Summary
Approximately 1,000[1] UK health and care workers have died from Covid-19. Many were working with Covid-positive patients and with substandard Personal Protective Equipment (PPE). It is estimated that a further 122,000 health service workers who contracted Covid-19 are struggling with prolonged symptoms, often referred to as Long Covid. It has also become clear that a significant number of inpatients who had Covid-19, acquired the virus whilst in hospital.[2][3]
In this opinion piece, Dr David Tomlinson argues that current PPE guidance still fails to adequately protect staff and patients against the airborne nature of the Covid-19 virus. David highlights the attempts made by many to raise their related safety concerns; arguing that the response to date has been inadequate, unsafe and unlawful.
Content
Frontline healthcare staff have undoubtedly been disproportionately affected by Covid-19 infections.[4][5][6] Issues with PPE supplies at the start of pandemic and a failure to respond to the virus as airborne, meant that many were working without adequate protection. This left thousands of staff and patients vulnerable to hospital acquired infections, and increased the risk of the virus being transmitted to loved ones at home.[7][8]
It is essential now that all measures are taken to prevent further avoidable harm. In this article, I talk about the dangerous holes that remain in current PPE guidance;[9][10] drawing on evidence and personal experience to explain why we need urgent action.
General ward staff most vulnerable
Denied access to enhanced PPE
The potential for this virus to be airborne was highlighted by experts[11] right at the start of the pandemic, and through preprint research papers.[12]
Despite these early findings, in March 2020 UK PPE guidance for Covid-19 facing healthcare workers was downgraded.[13] It went from requiring airborne protection for all, to reserving airborne PPE only for those undertaking aerosol generating procedures which are mainly performed in an Intensive Care Unit (ICU).
This left healthcare workers on general Covid wards without airborne PPE, at unnecessarily greater risk. That same Public Health England guidance remains in place today.
Treating patients at their most contagious
Significantly, data on Covid-19 patients also demonstrate that peak infectious viral loads occur around the time of initial symptom onset.[14] This is also the point at which people with Covid-19 were most likely to be first admitted to hospital (typically day 4 following symptom onset).
This means that patients were actually more infectious when being treated by staff working on a general ward, than when they were transferred, if necessary, to ICU (typically day 8).
Working in poorer ventilated spaces
To add another increased risk factor, minimum standards of hospital ventilation[15] for ICU are far superior to those for general wards. Staff working on general wards may only benefit from three air changes per hour compared to 10 in ICUs (unless they supplement manually, with open windows for example).
Coughing – a greater risk than intubation
In October last year, investigators from Bristol[16] demonstrated that voluntary coughing was a far greater aerosol generating process than either intubation or extubation (both of which remain at the top of the list of aerosol generating procedures; warranting enhanced PPE).[17]
The combination of factors highlighted above creates a ‘perfect storm’ for greater infection risk amongst non-ICU healthcare workers.[18]
Raising safety concerns: a wild goose chase
In October 2020, a third UK-based report was published demonstrating significantly greater risk of Covid-19 infection and/or death in non-ICU UK patient-facing staff.[19] Surely someone would listen now?
I emailed Public Health England South West, requesting the urgent provision of FFP3 respirators, or equivalent, to all UK healthcare workers in Covid-19 facing roles. I have yet to receive a reply.
While waiting, I emailed [Appendix A] Professor Peter Horby, NERVTAG Chair who advised I try the Department of Health and Social Care or Public Health England.
So, I emailed the Department.
They replied in December to say that I should try Public Health England, giving me a different email address.
So, I emailed Public Health England.
Before Christmas, my email was also sent to two MPs, who forwarded it to Sir Simon Stevens and Matt Hancock’s Special Advisor.
In January, Public Health England replied to say that I should contact NHS England.
So, I did.
They replied on 7 May advising, ‘you should wait for a response from your MP.’
The British Medical Association and Royal College of Nursing also wrote to Public Health England requesting enhanced PPE for all Covid-19 facing healthcare workers. It was denied.
Fresh Air NHS wrote to the Prime Minister, requesting better ventilation and airborne PPE for all UK healthcare workers. The letter was signed by around 1,600 professionals. There has been no response.
We were all raising serious safety concerns, but it felt like we were screaming into a vacuum. No one was listening. No one was taking responsibility.
Refusal to change the guidance
Finally, on 17 May 2021, I received this reply, via an MP:
‘The UK-wide IPC Cell, a team within NHSE that looks at the updating of the IPC guidance, recently reviewed evidence in relation to the transmission route of COVID-19 and the IPC precautions required, and agreed that no changes to the current PPE requirements were needed.’ (Appendix B)
I was appalled. Not only have approximately 1,000[20] UK healthcare workers died from Covid-19, with significantly greater risk in those working on general wards, but in December 2020, the World Health Organisation (WHO) had stated that airborne respirators:
‘…may be used by health workers when providing care to COVID-19 patients in other settings if they are widely available and if costs is not an issue.’ [21]
More recently, WHO strengthened its wording on aerosol transmission, stating:
‘A person can be infected when aerosols or droplets containing the virus are inhaled or come directly into contact with the eyes, nose, or mouth.’[22]
The airborne nature of the Covid-19 virus is now recognised by experts around the world,[23][24][25][26][27] yet in the UK we continue to be led by PPE guidance that is failing to respond to the threat this presents.
Consequences of inaction: A PPE postcode lottery
The consequences of continued inaction are clear. With novel variants demonstrating greater transmissibility and possible vaccine escape, non-ICU staff who are denied airborne PPE will continue to suffer disproportionately greater rates of infection, Long Covid and/or death.
Furthermore, with airborne PPE a legal requirement according to workplace safety legislation,[28] employers following Public Health England guidance risk substantial financial exposure. These issues have been recognised by 17[29] ‘exemplar’ NHS organisations, who mandate FFP3 respirator use for all Covid-19 patient care – not just ICU staff.
This PPE ‘postcode lottery’ will continue for as long as Public Health England, NHS England, IP Cell, the 4 nation Chief Medical Officers, or whoever has responsibility for PPE guidance, continue to remain anchored on a scientifically invalid model of respiratory virus transmission (ie via large droplets).
Questions need to be answered
In his recent evidence to the Coronavirus Lessons Learned, Science and Technology Committee, the Prime Minister’s former Special Advisor Mr Dominic Cummings stated:
“Even now—even today—the Government communications are still over-stressing ‘Wash your hands’ and under-stressing airborne.”[30]
This leads us on to a number of important questions that need to be answered:
- Why is the extensive literature indicating the importance of the aerosol / airborne route of transmission, still being ignored?
- Why are the safety requests of concerned NHS employees and pleas of their union representatives being denied?
- Why was the PPE guidance downgraded, advising basic surgical mask use amongst non-ICU teams, considering the virus was originally designated an ‘airborne high consequence infectious disease’,[31] requiring airborne PPE for all known or suspected Covid-19 patient contacts?
- Healthcare and medico-political leaders are aware of the increased risk to non-ICU, patient-facing healthcare workers, so why haven’t they changed the guidance to provide better protection?
Final thoughts and call to action
Denying the objective nature of reality never ends well. Such a persistent denial of the airborne nature of Covid-19 transmission indicates a gross and negligent failure of medico-political leadership. The safety of staff and patients is being gambled as a consequence.
There needs to be an urgent review of the PPE guidance to ensure that it is lawful, evidence-based, reflective of the airborne nature of the Covid-19 virus, and that safety is prioritised. Providing enhanced PPE to everyone working in non-ICU Covid-19 wards, would offer some much-needed reassurance that our leaders are committed to protecting both patients and staff from avoidable infection and the associated consequences.
Suggested reading
- Benefits of & reusable P3 respirators for UK COVID-19 PPE inequalities (a presentation by Dr Gillian Higgins)
- Why is staff safety a patient safety issue?
- We all want a culture of speaking up, don’t we? So, why isn’t it happening?
- How will NHS staff with Long Covid be supported?
Appendices
Appendix A – Email raising concerns
Dear …….,
At the 48th meeting of SAGE, 23rd July, you were part of a group which endorsed the EMG paper on aerosol transmission [of SARS-CoV-2] including this statement (p.6):“Well-fitting respiratory protective equipment which meets the standards for FFPs or FFP2 are shown to be effective at stopping small aerosols. However these are only considered to be appropriate where there is a significant risk of aerosol transmission, for example during aerosol generating procedures in a healthcare or dental setting.”
Following the release of a third report demonstrating significantly greater risk of SARS-CoV-2 infection and/or death in non-ICU UK patient-facing staff, I am writing to request your urgent review of the current PHE (UK) infection prevention and control (IP&C) PPE policy for all “front line” health and social care staff.
As you are probably aware, last week’s BMJ (https://doi.org/10.1136/bmj.m3582) included the third such report, describing how: "patient facing healthcare workers (HCWs, n=158,445) compared with non-patient facing HCWs, were at higher risk [of SARS-CoV-2 infection] (HR 3.30, 2.13-5.13)...after sub-division of patient facing HCWs into…front door, ICU, non-ICU aerosol generating settings and other, those in front door roles were at higher risk (HR 2.09, 1.49-2.94).”
The second report was released as a medRxiv preprint in June 2020 (https://doi.org/10.1101/2020.06.24.20135038, n=9,809 HCWs), in which an Oxford research team demonstrated: “Risk of Covid-19 infection varied by specialty, even accounting for working in a Covid-19 facing area. Those working in acute medicine were at increased risk, (aOR 1.5, 95% CI 1.05 – 2.15, p=0.03), while ICUs were at lower risk (0.46, 0.29 – 0.72, p=0.001).”
Finally, a report into 106 HCW deaths from Covid-19 dating to 22nd April 2020, described how none of the deceased medical or nursing staff were anaesthetists, intensivists, or worked on intensive care (https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article#.X6sZAWaIZ28.twitter).
These findings can be understood when considering that presently, front-door (non-ICU) HCWs involved with Covid-19 patient care are in a “perfect storm” of greater infection risk, yet with sub-optimal PPE:
Front door (non-ICU) HCWs are exposed to patients at a time of greatest Covid-19-associated viral load.
o The median duration of infectious viral shedding in hospitalised patients with Covid-19 is 8 days (IQR 5-11, https://doi.org/10.1101/2020.06.08.20125310), with peak infectious viral load from 1-2 days before the onset of symptoms (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/933225/S0824_SARS-CoV-2_Transmission_routes_and_environments.pdf).
o The median time from onset of symptoms of Covid-19 in the community to presentation at hospital is 4 days (IQR 1-8)" (ISARIC A4, n=20,133https://doi.org/10.1136/bmj.m1985).
o The median time from symptom onset to severe hypoxaemia and ICU admission is approximately 7–12 days (https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30161-2/fulltext#seccestitle30).
o The typical front door HCW working environments (i.e. non-isolation wards) are subject to lower standards of ventilation compared to the ICU: 6 air changes per hour (AC/hr) is permitted on general wards, half of which may be passive (i.e. requiring windows to be open and subject to important external environmental fluctuations), compared to 10 AC/hr on ICU, all of which must be mechanical (https://www.gov.uk/government/publications/guidance-on-specialised-ventilation-for-healthcare-premises-parts-a-and-b).
o Airborne transmission of SARS-CoV-2 is now acknowledged by WHO, CDC, ECDC, SAGE (UK) and PHE (UK), and speaking is recognised to be an important aerosol-generating activity (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/910885/COVID-19_Infection_prevention_and_control_guidance_FINAL_PDF_20082020.pdf).
o Front door (non-ICU) HCWs have a lower “requirement” for PPE, since only ICU staff are routinely permitted to wear FFP3-equivalent respirators offering suitable protection against aerosol transmission, according to current PHE (UK) IP&C guidelines (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/910885/COVID-19_Infection_prevention_and_control_guidance_FINAL_PDF_20082020.pdf).
Moreover, providing novel insights into the present designation of intubation and/or extubation as high-risk aerosol generating procedures through “real-time, high-resolution environmental monitoring”, investigators from Bristol in a manuscript accepted 2nd October 2020 (https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/anae.15292) concluded:
“The study does not support the designation of elective tracheal intubation as an aerosol generating procedure. Extubation generates more detectable aerosol than intubation but falls below the current criterion for designation as a high-risk aerosol-generating procedure.” This was based on the finding: “Using the quantity and concentration of aerosolised particles generated by volitional coughs as a reference, we have shown that both intubation and extubation sequences produce less aerosol than voluntary coughing.”
While it is technically impossible to re-engineer ventilation systems within all healthcare premises to achieve ICU-levels of safety, the provision of FFP3 (or equivalent) respirators to all UK HCWs in Covid-19 facing roles could be readily achieved at the necessary scale and pace to help reduce the risk of HCW-associated SARS-CoV-2 infection.
As a GMC registered clinician with a responsibility to protect the health of the public, my concern over this public health issue is genuine. I hope you are able to give this matter your urgent attention, please.
Many thanks.
Yours sincerely
David R. Tomlinson BM BSc MD MRCP
Appendix B – response received via an MP
References
[1] Shukman D, 2021. Covid-19: Health staff in plea for better protection. BBC, accessed 7/06/21.
[3] GOV.UK, 2021. Dynamic CO-CIN report to SAGE and NERVTAG, 5 May (page 5). Accessed 7/06/21.
[20] Shukman D, 2021. Covid-19: Health staff in plea for better protection. BBC, accessed 7/06/21.
[23] Gale J, 2021. Covid Is Airborne, Scientists Say. Now Authorities Think So, Too. Bloomberg. Accessed 07/06/21.
[25] Rabin R and Anthes E, 2021. The virus is an airborne threat, the C.D.C. acknowledges. New York Times. Accessed 7/06/21.
[28] HSE, 1974. Health and Safety at Work etc Act 1974.
[29] Shukman D, 2021. Covid-19: Health staff in plea for better protection. BBC. Accessed 7/06/21.
[31] UK Advisory Committee on Dangerous Pathogens, January 2020.
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