\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{How Covid-19 spreads: narratives, counter-narratives and social dramas}



\author[1]{Trisha Greenhalgh}%
\author[2]{M Ozbilgin}%
\author[3]{D Tomlinson}%
\affil[1]{Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX2 6GG, UK}%
\affil[2]{Brunel University London, Kingston Lane, Uxbridge UB8 3PH, London, UK}%
\affil[3]{University Hospitals Plymouth NHS Trust, South West Cardiothoracic Centre, Derriford Hospital, Plymouth, PL6 8DH, UK}%


\vspace{-1em}



  
  \date{June 14, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
This paper offers a critique of UK government policy based on mode of
transmission of SARS-CoV-2 (which in turn followed misleading advice
from the World Health Organisation) through the lens of policymaking as
narrative. Two flawed narratives---``Covid is droplet- not
airborne-spread'' and ``Covid is situationally airborne'' (that is,
airborne transmission is unusual but may occur during aerosol-generating
medical procedures and severe indoor crowding)---quickly became dominant
despite no evidence to support them. Two important
counter-narratives---``Covid is unequivocally airborne'' and ``Everyone
generates aerosols; everyone is vulnerable''--- were sidelined despite
strong evidence to support them. Tragic consequences of the flawed
policy narrative unfolded as social dramas. For example, droplet
precautions became ritualised; care home residents died in their
thousands; public masking became a libertarian lightning rod; and
healthcare settings became occupational health battlegrounds. In a
discussion, we call for bold action to ensure that the science of
SARS-CoV-2 transmission is freed from the shackles of historical errors,
scientific vested interests, ideological manipulation and policy
satisficing.%
\end{abstract}%



\sloppy


Original article submitted to BMJ Analysis November 2021 (preprint to
Authorea)

\textbf{Correspondence:} Professor Greenhalgh
trish.greenhalgh@phc.ox.ac.uk

\par\null

\section*{Policymaking as narrative}

{\label{policymaking-as-narrative}}

Policymaking is a contact sport involving competing narratives (about
problems, how they arose, and how they will be resolved), institutions
(especially government and its bureaucratic machinery) and interests
(financial, political, ideological).\textsuperscript{1 2} Policy
may---ideally---``follow science'' but a key question is
\emph{whose}science and why? Science shapes policy narratives via an
``inside track'' (e.g. official advisory committees) and to a lesser
extent by an ``outside track'' (e.g. less mainstream scientists, citizen
movements).\textsuperscript{3}

Pandemic policymaking has been characterised not by clearly-identified
knowledge gaps which science obligingly fills but by toxic clashes
between competing scientific and moral narratives. Policymakers have
risked losing control of the ``dramaturgy of political communication''
(page 78\textsuperscript{4}).

Getting the mode of transmission for a contagious disease right matters,
because preventive strategies follow (Table 1).\textsuperscript{5} Being
honest about scientific uncertainty also matters, because---among other
reasons---it is hard to back-track after declaring a policy
``evidence-based''.

Table 1: Droplet versus airborne transmission: implications for public
health and healthcare worker protection\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
1a. Droplet transmission & 1b. Airborne transmission\tabularnewline
If an infectious pathogen spreads predominantly through large
respiratory droplets that fall quickly, the most important public health
measures are: respiratory hygiene (e.g. sneezing into tissues)
disinfecting surfaces and objects (fomites) onto which droplets may have
fallen reducing direct contact (e.g. do not shake hands with others or
touch one's own face) staying physically apart from others at a distance
that reflects the effect of gravity on droplets (1-2 metres) wearing
facemasks within that droplet distance physical barriers (such as visors
of plastic screens) providing respirator-grade protection for healthcare
staff who undertake so-called ``aerosol-generating'' procedures.~These
contact, droplet and fomite precautions do not distinguish between
indoor and outdoor settings, since a gravity-driven mechanism for
transmission would operate similarly in both. & If an infectious
pathogen is mainly airborne, a person could potentially be infected when
they inhale aerosols emitted in the breath of an infected person. These
aerosols may remain suspended in the air for many hours. Reducing
airborne transmission requires measures to avoid inhalation of
infectious aerosols, including engineering controls in indoor spaces
(ventilation, air filtration) reducing crowding (e.g. by encouraging
people to work from home if possible) reducing time spent indoors (e.g.
frequent breaks for school classes) maximising physical distance between
people indoors (even beyond 2 metres) wearing masks whenever indoors
careful attention to mask quality (to maximise filtration) and fit (to
avoid air getting in via gaps) taking particular care in indoor
activities that generate aerosols (e.g. speaking, singing, exercising)
providing respirator-grade protection for health-care staff and other
front-line workers\tabularnewline
\bottomrule
\end{longtable}

In this paper, we contrast inside-track narratives of SARS-CoV-2
transmission from the World Health Organisation, UK government and their
official scientific advisers with outside-track counter-narratives
offered by aerosol scientists. We examine related events that unfolded
as social dramas\textsuperscript{6}---hand-cleansing rituals, care home
deaths, public masking and occupational health and safety.

\section*{Narratives and
counter-narratives}

{\label{narratives-and-counter-narratives}}

\subsection*{\texorpdfstring{``Covid is droplet-, not airborne-,
spread''}{Covid is droplet-, not airborne-, spread}}

{\label{covid-is-droplet--not-airborne--spread}}

On 11\textsuperscript{th} February 2020, the World Health Organisation's
Director-General announced that ``corona{[}virus-19{]} is
airborne''.\textsuperscript{7} After a prompt, he corrected himself and
declared firmly that the virus was not airborne but transmitted by
droplets (e.g. via coughs, sneezes and contaminated objects). The World
Health Organisation has long considered airborne diseases to be
potential bioterrorist threats\textsuperscript{8} (Dr Adnahom apologised
for using ``the military word''), and there was a dire international
shortage of respirator-grade personal protective
equipment.\textsuperscript{9}

The World Health Organisation's early public information campaign
promoted droplet measures---handwashing, respiratory hygiene and
disinfection of surfaces and objects (Table 1, column a). It also
reassured the public that the virus was not airborne (Figure
1).\textsuperscript{10} Droplet transmission was assumed rather than
scientifically substantiated,\textsuperscript{11 12} mainly because
infection prevention and control clinicians---whose day jobs included
enforcing droplet controls in hospitals, especially by promoting
handwashing---predominated in key committees.\textsuperscript{13}

\subsection*{\texorpdfstring{Figure 1: `Covid is not airborne' tweet from
World Health Organisation, 28\textsuperscript{th} March
2020}{Figure 1: Covid is not airborne tweet from World Health Organisation, 28th March 2020}}

{\label{figure-1-covid-is-not-airborne-tweet-from-world-health-organisation-28th-march-2020}}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

The UK government's narrative reproduced the World Health Organisation's
(Box 1). It did not reflect nuanced discussions in the Scientific
Advisory Group on Emergencies (SAGE), some of whose members had
published concerns that respiratory viruses in
general\textsuperscript{14} and coronaviruses in
particular\textsuperscript{15} may be airborne and had raised the
possibility of other transmission routes on
18\textsuperscript{th}February 2020.\textsuperscript{16} Rather, it
reflected advice from a small group of infection prevention and control
experts (known as the ``IPC Cell'') from Public Health England, Public
Health Wales, NHS Scotland and Public Health Agency Northern Ireland
(see Appendix on bmj.com). Like their World Health Organisation
counterparts, these clinicians adhered to a droplet-but-not-airborne
narrative.\textsuperscript{17} An inquiry criticised the UK government
for modelling its pandemic response on an influenza scenario and
assuming---wrongly, it turned out\textsuperscript{18}---that influenza
was transmitted via droplets not aerosols (page 19\textsuperscript{19}).

\begin{quote}
\subsection*{Box 1: Early announcements about preventing transmission of
SARS-CoV-2 from UK and
Japan}

{\label{box-1-early-announcements-about-preventing-transmission-of-sars-cov-2-from-uk-and-japan}}
\end{quote}

\textbf{Public Health England (posted 3\textsuperscript{rd} March 2020,
updated 30\textsuperscript{th} March 2020, withdrawn
1\textsuperscript{st} May 2020)\textsuperscript{20}}

\begin{quote}
\emph{``There are general principles you can follow to help prevent the
spread of respiratory viruses, including:}

\begin{itemize}
\tightlist
\item
  \emph{washing your hands more often - with soap and water for at least
  20 seconds or use a hand sanitiser when you get home or into work,
  when you blow your nose, sneeze or cough, eat or handle food}
\item
  \emph{avoid touching your eyes, nose, and mouth with unwashed hands}
\item
  \emph{avoid close contact with people who have symptoms}
\item
  \emph{cover your cough or sneeze with a tissue, then throw the tissue
  in a bin and wash your hands}
\item
  \emph{clean and disinfect frequently touched objects and surfaces in
  the home''}
\end{itemize}

This narrative assumes a droplet mode of transmission and implies a high
level of certainty.
\end{quote}

\begin{quote}
\textbf{Japanese Prime Minster's office, 9\textsuperscript{th} March
2020\textsuperscript{21}}
\end{quote}

\begin{quote}
\emph{``What we ask of you}
\end{quote}

\begin{quote}
\end{quote}

\begin{quote}
\emph{The locations where mass infections were confirmed so far are
places where the following three conditions were met simultaneously: (1)
closed space with poor ventilation, (2) crowded with many people and (3)
conversations and vocalization in close proximity (within arm's reach of
one another). It is believed that more people were infected in such
places. Therefore, we ask that you predict locations and settings where
these three conditions could occur simultaneously and avoid them.}

\emph{We do not have enough scientific evidence yet on how significantly
such actions can reduce the risk of spreading infection. However, since
places with poor ventilation and crowded places are increasing
infections, we ask that you take precautions even before scientific
evidence for clear standards is found.''} (page 2)

This narrative assumes the \emph{possibility} of airborne transmission
and asks citizens to share the uncertainty and act in a precautionary
way.
\end{quote}

The droplet-but-not-airborne narrative emphasised randomised control
trial evidence (see appendix on bmj.com);\textsuperscript{22} it drew
implicitly on the \emph{hierarchy of evidence} ---a formalisation of the
assumed superiority of randomised trials,\textsuperscript{23} which
``\ldots{} typically serve{[}s{]} the needs and realities of clinical
medicine, but not necessarily public policy'' (page
665).\textsuperscript{24} It did not acknowledge the \emph{hierarchy of
controls} ---a more public health-oriented framework which favours
system-level interventions aimed at pathogen elimination, followed by
environmental controls aimed at making air and water safe, and both of
these over interventions to influence human
behaviour.\textsuperscript{5} Since randomised trials are not considered
appropriate in the science of building design and
ventilation,\textsuperscript{25} this mindset led policymakers to reject
a wealth of wider evidence which we discuss in the next section.

\subsection*{\texorpdfstring{``Covid is unequivocally
airborne''}{Covid is unequivocally airborne}}

{\label{covid-is-unequivocally-airborne}}

Aerosol scientists study how fluids and particles travel in the air.
Some had specialised in how respiratory pathogens---including
tuberculosis, influenza and other coronaviruses such as SARS and
MERS---travel. They had shown, using laboratory studies, real-world case
studies and computer modelling, that these pathogens are transmitted by
aerosols and require airborne mitigation measures (Table 1, column
b),\textsuperscript{26 27} and that coughs and sneezes generate
turbulent gas clouds different-sized particles which can travel long
distances.\textsuperscript{28 29}

From early 2020, evidence accumulated from a range of study designs to
support the hypothesis that, like most other respiratory pathogens---and
perhaps more so than other coronaviruses---SARS-CoV-2 is transmitted
through the air (Box 2).\textsuperscript{18 30-32}

\begin{quote}
\subsection*{Box 2: 10 streams of evidence in support of airborne
transmission of
SARS-CoV-2}

{\label{box-2-10-streams-of-evidence-in-support-of-airborne-transmission-of-sars-cov-2}}
\end{quote}

\begin{quote}
\emph{Summarised from various sources\textsuperscript{18 30-32}}
\end{quote}

\begin{enumerate}
\tightlist
\item
  Superspreading events: the virus is often transmitted at mass events
  from one or a few people to many people.\textsuperscript{33 34}
\item
  Long-range transmission: the virus spreads in shared air among people
  who have never physically met or touched any common
  surface.\textsuperscript{35}
\item
  Asymptomatic and presymptomatic transmission: a high proportion of
  people who pass on the virus have no symptoms at the
  time.\textsuperscript{36-38}
\item
  Indoor dominance: transmission is many times greater indoors than
  outdoors,\textsuperscript{39} and ventilation reduces
  transmission.\textsuperscript{40}
\item
  Nosocomial infections occur despite strict contact-and-droplet
  precautions, and reduce when airborne precautions are
  added.\textsuperscript{41}
\item
  Whilst SARS-CoV-2 is difficult to isolate from
  air,\textsuperscript{42} viable SARS-CoV-2 has been detected in the
  laboratory\textsuperscript{43} and in real-world settings where
  infected people had been.\textsuperscript{44 45}
\item
  SARS-CoV-2 has been detected in air filters in building ducts (could
  only have got there via airborne route).\textsuperscript{46}
\item
  Transmission between animals has occurred when their cages were
  connected via air ducts.\textsuperscript{47}
\item
  The virus exhibits overdispersion (one person with Covid-19 may infect
  no-one; another may infect dozens).\textsuperscript{48}
\item
  Empirical evidence supporting droplet or fomite transmission is
  surprisingly sparse.\textsuperscript{11 12}
\end{enumerate}

C{}ountries such as Japan,\textsuperscript{21} where aerosol scientists
were part of the inside track with the ear of
government,\textsuperscript{13} had introduced airborne precautions
early in the pandemic (Box 1). But in most Western countries, the
aerosol narrative---at least initially---fell on deaf policy ears.

By July 2020, aerosol scientists were alarmed that official advice was
based on over-simplistic and incorrect models of transmission (which had
perpetuated for decades in the infection control
literature\textsuperscript{49}), and wrote an open letter to the World
Health Organisation offering to help.\textsuperscript{40}

\subsection*{\texorpdfstring{``Covid is `situationally'
airborne''}{Covid is situationally airborne}}

{\label{covid-is-situationally-airborne}}

The World Health Organisation's early guidance on protecting healthcare
workers from Covid-19 recommended a standard level of protection for
most activities but a higher level for so-called ``aerosol-generating''
ones,\textsuperscript{50} reflecting a long-established (but perhaps
flawed) research tradition.\textsuperscript{51} Its Infection Prevention
and Control Research and Development Expert Group for COVID-19
(IPCRDEG-C19) did not include any aerosol scientists and did not welcome
the open offer of help. A new scientific brief was quickly published,
reiterating the dominance of droplet transmission in most circumstances
but acknowledging airborne transmission in certain
situations---aerosol-generating medical procedures and crowded,
poorly-ventilated indoor settings.\textsuperscript{52}

This ``situationally airborne'' narrative has persisted despite evidence
against it (next section), and has far-reaching implications. If
aerosols transmit only when certain procedures are being performed, only
a small fraction of healthcare staff need higher-grade protection, and
only when performing particular procedures. If that assumption is
incorrect, staff (especially non-medical and less senior ones) and
patients in most healthcare facilities are
under-protected.\textsuperscript{53}

\subsection*{\texorpdfstring{``Everyone generates aerosols; everyone is
vulnerable''}{Everyone generates aerosols; everyone is vulnerable}}

{\label{everyone-generates-aerosols-everyone-is-vulnerable}}

A systematic review revealed wide disagreement among guideline panels
about which procedures and activities should count as ``aerosol
generating'' (and hence earn respirator-grade protection for the person
doing them).\textsuperscript{54} Many procedures (e.g. taking a
nasopharyngeal swab) were inconsistently classified, some
aerosol-generating acts (e.g. coughing) were not procedures, and several
procedures were classified as aerosol-generating only because they
induced coughing.\textsuperscript{54}

A detailed review of the physiology and aerodynamics of respiratory acts
concluded that coughing, sneezing, breathing (especially if laboured),
speaking (especially loudly) and singing generated significant amounts
of aerosol; well-documented super-spreader events for Covid-19 involved
a critical triad of poor ventilation, crowding and loud
vocalisation.\textsuperscript{34}

These findings raise some paradigm-challenging questions. Should
respirator-grade protection be worn by everyone---including other
patients---\emph{whenever patients are coughing} ? Should more attention
be paid to measures higher up the hierarchy of controls, such as
ventilation or filtration of air, or ensuring that fewer people share
air and for shorter periods\textsuperscript{5}?

In the sections which follow, we consider some dramatic consequences of
the government's decision to deny, dismiss or downplay the importance of
airborne transmission of SARS-CoV-2.

\section*{Social dramas}

{\label{social-dramas}}

\subsection*{Droplet precautions became
ritualised}

{\label{droplet-precautions-became-ritualised}}

The official droplet-but-not-airborne narrative materialised as
artefacts (e.g. posters, disinfectant dispensers, 2-metre distancing
markers) and social practices (actions accepted and expected in
particular contexts).\textsuperscript{55} Droplet-directed practices
became ubiquitous among individuals, who washed hands and forearms
assiduously for 20 seconds, quarantined and disinfected their post, and
stayed a measured distance apart, and also in institutions, who
installed and policed the various artefacts and practices.

These rituals of purification\textsuperscript{56} powerfully reinforced
the official narrative. ``Clean'' and ``contaminated'' came to be
demarcated in terms of how recently and thoroughly hands had been
sanitised and how far a droplet was assumed to travel (Table 1, column
a). They also served to downplay or obscure the narrative of aerosol
transmission---which demarcated ``clean'' and ``contaminated'' in terms
of air purity, with practices oriented to controlling indoor crowding
and time spent indoors, ventilating or filtering air, and optimising
quality and fit of masks (Table 1, column b). These material and enacted
features of policy discourse served to further silence the
``Covid-is-airborne'' narrative.

\subsection*{Care home residents died in their
thousands}

{\label{care-home-residents-died-in-their-thousands}}

On 23\textsuperscript{rd} March 2020, with up to 500,000 deaths and an
overwhelmed National Health Service predicted,\textsuperscript{57} the
UK Prime Minister announced a national lockdown (``stay at home'',
``protect the NHS''). Hospitals had switched into urgent discharge mode
from 19\textsuperscript{th} March, sending patients back to care homes
without routine pre-discharge testing. Between March and June 2020,
18,104 deaths involving Covid-19 and 11,169 additional deaths above the
5-year UK average occurred in care home residents.\textsuperscript{58}

Amnesty International depicted the UK's care home crisis as a gross
breach of human rights in which thousands of vulnerable people had been
treated as expendable.\textsuperscript{59} The crisis was also largely
avoidable. Public Health England's guidance for care homes had
emphasised a situationally-airborne narrative.\textsuperscript{60} Since
aerosol-generating procedures were rarely undertaken in care homes,
these settings had been considered low priority for personal protective
equipment.

Under-emphasis of the importance of ventilation and no routine use of
masks are likely to have greatly amplified transmission between
infectious residents and care home staff. In Hong Kong, by contrast,
surgical masks were mandated for all care home staff by late January
2020 and no excess care home deaths occurred in wave
1.\textsuperscript{61}

\subsection*{Public masking became a libertarian lightning
rod}

{\label{public-masking-became-a-libertarian-lightning-rod}}

Libertarianism is a political ideology which favours individual choice,
freedom and a retreat from state and institutional
control.\textsuperscript{62} Libertarians resist imposed rules and like
to ``do their own research'' rather than trust scientists or government.
Uncertainty and conflict about the value and place of public masking
allowed libertarian messages and practices to flourish.

At its 4\textsuperscript{th} February 2020 meeting, the Scientific
Advisory Group on Emergencies advised masks for symptomatic Covid-19
patients to reduce transmission ``if
tolerated''.\textsuperscript{63}This group had acknowledged the
potential for asymptomatic transmission of SARS-CoV-2 on 28th January
2020,\textsuperscript{64} but did not make the logical leap to recommend
masking asymptomatic people as source control. Indeed, in official
meetings between January and April 2020, either public masking was not
mentioned or arguments against it---lack of efficacy, harm,
wastage--were tabled (see Appendix on bmj.com). Public
announcements\textsuperscript{65} and professional
videos\textsuperscript{66} issued by Public Health England between
February and June 2020 presented masking as ineffective and potentially
harmful, on the grounds that people might take compensatory risks or
self-contaminate when they put on or removed their mask (the ``donning''
and ``doffing'' of infection control jargon\textsuperscript{66}). They
provided no evidence to support these claims.

The contested efficacy of facemasks in controlling SARS-CoV-2
transmission can be explained in terms of how much of the evidence base
one is prepared to consider.\textsuperscript{67} An influential
inside-track narrative appeared to conflate absence of relevant
randomised controlled trial evidence with evidence that masking was
ineffective.\textsuperscript{22} Outside-track scientists argued for the
precautionary principle, on the grounds that there was---as early as
March 2020---indirect and mechanistic evidence (notably, around
asymptomatic transmission) and strong theoretical arguments for public
masking, and huge potential risks associated with
delay.\textsuperscript{68 69}

Mask mandates were finally introduced in England on
15\textsuperscript{th} June 2020 (public transport) and
24\textsuperscript{th} July 2020 (all public places). By that time,
public opinion was polarised and many believed it was an ineffective
measure.\textsuperscript{70 71} Whereas most Asian countries had high
public compliance with early masking policies and extremely low death
rates, many Western countries introduced masking late and had many more
deaths, though causal links are complex and confounders
many.\textsuperscript{72}

Masking policies in UK, as in US, met with a strong libertarian backlash
aligned with populist political leaders, right-wing Christianity,
anti-authoritarian social media groups and---latterly---anti-vaccination
groups.\textsuperscript{73-76} In this context, masks came to symbolise
pointless restriction of individual freedom, mindless compliance with
authoritarian governments, and even blasphemy.\textsuperscript{77}

\subsection*{Healthcare settings became occupational health
battlegrounds}

{\label{healthcare-settings-became-occupational-health-battlegrounds}}

As a novel respiratory pathogen, SARS-CoV-2 was initially classified as
a High Consequence Infectious Disease (HCID) by the Four Nations Public
Health Agencies.\textsuperscript{78} Consequently, staff caring for
suspected or confirmed Covid-19 patients required filtering facepiece
{[}FFP3{]} respirators or equivalent.\textsuperscript{79} This reflected
guidance from the UK Health Security Agency (previously Public Health
England) and Health and Safety Executive on other
coronaviruses\textsuperscript{80 81} and avian
influenza,\textsuperscript{82} and legal requirements for employers to
protect their workers against airborne
biohazards.\textsuperscript{83}The Health and Safety Executive had
concluded in 2008 that surgical masks ``\emph{should not be used in
situations where close exposure to infectious aerosols is likely''}
.\textsuperscript{84}

However, minutes from the New and Emerging Respiratory Virus Threats
Advisory Group in March 2020 reflect growing concern about shortages of
respirators and the Department of Health and Social Care's request for
``adapted'' guidance that recommended surgical masks in most
circumstances.\textsuperscript{85} The Deputy Chief Medical Officer
agreed to meet with the Chair of the Advisory Committee on Dangerous
Pathogens,\textsuperscript{85} whose members: ``were unanimous in
supporting the declassification of COVID-19 as a HCID'' (paragraph
2.11)\emph{.} \textsuperscript{85}

A letter to UK healthcare organisations dated
28\textsuperscript{th}March 2020, sent jointly from NHS England and NHS
Improvement, Public Health England and the Academy of Medical Royal
Colleges, affirmed that because of rising Covid-19 cases and because
``more was understood about the behaviour of the virus and its clinical
outcomes'' (i.e. in view of the assumed droplet-but-not-airborne
narrative),\textsuperscript{86}respirator-grade protection would now be
restricted to aerosol-generating procedures.\textsuperscript{86}

The number of UK health and care workers infected with SARS-CoV-2 at
work is not officially documented. Press reports claim that by mid 2021,
around 1500 had died of Covid-19\textsuperscript{87} and 120,000 had
developed long covid (some of whom remained on long-term sick
leave).\textsuperscript{88} In April 2020, excess deaths were noted
amongst healthcare staff (especially men and minority ethnic groups)
working outside intensive care units,\textsuperscript{89} and this
impression was confirmed in subsequent academic
publications.\textsuperscript{90 91} In early 2021, the British Medical
Association\textsuperscript{92} and the Royal College of
Nursing\textsuperscript{93 94} demanded respirator-grade protection for
all staff working with Covid-19 patients.

The latest guidance from the UK Health Security Agency continues to
promote a situationally-airborne narrative and restrict respirator use
to aerosol-generating procedures.\textsuperscript{95} Its guidance cites
contradictory sources---from the World Health Organisation (which
reserves respirator-grade protection for aerosol-generating
procedures),\textsuperscript{52} and US Centers for Disease Control and
Prevention (which recommends respirator-grade protection during all
Covid-19 patient care).\textsuperscript{96} There remains wide variation
in infection control policies in different NHS trusts (perhaps because
some interpret the guidance as mandatory); those which provide
respirator-grade protection appear to have significantly lower
nosocomial infection rates for Covid-19.\textsuperscript{97}

\section*{Discussion}

{\label{discussion}}

At the root of the UK's limited success in controlling transmission of
SARS-CoV-2 lay flawed droplet-but-not-airborne and
situationally-airborne narratives. By presenting elements of the
pandemic as social dramas, we have argued that these narratives, and the
false certainty with which they were conveyed, produced ineffective
public health measures, contributed to shocking levels of care home
deaths, exacerbated toxic discourse on masking, and justified
withholding adequate protection from healthcare staff (especially less
senior doctors and non-medical personnel).

Why did the flawed narratives prevail? One explanation is psychological.
Individuals are unlikely to change their beliefs in light of complex and
contravening evidence, because this requires effort and presents an
aversive state for most people.\textsuperscript{98} Policymakers are
known to exhibit \emph{satisficing---} that is, narrowing the parameters
within which their decisions must make sense and be accountable,
especially when threats are complex and urgent.\textsuperscript{99}

Another explanation is scientific elitism. Scientists in infection
control have amassed considerable scientific capital (i.e. influence,
status, accolades); their favoured methods (randomised controlled
trials) are greatly valued; and they have much to lose if they discard
their long-held droplet narrative and concede the importance of other
kinds of evidence.\textsuperscript{13} The inside track for pandemic
policymaking in the UK and World Health Organisation was narrow and
partisan, enabling an unusual degree of symbolic
violence\textsuperscript{100} to be wielded against outside-track
scientific voices and precluding the kind of interdisciplinary
deliberation that might have allowed a full and fair consideration of
important competing narratives.\textsuperscript{13 101 102}

There are also political explanations. Droplet precautions are, by and
large, under the control of individuals and hence resonate with
neoliberal and libertarian discourses about individual freedom, personal
responsibility and restraint of the state. Airborne precautions require
strategic actions from those responsible for public safety, aligning
with a more socialist-leaning political
discourse.\textsuperscript{25}The World Health Organisation's tweet
(Figure 1) emphasises how to protect \emph{yourself} rather than what to
expect of your employer, your child's school or your government.

Finally, there is populism, whose modus operandi is cherry-picking
evidence that supports the policy drive and valorises anti-science
sentiment under the guise of bringing power to
people.\textsuperscript{76} Populism drew on public desires to return to
normalcy and further marginalised aerosol science by depicting its
recommended measures\textsuperscript{25} as obscure, unaffordable and an
enemy of the public interest.

The narratives and dramas presented in this paper are not exhaustive.
The framing of protection as a matter of individual responsibility, for
example, also accommodates the current political narrative of ``learning
to live with Covid-19'',\textsuperscript{103} in which good citizens
stoically accept the endemicity of a---hopefully attenuating---virus in
exchange for greater individual freedoms.

The Covid-19 pandemic can be framed as what Marcel Mauss calls a ``total
social fact'',\textsuperscript{104} a phenomenon which affects all
domains and layers of society (economic, legal, political, religious)
and requires us to draw evidence from across multiple scientific and
other sub-fields.\textsuperscript{105} In such circumstances, the
combination of policymakers' cognitive biases and satisficing behaviour,
scientists' desire to protect their interests, and politicians'
alignment with individualist values and populist sentiment proved
perilous.

As we approach the second anniversary of the UK's first case of
Covid-19, airborne transmission of SARS-CoV-2 and the mitigations needed
to address it (column b in Table 1) remain misunderstood and
under-recognised. Extraordinarily, a recent UK inquiry into errors made
in the pandemic did not mention masks or ventilation at
all.\textsuperscript{19}

Bold action is now needed to ensure that the science of SARS-CoV-2
transmission is freed from the shackles of historical errors, scientific
vested interests, ideological manipulation and policy satisficing.
Policymakers should actively seek to broaden the scientific inside track
to support interdisciplinarity and pluralism as a route to better
policies, greater accountability and a reduction in the huge inequities
that the pandemic has generated.

\textbf{Declarations} \textbf{of interest:~}MO declares no conflicts of
interest. In November 2020, DT contacted Public Health England, the
Chair of NERVTAG, the Department of Health and Social Care and NHS
England to request improved personal protective equipment for healthcare
staff. In February 2021, TG added her signature to a letter from the
Royal College of Nursing to the UK Prime Minister making a similar
request.

\textbf{Acknowledgements:} Thanks to Alex Hunt of News EU for permission
to reproduce the timeline of mask policy decisions in the Appendix, and
to Birgitte Nerlich for additional background material.

\textbf{Funding:} No specific funding was provided for the writing of
this article. The research on which it was based is funded from the
following sources for TG: UK Research and Innovation via ESRC and NIHR
(ES/V010069/1) and Wellcome Trust (WT104830MA).

\textbf{Author contribution:} The interdisciplinary author team was from
secondary care medicine (DT), primary care and public health (TG), and
critical social science (MO). All authors drafted sections of the
manuscript. TG produced an initial synthesis which was then improved by
iteration and discussion. All authors approved the final manuscript.

\textbf{Data availability:} Not applicable (all data are in the public
domain as this is a review).



\section*{References}

{\label{references}}

1. Klein R, Marmor TR. Politics and policy analysis:
Fundamentals.\emph{Politics, health and health care} 2012:1-21.

2. Stone DA. Policy paradox. New York: Norton 2013.

3. Davidson B. Storytelling and evidence-based policy: lessons from the
grey literature. \emph{Palgrave Communications} 2017;3(1):1-10.

4. Boin A, Stern E, Sundelius B. The politics of crisis management:
Public leadership under pressure: Cambridge University Press 2016.

5. Morawska L, Tang JW, Bahnfleth W, et al. How can airborne
transmission of COVID-19 indoors be minimised? \emph{Environment
international} 2020;142:105832.

6. Turner V. Social dramas and stories about them. \emph{Critical
inquiry} 1980;7(1):141-68.

7. World Health Organisation. Coronavirus press conference 11 February
(transcript). Geneva: WHO 2020.

8. World Health Organization. Public health response to biological and
chemical weapons: WHO guidance. Geneva: WHO 2004.

9. Burki T. Global shortage of personal protective equipment. \emph{The
Lancet Infectious Diseases} 2020;20(7):785-86.

10. World Health Organisation. How is COVID-19 spread and how do you
protect yourself against it? Geneva: WHO (accessed 28th February 2021 at
https://www.facebook.com/WHO/videos/how-is-covid-19-spread-and-how-do-you-protect-yourself-against-it/507223210199209/)
2020.

11. Goldman E. Exaggerated risk of transmission of COVID-19 by
fomites.\emph{The Lancet Infectious Diseases} 2020;20(8):892-93.

12. Chen W, Zhang N, Wei J, et al. Short-range airborne route dominates
exposure of respiratory infection during close contact. \emph{Building
and Environment} 2020:106859.

13. Greenhalgh T, Ozbilgin M, Contandriopoulos D. Orthodoxy, illusio,
and playing the scientific game: a Bourdieusian analysis of infection
control science in the COVID-19 pandemic. \emph{Wellcome Open
Research}2021;6(126) doi: 10.12688/wellcomeopenres.16855.1

14. Killingley B, Nguyen-Van-Tam J. Routes of influenza
transmission.\emph{Influenza Other Respir Viruses} 2013;7 Suppl 2(Suppl
2):42-51. doi: 10.1111/irv.12080 {[}published Online First:
2013/09/27{]}

15. Coia J, Ritchie L, Adisesh A, et al. Guidance on the use of
respiratory and facial protection equipment. \emph{Journal of hospital
Infection} 2013;85(3):170-82.

16. Scientific Advisory Group on Emergencies. Meeting 8, 18th February.
London: Gov.uk 2020.

17. Antimicrobial Resistance and Healthcare Associated Infection
Scotland (ARHAI). Assessing the infection prevention and control
measures for the prevention and management of COVID-19 in health and
care settings (version 11). Edinburgh: NHS Scotland 2021.

18. Wang CC, Prather KA, Sznitman J, et al. Airborne transmission of
respiratory viruses. \emph{Science} 2021;373(6558):eabd9149.

19. House of Commons Health and Social Care and Science and Technology
Committees. Coronavirus: lessons learned to date. Sixth report of the
Health and Social Care Committee and Third Report of the Science and
Technology Committee of Session 2021-22. London: Her Majesty's
Government 2021.

20. Public Health England. {[}Withdrawn{]} Guidance on social distancing
for everyone in the UK. London: PHE 2020.

21. Government of Japan. Expert Meeting on the Novel Coronavirus Disease
Control ''Views on the Novel Coronavirus Disease Control'', 9th March.
Tokyo: Japanese Government. Accessed 22nd March 2021 at
https://www.mhlw.go.jp/content/10900000/000608425.pdf 2020.

22. Jefferson T, Jones M, Al Ansari LA, et al. Physical interventions to
interrupt or reduce the spread of respiratory viruses. Part 1-Face
masks, eye protection and person distancing: systematic review and
meta-analysis. \emph{Cochrane Database of Systematic Reviews} 2020;11

23. World Health Organisation. Update on Covid-19 Guidelines
Development. Geneva: WHO 2021.

24. Parkhurst JO, Abeysinghe S. What constitutes ``good'' evidence for
public health and social policy-making? From hierarchies to
appropriateness. \emph{Social Epistemology} 2016;30(5-6):665-79.

25. Morawska L, Allen J, Bahnfleth W, et al. A paradigm shift to combat
indoor respiratory infection. \emph{Science} 2021;372(6543):689-91. doi:
10.1126/science.abg2025

26. Tang J, Li Y, Eames I, et al. Factors involved in the aerosol
transmission of infection and control of ventilation in healthcare
premises. \emph{Journal of Hospital Infection} 2006;64(2):100-14.

27. Sattar SA, Ijaz MK, Gerba CP. Spread of viral infections by
aerosols. \emph{Critical Reviews in Environmental Science and
Technology} 1987;17(2):89-131.

28. Bourouiba L. Turbulent gas clouds and respiratory pathogen
emissions: potential implications for reducing transmission of
COVID-19.\emph{Jama} 2020;323(18):1837-38.

29. Jones NR, Qureshi ZU, Temple RJ, et al. Two metres or one: what is
the evidence for physical distancing in covid-19? \emph{bmj} 2020;370

30. Greenhalgh T, Jimenez JL, Prather KA, et al. Ten scientific reasons
in support of airborne transmission of SARS-CoV-2. \emph{The
Lancet}2021;397(10285):1603-05.

31. Prather KA, Wang CC, Schooley RT. Reducing transmission of
SARS-CoV-2. \emph{Science} 2020;6498:1422-24.

32. Tang JW, Bahnfleth WP, Bluyssen PM, et al. Dismantling myths on the
airborne transmission of severe acute respiratory syndrome coronavirus
(SARS-CoV-2). \emph{Journal of Hospital Infection} 2021;110:89-96.

33. Lewis D. Superspreading drives the COVID pandemic-and could help to
tame it. \emph{Nature} 2021;590(7847):544-46.

34. Stadnytskyi V, Anfinrud P, Bax A. Breathing, speaking, coughing or
sneezing: What drives transmission of SARS-CoV-2? \emph{J Intern
Med}2021 doi: 10.1111/joim.13326 {[}published Online First:
2021/06/10{]}

35. Gelfand HM, Posch J. The recent outbreak of smallpox in Meschede,
West Germany. \emph{American journal of epidemiology} 1971;93(4):234-37.

36. Oran DP, Topol EJ. The proportion of SARS-CoV-2 infections that are
asymptomatic: a systematic review. \emph{Annals of internal
medicine}2021 doi: https://doi.org/10.7326/M20-6976

37. Johansson MA, Quandelacy TM, Kada S, et al. SARS-CoV-2 Transmission
From People Without COVID-19 Symptoms. \emph{JAMA network
open}2021;4(1):e2035057-e57.

38. He X, Lau EH, Wu P, et al. Temporal dynamics in viral shedding and
transmissibility of COVID-19. \emph{Nature medicine} 2020;26(5):672-75.

39. Bulfone TC, Malekinejad M, Rutherford GW, et al. Outdoor
Transmission of SARS-CoV-2 and Other Respiratory Viruses: A Systematic
Review. \emph{The Journal of infectious diseases} 2021;223(4):550-61.

40. Morawska L, Milton DK. It is time to address airborne transmission
of coronavirus disease 2019 (COVID-19). \emph{Clinical Infectious
Diseases} 2020;71(9):2311-13.

41. Klompas M, Baker MA, Rhee C, et al. A SARS-CoV-2 cluster in an acute
care hospital. \emph{Annals of internal
medicine}2021:https://doi.org/10.7326/M20-567.

42. Pan M, Lednicky JA, Wu CY. Collection, particle sizing and detection
of airborne viruses. \emph{Journal of applied
microbiology}2019;127(6):1596-611.

43. Van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface
stability of SARS-CoV-2 as compared with SARS-CoV-1. \emph{New England
Journal of Medicine} 2020;382(16):1564-67.

44. Santarpia JL, Rivera DN, Herrera VL, et al. Aerosol and surface
contamination of SARS-CoV-2 observed in quarantine and isolation
care.\emph{Sci Rep} 2020;10(1):12732. doi: 10.1038/s41598-020-69286-3
{[}published Online First: 2020/07/31{]}

45. Lednicky JA, Lauzardo M, Alam MM, et al. Isolation of SARS-CoV-2
from the air in a car driven by a COVID patient with mild
illness.\emph{International Journal of Infectious Diseases} 2021;epub
ahead of print. https://doi.org/10.1016/j.ijid.2021.04.063 doi:
10.1101/2021.01.12.21249603

46. Nissen K, Krambrich J, Akaberi D, et al. Long-distance airborne
dispersal of SARS-CoV-2 in COVID-19 wards. \emph{Scientific
reports}2020;10(1):1-9.

47. 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. \emph{Nature Communications} 2021;12(1):1-8.

48. Endo A, Abbott S, Kucharski AJ, et al. Estimating the overdispersion
in COVID-19 transmission using outbreak sizes outside
China.\emph{Wellcome Open Research} 2020;5:67.

49. 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.\emph{Available at SSRN} 2021

50. World Health Organisation. Infection prevention and control during
health care when coronavirus disease (COVID-19) is suspected or
confirmed. Geneva: WHO. Accessed 5th July 2020 at
https://www.who.int/publications/i/item/WHO-2019-nCoV-IPC-2020.4 2020
(updated 29th June).

51. Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and
risk of transmission of acute respiratory infections to healthcare
workers: a systematic review. \emph{PloS one} 2012;7(4)

52. World Health Organization. Transmission of SARS-CoV-2: implications
for infection prevention precautions: scientific brief, 09 July 2020.
Geneva: WHO, 2020.

53. Bahl P, Doolan C, de Silva C, et al. Airborne or droplet precautions
for health workers treating COVID-19? \emph{The Journal of infectious
diseases} 2020

54. Jackson T, Deibert D, Wyatt G, et al. Classification of
aerosol-generating procedures: a rapid systematic review. \emph{BMJ open
respiratory research} 2020;7(1):e000730.

55. Bourdieu P. Outline of a Theory of Practice: Cambridge university
press 1977.

56. Douglas M. Purity and danger: An analysis of concepts of taboo and
pollution. London: Routledge and Kegan Paul 1966.

57. Wu Z, McGoogan JM. Characteristics of and important lessons from the
coronavirus disease 2019 (COVID-19) outbreak in China: summary of a
report of 72 314 cases from the Chinese Center for Disease Control and
Prevention. \emph{JAMA} 2020;323:1239-42.

58. Office for National Statistics. Deaths involving COVID-19 in the
care sector, England and Wales: deaths registered between week ending 20
March 2020 and week ending 2 April 2021. London: ONS 2020.

59. Amnesty International. As if expendable: The UK government's failure
to protect older people in care homes during the COVID-19 pandemic.
London: Amnesty International 2020.

60. Public Health England. COVID-19 Infection Prevention and Control
London: UK Government 2021.

61. Health and Social Care Committee. Oral evidence from Professor Terry
Lum: Management of The Coronavirus Outbreak, HC36. London: Her Majesty's
Government 2020.

62. Boaz D. Libertarianism. New York: Simon and Schuster 2010.

63. Scientific Advisory Group on Emergencies. Meeting 4, 4th February.
London: Gov.uk 2020.

64. Scientific Advisory Group on Emergencies. Meeting 2, 28th January.
London: Gov.uk 2020.

65. Baynes C. Coronavirus: Face masks could increase risk of infection,
medical chief warns. \emph{Independent} 2020;12th March(Accessed
17.10.21 at
https://www.independent.co.uk/news/health/coronavirus-news-face-masks-increase-risk-infection-doctor-jenny-harries-a9396811.html)

66. Public Health England. COVID-19: Donning and doffing of Personal
Protective Equipment in Health and Social Care Settings. London: PHE
2020:Accessed 17.10.21 at https://www.youtube.com/watch?v=-GncQ\_ed-9w.

67. Czypionka T, Greenhalgh T, Bassler D, et al. Masks and face
coverings for preventing the spread of Covid-19: a narrative
review.\emph{Ann Int Med} 2020;174:511-20.

68. Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the
public during the covid-19 crisis. \emph{Bmj} 2020;369:m1435. doi:
10.1136/bmj.m1435 {[}published Online First: 2020/04/11{]}

69. Howard J, Huang A, Li Z, et al. An evidence review of face masks
against COVID-19. \emph{Proceedings of the National Academy of
Sciences}2021;118(4)

70. The Royal Society and British Academy. Face masks and coverings for
the general public: Behavioural knowledge, effectiveness of cloth
coverings and public messaging. London: The Royal Society and British
Academy. Accessed 27th September 2020 at
https://royalsociety.org/-/media/policy/projects/set-c/set-c-facemasks.pdf
2020.

71. Taylor S, Asmundson GJ. Negative attitudes about facemasks during
the COVID-19 pandemic: The dual importance of perceived ineffectiveness
and psychological reactance. \emph{Plos one} 2021;16(2):e0246317.

72. Leffler C, Ing E, Lykins J, et al. Association of country-wide
coronavirus mortality with demographics, testing, lockdowns, and public
wearing of masks. \emph{Am J Trop Med Hyg} 2020;103:2400-11. doi:
10.1101/2020.05.22.20109231

73. Lee C, Yang T, Inchoco GD, et al. Viral Visualizations: How
Coronavirus Skeptics Use Orthodox Data Practices to Promote Unorthodox
Science Online. \emph{Proceedings of the 2021 CHI Conference on Human
Factors in Computing Systems} 2021:1-18.

74. Harsin J. Toxic White masculinity, post-truth politics and the
COVID-19 infodemic. \emph{European Journal of Cultural
Studies}2020;23:1060-68.

75. McKee M, Gugushvili A, Koltai J, et al. Are Populist Leaders
Creating the Conditions for the Spread of COVID-19?; Comment on ``A
Scoping Review of Populist Radical Right Parties' Influence on Welfare
Policy and its Implications for Population Health in
Europe''.\emph{International journal of health policy and management}
2020

76. Speed E, Mannion R. The rise of post-truth populism in pluralist
liberal democracies: challenges for health policy. \emph{International
journal of health policy and management} 2017;6(5):249.

77. Lupton D, Southerton C, Clark M, et al. The Face Mask In COVID
Times: A sociomaterial analysis. The Face Mask In COVID Times: De
Gruyter 2021.

78. New and Emerging Respiratory Virus Threats Advisory Group. Minutes
01, 13th January. London: NERVTAG 2020.

79. Poller B, Tunbridge A, Hall S, et al. A unified personal protective
equipment ensemble for clinical response to possible high consequence
infectious diseases: A consensus document on behalf of the HCID
programme. \emph{Journal of Infection} 2018;77(6):496-502.

80. Care DoHaS. MERS-CoV: infection control for possible or confirmed
cases. London: Gov.uk 2013.

81. Health and Safety Executive. Severe acute respiratory syndrome
(SARS). London: HSA Undated.

82. Public Health England. Investigation and initial clinical management
of possible human cases of avian influenza viruses that have been
associated with severe human disease. London: Gov.uk 2020.

83. Legislation.Gov. Control of Substances Hazardous to Health (COSHH)
Regulations. London: Gov.uk 2002.

84. Health and Safety Executive. Evaluating the protection afforded by
surgical masks against influenza bioaerosols London: HSE 2008.

85. New and Emerging Respiratory Virus Threats Advisory Group. Meeting
09, 13th March. Lonodon: NERVTAG 2020.

86. NHS England and NHS Improvement. Letter to Chief Executives of all
NHS Trusts (publication reference 001559), 28th March. Lonfon: NHSE/I
2020.

87. King J. Over 1,500 NHS and care workers have now died with
Covid.\emph{Metro} 2021;14th July

88. Tucker M, Kenyon P. Long Covid pay decision for key workers could
take a year. \emph{BBC News online} 2021;18th May

89. Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from
covid-19 analysed. \emph{Health Service Journal} 2020;22nd April

90. Eyre DW, Lumley SF, O'Donnell D, et al. Differential occupational
risks to healthcare workers from SARS-CoV-2 observed during a
prospective observational study. \emph{Elife} 2020;9:e60675.

91. Shah AS, Wood R, Gribben C, et al. Risk of hospital admission with
coronavirus disease 2019 in healthcare workers and their households:
nationwide linkage cohort study. \emph{bmj} 2020;371

92. Tonkin T. Call for enhanced PPE. London: BMA 2021.

93. Royal College of Nursing. RCN Position on Personal Protective
Equipment (PPE) for COVID-19. London: RCN 2021.

94. Gould D, Purssell E. Guidelines for the prevention and control of
Covid-19 in health care settings in the United Kingdom: evaluation and
messages for future infection-related emergency planning. London: Royal
College of Nursing 2021.

95. UK Health Security Agency. COVID-19: guidance for maintaining
services within health and care settings -- infection prevention and
control recommendations. London: Gov.uk 2021.

96. Centers for Disease Control and Prevention (US). Scientific Brief:
SARS-CoV-2 Transmission (updated 7th May). Atlanta: CDC 2021.

97. Lawton T, Butler M, Peters C. Airborne protection for staff is
associated with reduced hospital-acquired COVID-19 in English NHS
Trusts. \emph{Authorea Preprints} 2021

98. Lewandowsky S, Ecker UK, Seifert CM, et al. Misinformation and its
correction: Continued influence and successful
debiasing.\emph{Psychological science in the public interest}
2012;13(3):106-31.

99. Gigerenzer G. Bounded Rationality: The Adaptive Toolbox. Cambridge,
MA: MIT Press 2002.

100. Bourdieu P, Wacquant LJd. An invitation to reflexive sociology.
Chicago: University of Chicago Press 1992.

101. Freedman L. Scientific Advice at a Time of Emergency. SAGE and
Covid-19. \emph{The Political Quarterly} 2020;91(3):514-22.

102. Whitty CJ. What makes an academic paper useful for health policy?:
BioMed Central, 2015.

103. Pugh J, Wilkinson D, Savulescu J. Learning to live with COVID --
the tough choices ahead. \emph{The Conversation} 2021;16th April

104. Mauss M. The Gift: The Form and Reason for Exchange in Archaic
Societies (translated by W.D. Halls with a foreword by Mary Douglas).
London: Routlledge {[}1925{]}, 1990.

105. Chanlat J-F. La catastrophe sanitaire actuelle: un fait social
total. \emph{Le Libellio d'AEGIS} 2020;16(7):3-30.

\selectlanguage{english}
\FloatBarrier
\end{document}

