerkhoff AD, Schrom J, Rojas S, Black D, Mitchell A, et al. Covid-19 symptoms and duration of rapid antigen test positivity at a community testing and surveillance site during pre-delta, Delta, and Omicron Ba.1 Periods. JAMA Network Open. 2022 Oct 10;5(10). doi:10.1001/jamanetworkopen.2022.35844
3. Davis HE, McCorkell L, Vogel JM, Topol EJ. Long covid: Major findings, mechanisms and recommendations. Nature Reviews Microbiology. 2023 Jul 13;21(3):133–46. doi:10.1038/s41579-022-00846-2
4. Douaud G, Lee S, Alfaro-Almagro F, Arthofer C, Wang C, McCarthy P, et al. SARS-COV-2 is associated with changes in brain structure in UK Biobank. Nature. 2022 7;604(7907):697–707. doi:10.1038/s41586-022-04569-5
5. Crunfli F, Carregari VC, Veras FP, Silva LS, Nogueira MH, Antunes AS, et al. Morphological, cellular, and molecular basis of brain infection in COVID-19 patients. Proceedings of the National Academy of Sciences. 2022;119(35). doi:10.1073/pnas.2200960119
6. Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nature Medicine. 2022;28(3):583–90. doi:10.1038/s41591-022-01689-3
7. Knight R, Walker V, Ip S, Cooper JA, Bolton T, Keene S, et al. Association of covid-19 with major arterial and venous thrombotic diseases: A population-wide cohort study of 48 million adults in England and Wales. Circulation. 2022;146(12):892–906. doi:10.1161/circulationaha.122.060785
8. Loretelli C, Abdelsalam A, D’Addio F, Ben Nasr M, Assi E, Usuelli V, et al. PD-1 blockade counteracts post–COVID-19 immune abnormalities and stimulates the anti–SARS-COV-2 immune response. JCI Insight. 2021;6(24). doi:10.1172/jci.insight.146701
9. Phetsouphanh C, Darley DR, Wilson DB, Howe A, Munier CM, Patel SK, et al. Immunological dysfunction persists for 8 months following initial mild-to-moderate SARS-COV-2 infection. Nature Immunology. 2022;23(2):210–6. doi:10.1038/s41590-021-01113-x
10. Sharma C, Bayry J. High risk of autoimmune diseases after COVID-19. Nature Reviews Rheumatology. 2023; doi:10.1038/s41584-023-00964-y
11. Li J, Bai H, Qiao H, Du C, Yao P, Zhang Y, et al. Causal effects of COVID‐19 on cancer risk: A Mendelian randomization study. Journal of Medical Virology. 2023;95(4). doi:10.1002/jmv.28722
12. Zarifkar P, Peinkhofer C, Benros ME, Kondziella D. Frequency of neurological diseases after COVID-19, influenza A/B and bacterial pneumonia. Frontiers in Neurology. 2022;13. doi:10.3389/fneur.2022.904796
13. Taquet M, Sillett R, Zhu L, Mendel J, Camplisson I, Dercon Q, et al. Neurological and psychiatric risk trajectories after SARS-COV-2 infection: An analysis of 2-year retrospective cohort studies including 1 284 437 patients. The Lancet Psychiatry. 2022;9(10):815–27. doi:10.1016/s2215-0366(22)00260-7
14. Turner S, Khan MA, Putrino D, Woodcock A, Kell DB, Pretorius E. Long covid: Pathophysiological factors and abnormalities of coagulation. Trends in Endocrinology & Metabolism. 2023 Apr 18;34(6):321–44. doi:10.1016/j.tem.2023.03.002
15. Shouman K, Vanichkachorn G, Cheshire WP, Suarez MD, Shelly S, Lamotte GJ, et al. Autonomic dysfunction following COVID-19 infection: An early experience. Clinical Autonomic Research. 2021;31(3):385–94. doi:10.1007/s10286-021-00803-8
16. Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re’em Y, et al. Characterizing long covid in an international cohort: 7 months of symptoms and their impact. eClinicalMedicine. 2021;38:101019. doi:10.1016/j.eclinm.2021.101019
17. Caul S. Deaths registered weekly in England and Wales, provisional: Week ending 5 may 2023 [Internet]. Office for National Statistics; 2023 [cited 2023 May 18]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredweeklyinenglandandwalesprovisional/weekending5may2023
18. He X, Lv F, Zhang Y, Zu J, Li M, Jiao Y, et al. Excess risk for acute myocardial infarction mortality during the COVID‐19 pandemic. Journal of Medical Virology. 2022;95(1). doi:10.1002/jmv.28187
19. Eujung Cha A. Young and middle-aged people, barely sick with covid-19, are dying of strokes [Internet]. WP Company; 2020 [cited 2023 May 18]. Available from: https://www.washingtonpost.com/health/2020/04/24/strokes-coronavirus-young-patients/
20. Tu TM, Seet CY, Koh JS, Tham CH, Chiew HJ, De Leon JA, et al. Acute ischemic stroke during the convalescent phase of asymptomatic COVID-2019 infection in men. JAMA Network Open. 2021;4(4). doi:10.1001/jamanetworkopen.2021.7498
21. Regulation 12: Safe care and treatment [Internet]. 2023 [cited 2023 May 20]. Available from: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-12-safe-care-treatment
22. Regulation 17: Good governance [Internet]. 2022 [cited 2023 May 20]. Available from: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-17-good-governance
23. Health and safety at work etc.. act 1974 – legislation.gov.uk [Internet]. 2023 [cited 2023 May 20]. Available from: https://www.legislation.gov.uk/ukpga/1974/37/data.pdf

Dear Infection Prevention and Control Team,

Thank you very much for taking the time to respond to my emails. However, I’m afraid they have done very little to convince me that your new policies do not cause direct harm to patients, visitors, and staff. I also apologise for the delay in writing back to you; despite it being nearly 8 weeks since I was infected with Covid-19 at your hospital, I am still experiencing daily symptoms which make everyday life challenging. Once again, I must make clear that this outcome was preventable and as a result I am considering seeking legal counsel.

The overall impression I gained from your response is that you are rightly aware that we are still within an airborne pandemic yet the only ongoing measures you are prepared to implement within the hospital are ventilation and air filtration, which you acknowledge are limited. I struggle to understand how a team whose priority is infection prevention and control can be content to do so little in the face of a novel SARS virus circulating at high levels throughout the country. I also take issue with many of the justifications for your decision to respond in this way, as many are unsubstantiated claims or have simple solutions which don’t require exposing a vulnerable population to this dangerous virus.

“It is in the current context of a relatively stable (in genomic terms with no new variants of concern) & more predictable period of clinical severity of COVID-19, driven by greater population immunity & available treatments, that recent decisions have been made in relation to infection prevention & control measures.”

Firstly, you state that the virus is currently genomically stable. This untrue, as we consistently see more mutations and recombinations emerging worldwide with several variants of interest in circulation (1, 2). Recent evidence also shows that Omicron subvariants are evolving increased pathogenicity (3). Regardless, this is also a moot point; genomic stability does not correlate with disease severity and is clearly not a factor in consideration for mitigation of other diseases.

Secondly, even if Covid-19’s clinical severity is more predictable, this again does not mean that it is not severe. As previously mentioned, the mortality rate of hospital acquired Covid-19 is estimated to be around 13% (4), as well as resulting in poorer outcomes for patients admitted due to other conditions (5, 6, 7). Ultimately, Covid-19 remains the leading infectious cause of death within the UK, with current death rates around 300 confirmed per week, despite severely reduced testing (8, 9). As an IPC team I struggle to comprehend how you could justify not implementing all possible mitigations based on this fact alone.

The position you take also entirely overlooks the common and severe long-term effects of even mild Covid-19 infection, for which there is now an abundance of evidence. I could not possibly include all of it, but may I emphasize some of the key points. Covid-19 infection:

• results in ongoing symptoms in at least 10-20% of infections, which can be disabling (10, 11)
• increases risk of cardiovascular illness for at least a year following mild infection, resulting in increased blood clots, heart attacks, strokes and pulmonary embolisms (12, 13, 14)
• increases heart attack risk by 3-8x (15) – smoking comparably increases heart attack risk by 2-4x and [NHS Trust] chooses to be “completely smokefree” (16)
• leads to reduced global brain size and grey matter loss in 100% of patients with mild illness, compared with controls as shown by MRI (17)
• causes cognitive impairment and reduced IQ- including 2.2-3x more cognitive impairment in healthcare workers following infection, with potential implications for healthcare delivery (18, 19, 20)
• increases risk of many autoimmune diseases, with one study finding an overall increased risk of 43% (21, 22)
• increases risk of Alzheimer’s and Parkinson’s diseases and accelerates existing disease (23-28)
• is causing autonomic nervous system dysfunction in previously health individuals (29-32)
• causes reduced sperm count, decreased sperm motility and increased risk of erectile dysfunction (33-43)
• causes immune dysfunction, including reduction in T, B, NK and dendritic cells, for an as yet undetermined time post-infection (44-55)
• is associated with increased severity of RSV and Group A Strep infections both during Covid-19 infection and for at least the next year (56, 57, 58)
• induces genes associated with cancer formation and may be accelerating existing cancers (59-65)
• during pregnancy results in twice the risk of a neurodevelopmental diagnosis at 1 year, as well as reduced lung volume and potential intestinal inflammation in baby (66,67,68)
• during pregnancy causes an increased risk of miscarriage, pre-term and still birth as well as increased maternal morbidity and mortality (69-73)
• results in subclinical heart and lung damage in children who have seemingly recovered (74,75)
• results in increased risks of epilepsy, encephalitis and nerve disorders in children for at least 2 years after infection (24)

These are just some of the severe health impacts of Covid-19 infection. We also know that each reinfection results in an increased risk of long-term symptoms, hospitalisation, and death (76, 77, 78). The virus is so severe that a report by Canada’s chief science advisor referred to the ongoing pandemic as a mass disabling event (79). Without reducing transmission as far as possible, it is certain the ongoing impacts of Covid-19 will worsen the healthcare crisis. To read these impacts of Covid-19 infection and deem it not severe enough to reintroduce mitigation policies is to show a total lack of appreciation for the science.

It is also essential that we learn from the past. The most similar human coronavirus to SARS-COV2, SARS-COV, also resulted in severe long-term symptoms in many of those infected during the 2003 outbreak. Twenty years later, many remain unwell and unable to work (80, 81). This does not bode well for the population’s ability to recover from Long Covid.

It is also untrue that we have substantial available treatments. We have a few antivirals such as Paxlovid which may help to increase survival in some cases. However, these have unpleasant side effects such as diarrhoea, vomiting and changes to taste and interact with many other drugs (82). Additionally, antivirals such as Paxlovid are likely to become ineffective with overuse, as the selection pressure causes the virus to develop resistance (83, 84, 85). In a similar way as for the sake of antibacterial stewardship, we do not say that bacterial infection is acceptable due to treatments, we cannot say the same about this virus. Additionally, for those who do leave hospital, ill-health is often ongoing with large proportions suffering from long-term sequelae meaning that the treatments that exist are far from a cure.

Moreover, your claim of greater population immunity is demonstrably false, as I addressed in my previous correspondence. Herd immunity with Covid-19 is not possible (86, 87). Vaccines provide some protection but effects wane rapidly, seen on a background of fewer and fewer people being offered boosters (88). They also provide very little protection from Long Covid (89, 90). Immunity from prior infection also wanes rapidly (91). Reinfections are common and with record of it happening in as little as 16 days (92, 93). All of this is bad enough, but I will again reiterate that we know these frequent reinfections increase risks of Long Covid, deaths and hospitalisations.

“[NHS Trust] has & continues to implement measures to identify & protect those who are clinically vulnerable and at highest risk from COVID-19 infection: through COVID-CV tagging, ongoing asymptomatic testing of this group and taking this into account on bed placement.”

Tagging clinically vulnerable (CV) patients does nothing to protect their health when there is no pathway triggered by this marker. I have seen doctors visit CV patients countless times and make no additional effort to mitigate their infection risk, even by pulling their mask up from under their chin. Additionally, asymptomatic testing of this population in no way protects them from infection, it merely alerts you if your IPC approach has already failed.

Furthermore, current policy works to counter the current NHS guidance for CV people. Current NHS guidance states that “if you are at increased risk of getting ill from Covid-19…wear a face covering when it’s hard to stay away from other people [and] think about asking people to wear a face covering or take a rapid lateral flow test if you’re meeting them inside.” (94) Evidently, it will not be possible for CV patients to ask everyone who is in close contact with them to wear a mask, including in waiting areas, corridors, lifts and examination rooms. Often the people around them are complete strangers, or staff members which leads to a power imbalance. There may also be situations where patients are physically incapable of advocating for their protection, such as arriving incapacitated in A&E or due to long-term communication difficulties. For a hospital to not be aiding these patients to maintain their health, and instead be placing them in an impossible position against the advice of the NHS, is absurd.

In addition, not all conditions shown to put patients at higher risk from Covid-19 infection are included on the official CV list. This means that your targeted protection policies will inevitably fall short of protecting the most vulnerable patients. For example, research suggests that patients with obstructive sleep apnoea, Sjogren’s syndrome, Ehlers Danlos Syndrome, Marfan Syndrome and Mast Cell Activation are at higher risk of acute and/or chronic complications (95-101). However, currently these conditions do not constitute official clinical vulnerability. Pregnant women are also at higher risk of adverse outcomes as previously mentioned. There will also be a substantial number of patients who will have conditions that make them CV yet be unaware, having come to the hospital for investigations and diagnosis.

Additionally, many groups of people are at higher risk of adverse outcomes and long-term symptoms, for example women, working class people, ethnic minorities and LGBT people (102-107). Given that you cannot possibly tag the files of these groups as such, this is further evidence that targeting protection to those most vulnerable will always fail. Furthermore, as women, ethnic minorities and LGBT people are protected groups who will be adversely and disproportionately affected by your new lack of Covid-19 policies, this breaches public sector equality duties outlined within the Equality Act (2010) (108).

Your protection of the CV also shows other holes, one of which I have myself fallen through. It only considers the protection of CV patients, as opposed to all people within the hospital such as staff, students and visitors. You have no way of knowing who is at highest risk. Not only is this clearly resulting in preventable infections, it puts people in impossible positions. For example, deciding to visit their dying relative and risk exposure to Covid-19 or never getting to say goodbye since they’re not the patient and therefore not afforded further protection. Additionally, I myself feel I am in an impossible position as I must choose between further risking my health to continue my training or giving up on my ambition to be a doctor.

Finally on this topic, your claim that you are protecting the CV appears to admit by omission that you are failing to protect the majority of patients as fully as possible. I question why it should be up to you to decide who is protected? It feels as though you are acting as judge, jury and executioner and I’m sure many patients and visitors would take issue with this if they were fully informed. You cannot possibly know who can afford in any way to become unwell, whether that illness is ultimately severe or not. People may be self-employed, have used all their sick days, already have post-viral illness, be a primary carer or have a premature baby. These people can avoid many public indoor spaces to reduce their risk, but hospital visits cannot be postponed indefinitely. As previously stated, the law and the NHS values require you to protect all people who use and work in the hospital from infection, to mitigate their risks and provide safety (109-112).

“PPE usage, whilst an important IPC intervention, sits below other interventions according to the hierarchy of controls for prevention of transmission of infections.”

PPE usage may not be first line, but is clearly still a necessary whilst frequent community spread persists. A recent study in hospitals indicates that for R₀ to remain below 1 with no masks, CO₂ concentration must remain below 620ppm in outpatient settings and below 540ppm in inpatient settings. If you cannot guarantee this is the case, then your policy is actively promoting increased transmission of Covid-19. Of course, a higher CO₂ concentration is permitted for R₀<1 when surgical masks are worn. In outpatient settings it must be below 1000ppm and in inpatient settings below 770ppm. N95 masks permit even greater concentrations (113).

“Universal masking for respiratory viral infection, which was not widely practiced or recommended prior to COVID-19, is most effective when the majority of a given population comply. Throughout the pandemic there have been challenges in achieving this uniformly across our populations both inside and outside hospital. For inpatients, unwell patients have struggled to wear masks. Additionally, mask wearing runs the risk of compromising delivery of care for some (e.g. those needing oxygen treatment).”

It seems nonsensical to justify removal of masks by saying that it interferes with delivery of care. Patients with breathing difficulties, such as those using oxygen have always been exempt from mask wearing. If anything, it means that those around them should be taking more precautions, in order to avoid infecting them with a virus that would likely worsen their lungs. Additionally, the elevated Covid-19 risks of current policy are certainly also interfering with care as many are afraid to attend the hospital (114, 115).

Similarly, to say that poor compliance with mask wearing justifies the removal of masks is bizarre. Many patients do not wash their hands after using the toilet, but does this mean we should stop asking for hand hygiene from all staff, at a minimum? Not to mention that compliance could be improved by education on the reasons for mask mandates and their importance, especially given the distinct lack of this in wider public health. Studies show that providing regular reminders and a scientific basis for instructions leads to improved compliance with Covid-19 guidance (116, 117)

“We recognise, in line with IPC professionals elsewhere, that inappropriate, or incorrect usage of PPE conversely carries risk of increasing transmission of other infections with associated harm.”

There is a lack of substantial evidence to support this claim. Most studies have found a reduction in hospital-acquired infections since the pandemic began, and the few reporting an increase in incidence do not attribute this to PPE usage (118-121). In fact, much of the evidence indicates that incidence of hospital-acquired infections only seems to be increased in patients already infected with Covid-19, likely due to virus’ impacts on the immune system (122, 123). All of this serves to support continued efforts to minimise Covid-19 transmission as far as possible.

It can also be argued that if masks are a serious issue for infection control, they should not be used in surgery which is one of the most critical areas for infection prevention. Evidently, this is not the case.

Furthermore, if mask wearing did result in any minor increases in other infections, mitigation of Covid-19 should surely still take precent due to its high prevalence and remaining the leading infectious cause of death. To prioritise the control of other infectious agents would be illogical.

“We have observed very good efficacy and low acquisition of COVID-19 infection in staff delivering care wearing appropriate, fit-tested respiratory protective equipment even at the height of the pandemic during waves 1 & 2 when the risk of exposure from infected patients on aerosol generating procedures was high.”

Your reiteration of the trusts’ previous successes with regards to adequate Covid-19 mitigation only serves to disappoint me further that you have now chosen to remove the measures which made it possible. Low levels of staff sickness during earlier waves of Covid-19 can no doubt be attributed to universal masking, longer isolation periods, testing to return, PCR test availability and improved isolation of Covid-19 patients. In essence, the trust’s previous successes came from following the science.

Between then and now, the science has not changed, if anything it has further confirmed that we should do everything in our power to stop transmission of this virus. What has changed is the media and governments support of the science, or lack thereof, as is becoming clear through the ongoing Covid Inquiry (124, 125, 126). Now in 2023, what is right and what is easy are not the same, but with current hospital policies it seems you are choosing what is easy.

It should also be said the aerosol generating capability of newer Covid-19 variants is higher, thus resulting in higher risks with aerosol generating procedures than existed during the first and second waves (127).

“We have also considered the challenges & adverse impact posed by universal mask wearing, particularly in communication with children and those with cognitive impairment, mental health conditions and those with communication difficulties (e.g. hearing loss).”

It is true that mask wearing can present some challenges to certain populations. However, these can be easily resolved by use of masks with transparent windows, which are widely available and already used in some NHS trusts (128, 129). In fact, the National Deaf Children’s Society state that they have previously written to all NHS trusts in England to purchase a supply of these masks so that they are available for deaf staff and patients (130). Consequently, these challenges do not justify exposing a vulnerable population to the Covid-19 virus by mask mandate removal.

“The most appropriate & valuable use of finite NHS resources to optimise clinical care for all patients, together with sustainability have also been always considered in our approaches”

This point is very short sighted. Allowing recurrent infections amongst staff and patients will lead to longer patient stays, more complex illnesses, and greater staff sickness, all of which will cost the trust more (131-135). Enabling a mass disabling event will never result in a positive outcome for the already struggling health service.

Additionally, to be asking you to consider implementing universal masking with surgical masks is already a compromise with consideration of NHS resources. FFP2/3 masks would provide superior protection against Covid-19 given its airborne nature, but they are more expensive (113). Alternatively, you could consider providing reusable respirators for all staff as this would provide both better protection and a cheaper cost long-term (136).

“It is in the current context of severity of COVID-19 above, in line with national guidance, and in consultation with neighbouring regional NHS Trust & Integrated Care Board (ICB) NHS IPC professionals, that we have taken decisions on our measures at each stage.

In relation to IPC we are aligning our approach in standard infection control precautions & transmission based precautions, including for use of PPE with the principles outlined in the National Infection Prevention & Control Manual for England”

As discussed in previous correspondence, if the guidance states that universal masking and negative testing policies are not required during this airborne pandemic, then the guidance does not reflect the current science. To be justifying policy by citing guidance which does not reflect evidence does not instil confidence. Additionally, the assertion that you are simply doing the same as neighbouring NHS trusts only serves to reflect a serious inflexibility in your practice. This contradicts the core NHS value of always striving to improve patient care (112).

Furthermore, your insistence on following guidance is at odds with those provided by the World Health Organisation. Though not perfect, the WHO is not currently facing an inquiry into its handling of the pandemic unlike the UK government. The WHO states that to avoid being infected with Covid-19, people should “Wear a properly fitted mask when physical distancing is not possible and in poorly ventilated settings” (137). By your own admission, ventilation in the trust’s hospitals is limited. Additionally, physically distancing is of course not possible when examining patients and providing treatments and personal care. The WHO also states that people should “stay home and self-isolate for 10 days from symptom onset, plus three days after symptoms cease. If you need to leave your house or have someone near you, wear a properly fitted mask to avoid infecting others” (137). This differs substantially from the hospital policy of only 5 days isolation, followed by immediate return to work where masks are not worn, if well enough. The WHO also recommends people protect themselves from Long Covid, by “protecting yourself and others from COVID-19 infection in the first place” (138). This guidance from the WHO aligns with the current evidence.

Further points for your consideration

Unfortunately, a large majority of the general population remain naïve to the full risks of Covid-19 infection due to ongoing inadequate public health messaging. I met a frail 90-year-old patient recently who informed me she hadn’t heard about Covid-19 in years and asked me if it is still around. She had no idea that she still needed to protect herself. However, if most people were fully informed about the ongoing spread, the probability of hospital-acquired infection, mortality rates and common post-acute sequelae, do you believe the public would agree with your current policies? Do you truly think that most would provide informed consent on the exposure of themselves or their unwell relatives to Covid-19?

Currently, the policies of your trust create the impression that Covid-19 is no longer a threat and that the pandemic is behind us. It is likely many will rely on this policy-change as confirmation that they are safe, including if CV. You yourselves admit that this is not true. Does this implicit misinformation not contradict your duty of candour to patients and staff?

Ultimately, there is very little to lose through continuing with universal masking and negative tests for returning. If Covid-19 truly isn’t a problem, then resources will still have been used to prevent outbreaks of all infections with an airborne component, as well as improving the wellbeing of vulnerable patients currently too afraid to access healthcare. Conversely, there is much to lose through removal of these policies. Even if you still do not consider it severe, this is a novel SARS virus that will undoubtedly have impacts on health decades on from infection. By removing universal masking and testing, you are risking the current and future health of patients who come to the trust’s hospitals for help in their time of need. Without adequate attempts to prevent Covid-19 infection, the trust becomes responsible for significant morbidity and mortality, as well as destruction of community confidence in the healthcare system. To me, this does not appear to be a difficult decision.

Conclusion

In conclusion, it seems that you are aware of the ongoing pandemic and high levels of transmission but are choosing to no longer do all that is reasonably practicable to prevent spread for reasons which are dubious at best. Neither the Health and Social Care Act nor the Health and Safety at Work Act stipulate that protection from infection within the hospital is dependent on the severity, mutation risk or population immunity of that infection. Furthermore, the current policies have an unequal impact on the population, whereby those from minority communities will be more severely impacted by their outcomes. The tools are available to mitigate the spread of Covid-19 throughout the hospital, the place where the sickest people have no choice but to visit, and you are choosing not to use them. This means that I do not believe your hospitals are safe and I implore you to reconsider.

Many thanks in advance for reading, once again.

Yours faithfully,

Charlie Dennis

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