COVID‐19 NHS infection control strategy: Errare humanum est, perseverare autem diabolicum

A recent BMJ Editorial ("Getting it right in the pandemic") has discussed examples of countries that have done better than others in responding to COVID-19 pandemic and, conversely, those policymakers and health systems that got it wrong. (Loder, 2020) There is little doubt that, when facing a pandemic with a high speed of onset and transmission, "nobody should be surprised that errors were made" (Adebowale et al, 2020) and "what it was done some weeks ago is not what we would do today".


| US ING MA S K S AT ALL TIME S IN HOS PITAL S TO REDUCE NOSO COMIAL TR ANS MISS ION
One example of persisting errors during the pandemic is the recommendation (or lack thereof) of using masks within all areas of NHS hospitals including the non-patient-facing areas. The benefit of using masks/facial covering in order to reduce the risk of SARS-CoV-2 transmission in both the community and healthcare setting has been increasingly reported. (Chu et al., 2020;Esposito, Principi, Leung, & Migliori, 2020;Feng et al., 2020;Gray & Back, 2020) (Grubb, 2020;Thomas, 2020), though not the medical literature. The general perception within NHS organisations was that SARS-CoV-2 infection transmission could only occur from patient to staff in clinical areas, and not between staff members and potentially in any part of the hospital. Although NHS organisations have been experiencing a large number of HCWs infected with SARS-CoV-2 during the outbreak (e.g. up to more than 40% of frontline staff), (Houlihan et al., 2020) little attention was paid towards the additional benefit of using masks at all times in preventing transmission among HCWs. Other countries' healthcare organisations have adopted a much more rigid infection control policy including the use of masks at all times and have demonstrated that transmission among HCWs can be minimised, if not completely prevented. (Liu et al., 2020) The pandemic outbreak hit those countries notably earlier than UK, and it remains unclear why NHS policy makers did not look at those experiences as an example of good practice. Beyond prudence and common sense, there is a lesson to learn regarding the ability of the NHS as healthcare organisation to capture, digest and adapt to the emerging knowledge and experience, even when not supported by the highest level of evidence. With a pandemic evolving at such high speed, the persistence in not considering, for months, a simple, inexpensive, adverse-effect free and likely beneficial infection control measure was indeed, to our eyes, diabolical.

| IND IVIDUAL COMPL ACEN C Y AND P OLIC Y LOOPHOLE S
Following the 15th June introduction of mandatory mask in all areas of NHS hospitals, (Public Health England, 2020) there have been reports of HCWs declining to comply with the new policy, in one particular case leading to an outbreak of some 70 staff and immediate closure of the A&E department. (Siddique & Campbell, 2020) Although complacency has been previously reported among HCWs dealing with infectious respiratory disease prevention, (Schmid, Rauber, Betsch, Lidolt, & Denker, 2017) (Chu et al., 2020;Esposito et al., 2020;Feng et al., 2020;Gray & Back, 2020) and the likelihood of SARS-CoV-2 airborne transmission in enclosed poorly ventilated spaces (see below), it is difficult to understand why these NHS organisations introduced policy loopholes rather than following the precautionary principle. Nonetheless, from late March/early April, an increasing body of literature has questioned this approach, culminating in a recent appeal to national and international medical bodies signed by 239 scientists. (Morawska & Milton, 2020) They state that available evidence demonstrates, beyond any reasonable doubt, the significant potential for airborne transmission of SARS-CoV-2: virus-carrying respiratory microdroplets can be released into the air by infected people while coughing, sneezing or simply with exhalation or talking. (Morawska & Milton, 2020) They called for the adoption of adequate airborne preventive measures, with hand washing and social distancing, albeit helpful, being insufficient to provide full protection from airborne transmission, especially in crowded enclosed environments with poor ventilation. (Morawska & Milton, 2020;Somsen, van Rijn, Kooij, Bem, & Bonn, 2020).

| AIRBORNE OR NOT AIRBORNE: THAT IS THE QUE S TI ON
It is singular to see that, although evidence remains incomplete for both COVID-19 microdroplet and large droplet/fomite transmission, the NHS policy has repeatedly ignored the former and embraced the latter, with the only exception being AGPs. Paradoxically the evidence supporting the increased risk of SARS-CoV-2 transmission with AGPs is similarly not robust. (Wilson, Norton, Young, & Collins, 2020).
Recognising the potential for SARS-CoV-2 airborne transmission also translates into accepting that N95 or similar respirators would offer enhanced protection as compared to surgical masks in the healthcare setting, which is in keeping with the results of a recent meta-analysis (Chu et al., 2020).
Frontline HCWs of healthcare organisations adopting strict infection control measures (including airborne PPE at all times) were infected at a notably lower rate than frontline HCWs of a NHS central London hospital. (Houlihan et al., 2020;Lai et al., 2020;Liu et al., 2020) Similarly, a recent report from China shows that non-frontline HCWs, although theoretically at lower risk, had a significantly higher rate of SARS-CoV-2 infection with respect to frontline HCW, likely due to differences in PPE (basic vs. enhanced) (Lai et al., 2020).
Nonetheless NHS guidance on PPE has remained unchanged.
Furthermore, NHS policy makers have also dismissed appeals for PPE use to be based on a better-tailored and targeted risk assessment rather than the current one-size-fits-all policy. This is particularly relevant to those HCWs (e.g. specialists in Oral and Dental Medicine, Otolaryngology and Maxillofacial Surgery) who are believed to be at increased risk as they get routinely in close proximity of anatomic regions where the exposure to respiratory droplets and secretions, as well as the SARS-CoV-2 viral loads, can be notably higher and with no option for source control (patients cannot wear a mask during consultations to NHS leaders and policymakers to recognise past mistakes, learn from their and others' experience, and develop a new enhanced infection control strategy that could effectively mitigate the risk of further nosocomial transmission and ensure that HCWs feel, and indeed are, safe at work (Academy of Medical Sciences, 2020).

CO N FLI C T O F I NTE R E S T
SF and SRP reports no conflict of interest.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/odi.13605.