“If you don’t tell people the truth about COVID, how can you expect people to make good judgements about risk.”  Kernow Jones

This week’s blog is by Dr Evonne T Curran (@EvonneTCurran).

For me this pandemic is a simple ‘consequent argument’ (if P then Q), i.e., if airborne transmission is evident, then recommend airborne precautions. The challenge is that this argument is not universally accepted even though airborne transmission is considered the main route in this UK government document on ventilation.  However, the importance of this argument has begun to seem moot in the eyes of many, as precautions have been lifted, personal experience of COVID, is ‘it’s not that bad’, and the government’s position of ‘let it rip’ has not killed anyone they know (yet). So, this blog must show that the ‘consequent’ argument’ is still worth fighting for. Which brings us to the above quote – what is the ‘current truth’ about COVID?

The current truth / reality

In every outbreak the truth or reality of the situation is revealed iteratively like the fitting together of jigsaw pieces. But there is no reference picture and the number of jigsaw pieces to be fitted is unknown.  Additionally, as new information comes to light the reality itself changes – some bits that fitted together well become ill-fitting.

Look at this HIV/AIDS timeline. In 1981, a report appeared of 5 young gay men with Pneumocystis carinii pneumonia. Three years later, it was known there were other opportunistic infections involved as well as Kaposi’s sarcoma. Cases were then identified outside of Los Angeles and then outside the USA. Blood transfusions were a risk factor, perinatal transmission was recognised, and haemophilia patients identified as vulnerable. It wasn’t until September 1983 that transmission by casual contact, food, water, air, or environmental surfaces, was excluded. In 1984 transmission via needle-sharing was identified as a risk. Three years after the first report there remained many ‘unknown unknowns’ which took decades to be revealed. I am not comparing COVID-19 with HIV as a disease. I am illustrating through the timeline, how much of the ‘HIV jigsaw’ was still missing by the end of the third year. We are just 3-years in with our knowledge of SARS-CoV-2.

So where is the COVID-19 reality? The plan was that the lockdowns would buy sufficient time until the vaccines became widely available when we could all go back to normal. However, the reality illustrated in Box 1 below is that the current approach is not safe enough.

Box 1: The current covid reality

COVID-19 can result in immune dysregulation lasting for months (and possibly years).

Approximately 1.8 million people in the UK are suffering from severely debilitating Long Covid

COVID–19 is a vascular disease increasing the risks of many conditions including myocardial infarction.

The precise causes of Brain Fog are being determined – but it’s covid-related.

The more times you get COVID, the greater the risk of additional diseases and mortality.

The excess mortality in 2022 is insufficiently explained, but likely covid related.

Herd immunity has not materialised; there is no sign yet of a final wave.

COVID-19 is still placing a significant burden on the NHS, hospitals are full, and we should all take steps to avoid exposing ourselves to infections and risking the need for hospitalisation.

The greater the number of community infections, the greater the burden on the NHS and its staff.

Nosocomial transmission is obscenely high – sick people should not be exposed to SARS-CoV-2 in health and social care settings.
Box 1: The current covid reality

So, the reality is that the vaccines have done well – but not well enough. Therefore, until better vaccines are available, we must do more to reduce transmission. When control measures are insufficient to gain control, the standard approach is to undertake a reassessment, do more investigations, test more hypotheses, and add more control measures. This approach to reducing ill-health and the burden on the NHS appears to have ceased. What we have in place is a plan for repeated infection and repeated vaccination in the hope the sequalae will not be that bad; but, without any evidence this will be the case. The strategy is best described as an ‘as you were in 2019’. However, the data show more infection waves coming closer together. Further significant variants are possible. Realistically, three years in the SARS-CoV-2 timeline has yet to reveal its many ‘unknown unknowns’. It’s clear there needs to be ongoing reassessment and additional transmission suppressing measures.

Reducing community infections cannot be achieved without mitigations against indoor airborne infections. Based on our understanding of the disease thus far this can only be done by improving indoor air quality (IAQ) and indoor masking. As it is engineering controls that will suppress aerosol transmission, leadership in the control of this pandemic should now rest with the engineers and the aerosol scientists.

Adam Grant1 encourages us to find common ground and reject the usual role of preacher, prosecutor, or politician in trying to persuade people to agree with us. So, what common ground can we agree on? Firstly, we want to aim for zero nosocomial covid in all health and social care settings, and secondly, we all want to go back to a safe pre-pandemic life. For many debilitated or at risk this will not be possible. Without additional IAQ in our healthcare, social care and community settings (including transport), it’s difficult to see a safe pre-pandemic lifestyle ever permanently being achieved.

Clearly, the consequent argument remains valid. If airborne transmission is evident, then airborne precautions are necessary. Of note, Adam Grant advises never to reject an argument because you don’t like the consequences. The consequences of not making the decision for IAQ and airborne mitigations are likely to be more detrimental – the ‘as you were in 2019’ strategy appears too dangerous. The precautionary principle has yet to be applied in this pandemic – it is needed now.

Finally, to the opening quote from Kernow Jones:

If you don’t tell people the truth about COVID, how can you expect people to make good judgements about risk.”

So, the question for all of us is: are we aware of and accepting the current truth about COVID?

1 Adam Grant, Think Again. Penguin, Random House Publishing.

Author: Alison Twycross PhD RN

Chair - Supporting Healthcare Heroes UK; Editor-in-Chief - Evidence Based Nursing; Former Deputy Dean and Professor of Children’s Nursing

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