A seven point plan to suppress covid infections and reduce disruptions
BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1793 (Published 19 July 2022) Cite this as: BMJ 2022;378:o1793
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Dear Editor,
It is not so much that correct directives regarding safety during the Pandemic are not available or not understood.
Firstly the guidelines are slow to arrive, for example, the risk of CoVID-19 becoming Pandemic was declared so late that it became unstoppable;
When the guidelines arrive they are proved wrong at a later time, for example, guidelines for handwashing were issued but necessity of mask was declared late;
Such ditherings and indecisions confuse people and do not earn public confidence and compliance;
But most important is flawed human nature which rebels against wisdom; was this not true, nobody would fall prey to vices.
Arvind Joshi,
MBBS MD FCGP FAMS.
Competing interests: No competing interests
Dear Editor,
The authors' suggestion for promoting high grade masks for the use by the general public in shared indoor spaces cannot be emphasised enough.
However, the UK government has failed to recognise the value of such masks and it has failed to consider that those have to be worn correctly to be effective in preventing transmission and providing protection.
If even in countries where the wearing of masks is very common (i.e. Japan), the incorrect use of masks can compromise the effectivity of such a vital public health tool (Machida et al. 2020), how could and can then the British public be expected to possess the required knowledge if no relevant education campaign has ever taken place?
It is time to finally start such an education campaign. It will benefit public health not only in this ongoing pandemic but pave the way for effective infection prevention and control in the next such event.
Furthermore, I would suggest to add a specific additional point to the proposed plan: The re-introduction of a strict mask mandate in health and care settings for staff, patients and visitors. In the absence of such a mandate, exposure to unnecessary nosocomial infection risks - by default - of people seeking care or treatment, which may include the clinically vulnerable, could be considered negligent or even dicriminatory because it puts those groups at a disproportionately high risk.
Machida, M., Nakamura, I., Saito, R., Nakaya, T., Hanibuchi, T., Takamiya, T., Odagiri, Y., Fukushima, N., Kikuchi, H., Amagasa, S. and Kojima, T., 2020. Incorrect use of face masks during the current COVID-19 pandemic among the general public in Japan. International Journal of Environmental Research and Public Health, 17(18), p.6484.
Competing interests: No competing interests
Dear Editor,
To the 'seven-point plan to suppress covid infections and reduce disruptions' put forward by Independent SAGE , I would suggest adding:
8. Ensuring optimal vitamin D status (25-hydroxy-vitamin D > 125 nmol/L / 50 ng/ml). (1,2, 3, 4, 5)
…making it an eight-point plan!
1. Bae, J.H., Choe, H.J., Holick, M.F. et al. Association of vitamin D status with COVID-19 and its severity. Rev Endocr Metab Disord 2022; 23, 579–599. https://doi.org/10.1007/s11154-021-09705-6
2. Oriana D’Ecclesiis, Costanza Gavioli, et al. Vitamin D and SARS-CoV2 infection, severity and mortality: A systematic review and meta-analysis. Plos One 2022; https://doi.org/10.1371/journal.pone.0268396
3. Marcos Pereira, Alialdo Dantas Damascena, Laylla Mirella Galvão Azevedo, Tarcio de Almeida Oliveira & Jerusa da Mota Santana. Vitamin D deficiency aggravates COVID-19: systematic review and meta-analysis. Critical Reviews in Food Science and Nutrition 2022; 62:5, 1308-1316, DOI: 10.1080/10408398.2020.1841090
4. Timotius Ivan Hariyanto, Denny Intan, et al. Vitamin D supplementation and Covid-19 outcomes: A systematic review, meta-analysis and meta-regression. Rev Med Virol 2022; 32:e2269
5. Rastogi A, Bhansali A, Khare N, et al. Short term, high-dose vitamin D supplementation for COVID-19 disease: a randomised, placebo-controlled, study (SHADE study). Postgraduate Medical Journal 2022; 98:87-90
Competing interests: No competing interests
Dear Editor
Thank you for this excellent statement, which rightly begins by highlighting the Government's dismissal of evidence from its own advisors.
There is an additional issue on point 2. Vaccine uptake is not simply a question of age and ethnicity. It is also affected by deprivation, and varies by employment, Region, and local authority.
Increases in local authority public health budgets are linked to improved uptake. This would be a simple target for intervention, if the Government had any interest in funding it.
In other words, vaccine uptake is not just about the people, it's also where they live. And it's not a "postcode lottery", it's the result of economic policy decisions.
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0270624
Competing interests: No competing interests
Dear Editor
The Authors of this article should be commended for their effort in developing such a straightforward plan ‘…to suppress covid infections’.
However I’m baffled about the recommendation regarding ‘….Systematic promotion of the use of FFP2/FFP3 masks in indoor public spaces and public transport when infection rates are high’. The reference used to support this measure is a mere narrative review and cannot be used to support such recommendation. In fact, as of today despite an almost 2 years of semi-mandatory worldwide use of masks, including FFP2/3 (see Germany, Austria, Italy …etc.), there are no sound RCTs nor observational studies showing efficacy or effectiveness in preventing covid associated with the use of masks. Moreover, the extended use of FFP2/3 pose respiratory consequences due to the reduction in blood oxygen saturation level and ultimately it can be harmful.
In summary, in my opinion without clear evidence showing masks efficacy/effectiveness in preventing covid, these should not be recommended. Given the current evidence, the risks associated with FFP2/3 masks for extended period of time outweigh the benefits given that these has not been shown.
Competing interests: No competing interests
Further Actions to minimise Disruption and Transmission Risk from Professional Engineers
Dear Editor
The Engineers’ Covid Task Force was formed in March 2020 to offer pragmatic cost effective solutions to preventing transmission, given earliest advice as to the mechanisms of infection from Clinicians and Academia.
Professional Engineers understand the mechanisms of Infection transmission and have lifelong experience of controlling, not just infection, but all forms of pollution and contamination, as well as managing human behaviour, be it for production, quality, H&S, operational or environmental purposes. Such expertise complements that of those who have put forward this plan.
We welcome the recommendation for use of better masks in highest risk areas but to minimise transmission the public needs the best masks, together with more precise advice as to which to use, where and all other “Personal Infection Control” measures they can take.
Mask Development
Custom development of higher performance masks is long overdue, to complement that of vaccine development, as they can be more effective at preventing transmission but “Face Coverings” are so poor that they inspire false confidence and should be outlawed. Their BS/EU standard specifies only 70% efficiency, such that 30% can still escape or penetrate.
In contrast, virtually all surgical masks achieve 95-98%. The best Type IIs are now 600 times better at 99.95% and they can be particularly effective against finest aerosols. They provide far more effective transmission control at less cost, as was proved in Taiwan and Vietnam, where 2020 death rates were 4000 times less than UK and Western averages. In areas of highest infection risk, a simple mask brace can be added to all but eliminate leakage.
FFP2/3 masks were developed to retain incoming bacteria/solids rather than liquid aerosols or droplets, to protect the wearer rather than those around them. They are costly and can become virtually unwearable in current temperatures but their leakage is low, providing protection in highest risk areas.
To minimise the risk of transmission, as an interim measure they could also be worn by those testing positive or potentially infected, allowing them to continue working as an alternative to isolation, vital to economic recovery and to public services, including NHS and care homes, still suffering seriously from staff absence.
However, no clinical mask has yet been specifically developed and optimised to catch liquid aerosols/droplets to protect both wearers and those around them, yet such a mask would be more breathable and easier to speak through. It could be manufactured in volume using existing surgical mask equipment at a fraction of the cost and, to Engineers, reducing their leakage is a simple challenge. Such a development, first offered in April 2020, would take a fraction of the time/cost of vaccine development or ventilation upgrades and could be far more effective at preventing transmission, albeit, all such preparation is important for the next pandemic.
Revised Personal Infection Control Advice
The nature and effectiveness of public advice urgently needs re-evaluation and revision, possibly using input from ZOE App participants and comparison between Far East and Western World practice.
Whereas Engineers’ CTF advice for the WHO to “avoid breathing in what others breathe out and spending time with the same people indoors” reinforces the public’s prior understanding of Personal Infection Control, following arrows etc. has proved counter-intuitive and earliest Western advice led to cross-infection between home, transport and workplace bubbles.
In summary, whereas Academia has an in-depth understanding of the mechanisms of infection, i.e. the “problem”, Professional Engineers from the private sector can provide a wider range of proven “solutions” to control transmission, as they did for vaccine production and roll out. Wider collaboration is key.
Peter Hebard
BSc, CEng, FIMechE, MCIWEM
Chair of Engineers’ Covid Task Force
Co-Founder of IMechE Covid Task Force
References
Zeynep Tufekci This Overlooked Variable Is the Key to the Pandemic - It’s not R. The Atlantic 30 Sept 2020
De Kai, Guy, Phillippe Golstein, Alexey Morgunov, Vishal Nangalia. Universal Mask Wearing is Urgent in the COVID-19 Pandemic Covid 19 e print - Cornell University 22 Apr 2020 arXiv:2004.13553v1 [physics.soc-ph]
Kazuhiro Tatada. A Third Mechanism of Infection - the Key to Controlling the spread of the Virus. Video clip from NHK World TV May 2020
IMechE Covid Task Force Manual Institution of Mechanical Engineers website November 2020
Mariano Zafra, Javiar Salas. A room, a Bar and a Classroom: How Coronvirus is Spread through the Air El Pais Journal 28 Oct 2020
Jose Jimenez. 2020 Aerosol Transmission Estimator Cooperative Institute for Research in Environmental Sciences at the University of Colorado Boulder 25 June 2020
Hong Kong Consumer Council. Face Masks Tested with Desirable Filtration Efficiency HKCC website press release 15 December 2020. https://www.consumer.org.hk/ws_en/news/press/530/disposable-masks.html
Nhan Phuc Thanh Nguyen,Tuyen Dinh Hoang, Vi Thao Tran, Cuc Thi Vu, Joseph Nelson, Siewe Fodjo, Robert Colebunders, Michael P. Dunne,Thang Van Vo. Preventative Behaviour of Vietnamese People in Response to the COVID-19 Pandemic Journal of Plos Pathogens Sept 2020
Govt of Hong Kong. Cu Mask – Test Reports and Patent Information Government of Hong Kong Administrative Region website 2020 https://www.qmask.gov.hk/about/
Ministry of Health and Welfare, Taiwan. Crucial Policies for Combatting Covid 19 MOHW website 2021 https://covid19.mohw.gov.tw/en/np-4769-206.html
Johns Hopkins CRC. Mortality Analyses. Johns Hopkins Coronavirus Resource Center website 24 Jan 2021 https://coronavirus.jhu.edu/data/mortality
SPI-B. Return to SAGE on the use of facemasks in a community setting UK Government Website. 20 April 2020 https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
European Centre for Disease Prevention and Control. Using face masks in the community: first update - Effectiveness in reducing transmission of COVID-19 ECDC Website 15th Jan 2021
Centre for Health Protection. Covid -19 Guidelines for All parties and Situations Hong Kong Department of Health February 2021
Gov’t of Hong Kong SAR. Together We Fight the Virus Hong Kong Gov’t Coronovirus information website live 2021
Competing interests: No competing interests