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Analysis Covid Inquiry

How covid-19 spreads: narratives, counter narratives, and social dramas

BMJ 2022; 378 doi: (Published 31 August 2022) Cite this as: BMJ 2022;378:e069940

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COVID-19 Pandemic, SARS-CoV-2 transmission and the unsettled narratives: Time to be guided by the correct science to inform appropriate precautionary interventions for the pandemic control

Dear Editor

The ‘COVID-19 Pandemic’ remains an ‘Unprecedented Ravaging 21st Century Scourge’ defying, for several reasons, ‘Pandemic Interventions’; recent ‘Communication’[1] is quite intriguing re: ‘Unsettled SARS-CoV-2 Transmission Narratives’ (‘Droplets-based Transmission’-‘Airborne/ Aerosols-based Transmission’). The ‘Airborne Transmission’ was recently revisited-highlighted in ‘Communications’[2-16] with critical discourse of current ‘COVID-19 Pandemic Control Interventions’.

This ‘Communication’[1] is very incisive in critically distilling the ‘Science’-‘Politics’-‘Ideology’ of ‘SARS-CoV-2 Transmission’-‘Public Health Control Interventions’. The ‘COVID-19 Pandemic Chameleonic Reality’[16,17] is compounded by the ‘Flip-flop SARS-CoV-2 Transmission Narratives’[1] Reportedly, ‘Pointers’ to ‘Flip-flop Narratives’ by several ‘Regulatory National/ World Authorities’ exist re: ‘Proclaimed SARS-CoV-2 Airborne Transmission’ but with ‘Preferred ‘Droplets Transmission’-guided Policy Pronouncements’ and related ‘Predominant Public Health Precautionary Measures’-consequent ‘Inappropriate Interventions’.

The WHO, for instance, reportedly declared at the outset (11/2/20) ‘SARS-CoV-2 Airborne Transmission’[18] but only with a volte-face to uphold ‘Droplets Transmission’ later (28/3/20)[19,20]; reportedly overlooked the ‘Airborne Transmission’ for over 2 years[21]. Also, UK Policy-makers focused on ‘Droplets Transmission’, ignored ‘Airborne Transmission’ and neglect of ‘Indoor Air Quality Interventions’[22]. Some members of the UK Scientific Advisory Group for Emergencies (SAGE) conjectured ‘Other Transmission Modes’ (18/2/20)[23]; therefore, ‘Airborne Transmission’ was ‘Posted’ (3/3/20) but later ‘Withdrawn’ (1/5/20): the ‘Flip-flop Transmission Narrative’[24].

The New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) (9/1/20) reportedly adopted ‘Airborne Transmission’ with ‘High Consequence Infectious Diseases’/ recommended ‘Filtering Face-piece Respirators (FFP3) or Equivalents for Healthcare Staff caring for Suspected/ Confirmed COVID-19 Cases’[25]. The WHO (22/12/21) subsequently accepted ‘Airborne Transmission’-‘Aerosols Scientists Prevention Strategies’ including use of ‘N95 Masks for Patient Care’[26].The Aerosols Scientists disagreed with the ‘Droplets Transmission’ and wrote formally to the WHO (July 2020)[27,28]. Again, the Government Advisory Committee on Dangerous Pathogens in early March 2020 proposed declassifying ‘COVID-19’ as ‘High Consequence Infectious Disease’[25]; why?

By not adopting the ‘Airborne Transmission Precautionary Interventions’-persistently implementing ‘Droplets Transmission-related Measures’, the UK reportedly may have experienced avoidable excess ‘COVID-19 Deaths’ including ‘Care Home Deaths’[29]. In contrast, Countries (e.g. Japan[30] and Hong Kong[31]) that adopted the ‘Airborne Transmission’ early in the ‘COVID-19 Pandemic’ and related ‘Appropriate Air Quality and other relevant Interventions’ had much less ‘COVID-19 Deaths’. CNN Broadcast today (15/9/22; about 1930Hrs WAT) highlighting a ‘Lancet Commission on COVID-19 Report’-‘Commission Chairman Interview’ described ‘COVID-19 Death Toll (>18m Deaths)’ a ‘Massive Global Failure’.

It is pertinent to highlight the discordant ‘COVID-19 Pandemic Precautionary Interventions’ as they relate to ‘Droplets Transmission’-‘Airborne/ Aerosols Transmission’. For ‘Droplets Transmission’, the ‘Particle is large-travels short distance-drops to the ground/ surfaces’ with ‘Precautionary Measures’ viz: Respiratory Hygiene-Surface Fomites Disinfection-Reduced Direct Contact-Social Distancing (1-2m)-Face-mask-Physical Barriers/ Screens-Respiratory Grade Facial Protection for Healthcare Staff involved with ‘Aerosols-Generating Procedures (AGPs)’ etc[1,27,32]; ‘Self-Contamination Control’. For ‘Airborne Transmission’, the ‘Particle is small-travels a much longer distance-stays longer in the air’ with ‘Precautionary Measures’ viz: Engineering Indoor Spaces Controls-Reduced Crowding/ Time Indoors-Increased Social Distancing (>2m)-Face-masks Indoors-More ‘Filtration/ Tightly Fitting Masks’-Reduced AGPs (Singing-Speaking-Exercising etc)-Respiratory Grade Facial Protection for Staff caring for Patients etc[1,27,32]; ‘Masks and Air Quality Control’.

‘Airborne Transmission’ is facilitated by ‘Super-spreader Events’-‘Triad’: ‘Poor Ventilation-Overcrowding-Vocalizations’[33]. The WHO ‘Infection Prevention and Control Research and Development Expert Group for COVID-19’ canvassed a ‘Situationally Airborne Transmission Narrative’; a subtle volte-face[34]. With ‘Droplets Transmission’, ‘Government Libertarianism’ allowed ‘Freedom/ Choice with less Enforcement of Interventions’ with poor ‘COVID-19 Pandemic Control’; ‘Masks for only ‘Asymptomatic if Tolerated’’ but ‘Asymptomatic Transmission’ supports ‘Airborne Transmission’[23]. Also, Laboratory Studies-World Case Studies-Computer-generated Models-‘Aerosols Scientists’ reinforced the ‘Airborne Transmission Narrative’[27,35-38].

The ’Flip-flop SARS-CoV-2 Transmission Narratives’ highlight, once again, the vulnerability of ‘Science’ to ‘Politics’ as the more rational ‘Airborne Narrative’ is reportedly submerged by the ‘Droplets Narrative’ owing to ‘Non-Evidence-based Dispositions’. The ‘Science’ of the ‘COVID-19 Pandemic Specifics’ should be shielded from ‘Politics’[39-45].

1. Greenhalgh T, Ozbilgin M, Tomlinson D. How covid-19 spreads: narratives, counter-narratives and social dramas. BMJ 2022; 378:e069940
2. Morawska L, Milton DK. It is time to address airborne transmission of coronavirus disease 2019. Clin Infect Dis 2020; 71:2311-3
3. Dancer SJ. Airborne SARS-CoV-2. BMJ 2022; 377:o1408
4. Tang JW, Marr LC, Li Y, Dancer SJ. Covid-19 has redefined airborne transmission. BMJ 2021; 373:n913
5. Tang JW, Bahnfleth WP, Bluyssen PM et al. Dismantling myths on the airborne transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). J Hosp Infect 2021; 110:89-96
6. Wang CC, Prather KK, Sznitman J et al. Airborne transmission of respiratory viruses. Science 2021; 373:eabd9149. doi:10.1126/science.abd9149.pmid:34446582
7. Duval D, Palmer JC, Tudge I et al. Long distance airborne transmission of SARS-CoV-2: rapid systematic review. BMJ 2022; 377:e068743
8. Kang M, Wei J, Yuan J et al. Probable evidence of fecal aerosol transmission of SARS-CoV-2 in a high-rise building. Ann Intern Med 2020; 173:974-80
9. Wang Q, Li Y, Lung DC et al. Aerosol transmission of SARS-CoV-2 due to the chimney effect in two high-rise housing drainage stacks. J Hazard Mater 2022; 421:126799
10. Yu IT, Li Y, Wong TW et al. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med 2004; 350:1731-9
11. Dancer SJ, Li Y, Hart A, Tang JW, Jones DL. What is the risk of acquiring SARS-CoV-2 from the use of public toilets? Sci Total Environ 2021; 792:148341
12. Chen Y, Chen L, Deng Q et al. The presence of SARS-CoV-2 RNA in the feces of COVID-19 patients. J Med Virol 2020; 92:833-40
13. Kutter JS, de Meulder D, Bestebroer TM et al. SARS-CoV and SARS-CoV-2 are transmitted through the air between ferrets over more than one meter distance. Nat Commun 2021; 12:1653
14. Port JR, Yinda CK, Avanzato VA et al. 2021. Increased aerosol transmission for B.1.1.7 (alpha variant) over lineage A variant of SARS-CoV-2. BioRxiv (doi:10.1101/2021.07.26.453518)
15. Hawks SA, Prussin AJ 2nd, Kuchinsky SC, Pan J, Marr LC, Duggal NK. Infectious SARS-CoV-2 is emitted in aerosol particles. MBio 2021; 12:e0252721
16. Eregie C.O. COVID-19 Pandemic, SARS-CoV-2 Transmission and Pandemic Control Interventions: The Unrelenting Bothersome Chameleonic Reality of COVID-19 Pandemic Specifics. of 5th July 2022
17. Eregie C.O. COVID-19 Pandemic, still evolving manifestations and Long Covid: Appreciating the ‘Chameleonic COVID-19’ for better ‘COVID-19 Pandemic Control’. of 13th August 2022
18. World Health Organization. Coronavirus press conference 11 February (transcript). WHO, 2020.
19. World Health Organization. Public health response to biological and chemical weapons: WHO guidance. 2004.
20. Xu Z, Elomri A, Kerbache L, et al. Impacts of covid-19 on global supply chains: facts and perspectives. IEEE Eng Manage Rev2020;48:153-66doi:10.1109/EMR.2020.3018420
21. Lewis D. Why the WHO took two years to say covid is airborne. Nature2022;604:26-31. doi:10.1038/d41586-022-00925-7 pmid:35388203
22. Dancer SJ, Bluyssen PM, Li Y, Tang JW. Why don’t we just open the windows? BMJ2021;375:n2895. doi:10.1136/bmj.n2895 pmid:34836876
23. Scientific Advisory Group on Emergencies. SAGE minutes archive London: UK Government Transparency and Freedom of Information Releases 2020.
24. Public Health England. Guidance on social distancing for everyone in the UK. PHE, 2020. [Withdrawn].
25. New and Emerging Respiratory Virus Threats Advisory Group. NERVTAG minutes archive. 2020.
26. World Health Organization. WHO recommendations on mask use by health workers, in light of the Omicron variant of concern: WHO interim guidelines. 22 Dec 2021.
27. Morawska L, Milton DK. It is time to address airborne transmission of coronavirus disease 2019 (COVID-19). Clin Infect Dis2020;71:2311-3. doi:10.1093/cid/ciaa939 pmid:32628269
28. Jimenez J, Marr L, Randall K, et al. Echoes through time: the historical origins of the droplet dogma and its role in the misidentification of airborne respiratory infection transmission. SSRN2021doi:10.2139/ssrn.3904176
29. Public Health England. COVID-19 Infection Prevention and Control London: UK Government 2021.
30. Government of Japan. Expert meeting on the novel coronavirus disease control. Views on the novel coronavirus disease control (summary version). 9 Mar 2020. 2020.
31. Health and Social Care Committee. Oral evidence from Professor Terry Lum: Management of The Coronavirus Outbreak, HC36. 2020.
32. Morawska L, Allen J, Bahnfleth W, et al. A paradigm shift to combat indoor respiratory infection. Science2021;372:689-91. doi:10.1126/science.abg2025 pmid:33986171
33. Stadnytskyi V, Anfinrud P, Bax A. Breathing, speaking, coughing or sneezing: What drives transmission of SARS-CoV-2?J Intern Med2021;290:1010-27. doi:10.1111/joim.13326 pmid:34105202
34. World Health Organization. Transmission of SARS-CoV-2: implications for infection prevention precautions. Scientific brief. 9 July 2020.
35. Bourouiba L. Turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of COVID-19. JAMA2020;323:1837-8. doi:10.1001/jama.2020.4756 pmid:32215590
36. Greenhalgh T, Jimenez JL, Prather KA, Tufekci Z, Fisman D, Schooley R. Ten scientific reasons in support of airborne transmission of SARS-CoV-2. Lancet2021;397:1603-5. doi:10.1016/S0140-6736(21)00869-2 pmid:33865497
37. Wang CC, Prather KA, Sznitman J, et al. Airborne transmission of respiratory viruses. Science2021;373:eabd9149. doi:10.1126/science.abd9149 pmid:34446582
38. Tang JW, Bahnfleth WP, Bluyssen PM, et al. Dismantling myths on the airborne transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). J Hosp Infect2021;110:89-96. doi:10.1016/j.jhin.2020.12.022 pmid:33453351
39. Eregie C.O. COVID-19 Pandemic: The multifaceted picture of compromised COVID-19 research and the COVID Phenomenon’. of 10th June 2020
40. Eregie C.O. COVID-19 Pandemic, the quest for urgent information and solutions and the paradox: making haste slowly to avoid ‘COVID-19 Research Waste’. of 17th July 2020
41. Eregie C.O. COVID-19 Pandemic, vaccines, vaccinations and antibody therapies: The paradox of making haste slowly with cautious optimism. of 27th July 2020
42. Eregie C.O. COVID-19 Pandemic and compromise of science and standards: First was ‘COVID-19 Research Waste’ and now ‘COVID-19 Pharmaceuticals Catastrophe’. of 1st October 2020
43. Eregie C.O. COVID-19 Pandemic and vulnerability of science to assault: Imperatives to uphold research governance principles. of 22nd January 2021
44. Eregie C.O. COVID-19 Pandemic: A persisting pervading devastating unprecedented 21st century scourge; the imperative to protect, project and promote the immutability of the factuality of science to the rescue. of 23rd August 2021
45. Eregie C.O. COVID-19 Pandemic, COVID-19 Vaccines and successful vaccination programmes: a further clarion call to observe research governance-related best practices and a critical look at preprints. of 23rd February 2022

Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria,
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria,
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria,
*No Competing Interests.

Competing interests: No competing interests

16 September 2022
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria and Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria
Institute of Child Health, University of Benin, PMB 1154, Benin City, Nigeria.