Thread by @jvipondmd

So, it's time for a long tweet thread on airborne transmission, and the resistance of AHS, AH, and Canadian IPAC (that's Infection Prevention and Control) to acknowledge the problem, and mitigate it, resulting in umpteen preventable illnesses and deaths. 1/

We've known from at least May 2020 (perhaps China recognized it in Jan '20) that COVID was primarily transmitted via airborne means, by inhaled aerosols. However, IPAC has been using an alternate concept known as contact/droplet (c/d). 2/ pnas.org/content/117/26…

As time has gone on, there has been increasing quality and quantity of scientific studies supporting airborne/aerosol transmission. It's quite irrefutable now. 3/
bmj.com/content/373/bm…
cmaj.ca/content/193/26…
thelancet.com/journals/lance…

Let's go looking for evidence of c/d transmission. 1st, contact. This means touching snot/spittle w/ COVID, then inadvertently touching mucous membranes (eyes/nose/mouth). Best review? The @CDCgov,finding this a very rare method of transmission.4/cdc.gov/coronavirus/20…

Droplet spread means the spittle arcs thru the air and happens to land on your mucous membranes. The evidence for this? Very little (a challenge to all epidemiologists, share your primary literature on this here). 5/

Traditionally, short range transmission (<2m) was thought to be indicative of droplet transmission. But aerosols also preferentially transmit short-range. Think cigarette smoke, and where the smell is strongest. Right next to the smoker. 6/

The other argument was that COVID wasn't a transmissible as measles or chickenpox. But in actual fact, now the evidence for COVID being airborne now is much stronger than that for measles. 7/

https://twitter.com/JenniferKShea/status/1373840694176010240?s=20

So why does it even matter? Could this just be an academic argument, which has no impact on the real world? The reality is, if you get the means of transmission wrong, you'll fail to recognize the means of preventing that transmission. 8/

Certain mitigation measures are important for both. Masks, and physical distancing. But a bunch of mitigation measures for c/d are useless for airborne transmission: plexiglass sneeze guards, and deep cleaning surfaces, in particular. 9/

Most importantly, some measures to protect against airborne spread are not important for c/d. In particular, good fitting masks (respirators), ventilation, filtration, and preferential outdoor interactions. 10/

The CDC has come far down this path, with lots of recommendations for airborne mitigation, including all of the above. And now,after recommending respirators for HCWs working with COVID, even suggesting that the public use them in high risk situations. 11/ cdc.gov/coronavirus/20…

Which brings us back to good ol' Alberta (and much of Canadian IPAC), where @AHS_media continues to recommend surgical masks for interactions with COVID and COVID suspected patients, with c/d precautions. 12/ albertahealthservices.ca/assets/healthi…

The exception to this is an AGMP, or Aerosol-Generating Medical Procedure, where a respirator is recommended. Problem is, most routine activities, such as breathing, talking, and coughing, produce more aerosols than these procedures. 13/ first10em.com/aerosol-genera…

it has been argued that since @AHS_media is doing so great with Hospital Acquired Infections (HAIs), that is proof of how well the c/d paradigm is working. But is it? Right now, there are 27 hospitals with outbreaks on 38 different units. 14/ albertahealthservices.ca/assets/info/pp…

Imagine if these were TB outbreaks. Or C. diff. Would we reconsider our protocols? I would hope so. But for some reason, COVID outbreaks get a special pass. 15/

Another argument put forward is that no one has proven that respirators are better than surgical masks in preventing HAIs. The highest level of medical evidence is the Randomized Control Trial (RCT). Until this threshold is breached, there will be no recommendation. /16

But this isn't a medical intervention, it's a safety intervention. In the same way that seat belts or parachutes have never been studied with an RCT (wouldn't that be unethical), engineering principles should guide respirator recommendations. /17 bmj.com/content/363/bm…

In Feb, AHS did come to an agreement with the health care unions allowing respirator use, after a PCRA (patient care risk assessment) was performed. But respirator use never increased, likely because the agreement was never shared with HCWs until Apr. 18/ albertahealthservices.ca/assets/news/nr…

And even then, use wasn't encouraged, even discouraged, as seen in this embarrassing video. Certainly no training ever occurred to explain what a highrisk pt was.Less than 5% of docs, and almost no RNs, in my ER use respirators routinely with COVID pts. 19/

In ON, the @TorontoStar did some great investigative reporting and found 860 (860!) deaths from HAIs, or 15% of all deaths. So obviously, this is a big deal. 20/ thestar.com/news/gta/2021/…

I've been asking for this data for Alberta for over a year now, but we still don't know it. The pdf daily release (well, weekdaily release) is changed every day, making it difficult to determine the cumulative damage. 21/

https://twitter.com/jvipondmd/status/1372951493830057987?s=20

Fortunately, the mysterious @CPita3 has been collecting the data during the #intentionallycruelwave. And they've found (as of Friday): over 250 cases, and 15 deaths, from HAIs. 22/

So when does IPAC get to reassess the paradigm? With even more evidence of airborne transmission? With more evidence refuting c/d transmission? When we get to 300 preventable HCW and patient infections? Or 20 deaths? I'd like to know the trigger. 23/

For it doesn't just impact my patients and colleagues. This faulty paradigm is also being used to inform the public, and non-HCWs. Leading to even more community transmission. Check out this letter recently sent out to a parent, full of droplet dogma. 24/

This is indeed, the #intentionallycruelwave. I now come to expect it of my gov't. But we need better protection from AHS and IPAC, right across the country. #COVIDisAirborne #ReleasetheN95s. We all deserve to be safe. fin/

addendum: you may wonder why a tweet thread? Why not just advocate directly to AHS? I've asked for multiple meetings at multiple levels of AHS, only to be rebuffed, or ghosted. This is, indeed, a last resort.

2nd addendum: @joshuabergman has outlined some of communications from UNA and AHS. It did exist in early Mar. But in reality none of the staff that I encountered knew of its existence until at least late Apr. 1/3

There has been recent communications underplaying the utility of respirator use.Most obviously this SAG (Scientific Advisory Group) review in mid-Sept: albertahealthservices.ca/assets/info/pp…. @CPita3 has done a great analysis of why this review is irreparably flawed 2/3

https://twitter.com/CPita3/status/1439655036083134464?s=20

on Sept 20th, the @UnitedNurses put out a statement pointing out some of the discrepancies in AHS advice. You can read it here: 3/3 una.ca/1291/n95-masks…

It's been pointed out this May 2020 study isn't particularly good science. So maybe we can point to Jul 6 2020 as another important early landmark, when 363 scientists called on the WHO to recognize the importance of airborne transmission; academic.oup.com/cid/article/71…