2026/05/01 by Raymond Agius, Raymond M Agius, Amy Small +1 · 1 voice
Health Professions · #Disaster Response and Management #Ethics in medical practice #Healthcare Systems and Challenges
paper · doi:10.1093/occmed/kqag055
openalex publication_date 2026/05/01 · openalex created_date 2026/05/31 · openalex updated_date 2026/07/31
The UK Covid-19 Inquiry March 2026 Module 3 report has revealed ‘fundamental flaws in the UK’s approach to infection prevention and control in health care settings’ [1]. There had been ‘an initial misunderstanding of the level of risk posed by aerosol transmission’ which was aggravated by ‘insufficient caution’ and the lack of multidisciplinary expertise among the decision-makers. ‘The guidance therefore failed to recommend measures, such as wider use of respiratory protective equipment and increased ventilation’, and together with ‘shortages of PPE’ (Personal Protective Equipment) led to ‘a failure to properly protect patients and health care workers’ (HCW) [1]. Planning for aerosol-transmitted infections had been advocated before the pandemic [2], and potential risks to HCWs had been highlighted early in the pandemic [3]. Epidemiologic and experimental research convincingly showed that COVID-19 was transmitted by the airborne route [4]. Infected aerosols arose from patients’ breathing and coughing and not primarily from so-called ‘Aerosol Generating Procedures’ – a concept which, as recognized by the Inquiry [1], lacked an evidence base and was misleading [5]. The importance of adequately controlling the dominant aerosol spread was not acknowledged and acted upon when it should have been early in the pandemic [6]. The medical profession should now be further empowered to exhort the authorities to follow the Inquiry’s recommendations and thus to protect the health of HCW. Improved risk assessments are needed to implement effective measures within a ‘hierarchy of controls’ to interrupt the pathways of ‘aerosol transmission’, and not merely the traditional default assumption of ‘droplet spread’ alone. Earlier in the pandemic, a paradigm shift in engineering measures, including ventilation, filtration and ultraviolet germicidal irradiation (UVGI) [7] was advocated to reduce the risk of contracting COVID-19 and other airborne infections. The Inquiry recommended improvements in the NHS estate, especially the incorporation of suitable ventilation within hospital design, with interim measures such as portable High Efficiency Particulate Air filtration [1]. To help implement the wider recommendations of the Inquiry, ‘respiratory hygiene’ should be practised in the healthcare system as a ‘transmission-based precaution’ [1]. When the residual risk of personal exposure is high enough, as it was during the pandemic waves and as it can still be in circumstances of caring for patients with airborne infections, HCWs should wear filtering facepiece respirators (e.g. FFP2/3) or equivalent [8,9]. These measures interrupt transmission pathways and thus reduce the risk both to HCW and to patient safety [10]. As asserted by the Inquiry [1], fit testing and adequate training in respirator use, as well as a diverse range of PPE (including powered respirators), are important measures. These steps should be pursued to at least the same degree as ‘hand hygiene’ has been traditionally advocated in the health care sector. Corresponding efforts are required to amend the General Medical Council’s ‘Good Medical Practice’ and to update the training and educational curricula of Royal Colleges, Faculties and medical schools. The Inquiry acknowledged that ‘the evidence suggests that HCW were at a higher risk of developing long COVID during the pandemic as a consequence of their greater exposure to COVID-19’, and recommended improved data collection, such as on ‘deaths of HCW in the event of a pandemic’ [1]. An official evidence synthesis by the Industrial Injuries Advisory Council (IIAC) had concluded that occupational exposure of HCW had resulted in at least a doubling of risk of long COVID outcomes in HCW arising from their occupational exposure [11]. Powerful cohort studies, both in England [12] and elsewhere [13], show the high risk of long COVID associated with occupational exposure, especially in health and social care. The Inquiry’s findings of shortfalls in the protection of HCWs should put further pressure on the Government to implement the IIAC recommendations for statutory compensation of the specified reliably diagnosed long COVID outcomes. Better means of diagnosing other COVID sequelae, for which IIAC has shown that the risk threshold has been exceeded, would provide support for widening the extent of statutory compensation. In parallel with this, the rehabilitation of affected workers, especially HCW still suffering from long COVID, should be actively pursued. This needs ‘the timely collection and analysis of reliable data, research into the impact of long-term illnesses and the evaluation of treatments as they develop’ [1,14]. The Inquiry also recognized ‘the negative impact of the pandemic upon the mental health of HCW’ and that it was ‘likely to have affected patients’ and correspondingly recommended psychological support for HCW as another component of future pandemic planning [1]. It is essential that in post-COVID outbreaks caused by airborne pathogens, whether they be viruses or other organisms (such as Hantavirus [15] and Meningococcus B), the authorities should adopt the recommendations made in the Inquiry’s Module 3 report. They must implement adequate precautionary measures, including using effective respirators to protect HCWs caring for infected patients, and eschew the ‘false dichotomy’ between droplet and aerosol transmission [1]. None declared. R.M.A. is a member of the Council of the British Medical Association (2022–26). From 2019 to 2024 he was an Independent Expert Member of the Industrial Injuries Advisory Council. A.S. is Clinical Advisor to Chest Heart and Stroke Scotland, supporting people living with long COVID. She is on the National Services Scotland Long COVID Implementation Group and gave evidence to the Scottish COVID Inquiry in 2024. A.S. is elected to several BMA committees and sits on the COVID Steering Group. A.S. lives with long COVID. From September 2020 to December 2022 M.R.S. was a member of the Infection Control Expert Group providing advice to the Australian Government during the COVID-19 pandemic.