Respiratory protective equipment: An unequal solution for healthcare workers? A blog by David Osborn

Summary

In this blog, I discuss the limitations associated with FFP3 (Filtering Face Piece) tight-fitting masks as respiratory protective equipment (RPE) for the healthcare sector during the ongoing Covid pandemic. I highlight inequalities in the distribution of effective RPE among healthcare workers (HCWs) and also draw attention to the underlying reasons for the shortage of RPE that has beset our healthcare services since the start of the pandemic.

Content

The opening sequence of the new ITV drama, Breathtaking,  shows Dr Abbey Henderson failing a ‘face fit test’ when using a FFP3 respirator during the Covid pandemic. The explanation by the person carrying out the test "...these FFP3s are made for wider jaws" and Dr Henderson’s comment in return "...life-saving for men!" ring true – i.e., with a respirator that didn’t provide a tight fit to her face she was endangered by the airborne virus being able to enter the FFP3 and infect her. This short clip from the TV drama exposes a major failing in the provision of tight-fitting RPE for healthcare workers during the pandemic.

The 'Sheffield Dummy Head'

With no offence to white men living in Sheffield, let me introduce the 'Sheffield Dummy Head'

Source: Scince Purge Technology

FFP3 respirators must be tested and certified to conform to the standard BS EN 149:2001. This requires the FFP3 to be mounted on a Sheffield Dummy Head, which represents the facial features of a white male. The same dummy head is also used for BS EN 140:1999 which is the standard for a reusable type of tight-fitting RPE such as elastomeric half-masks. The use of this device for testing and certifying RPE dates back over 30 years.

It is illegal for PPE suppliers to sell RPE in the UK which does not conform to these standards. No provision was made during the pandemic planning process to cater for and protect other ethnic groups or females who have different facial characteristics (morphology). In a diverse working community such as the NHS this was a major omission.

There was also a failure to consider men of certain faiths who are required to have beards and other faiths where they choose to do so as a symbol of religious piety or devotion. Tight-fitting masks simply don’t provide an effective seal to the face when used with facial hair.

Therefore, we have to call into question the level of compliance with the Equality Act 2010 since, on the face of it, the omission to provide effective RPE protection for all workers regardless of gender, faith or ethnicity would appear to be a contravention of this legislation.

In my opinion, as a health and safety consultant, the biggest failing of all was the single-focus on FFP3 tight-fitting masks as RPE for the healthcare sector. I do not consider them at all appropriate for prolonged close-quarter care of infectious patients.

Powered Air Purifying Respirators (PAPRs)

FFP3s are uncomfortable, shouldn’t be worn for more than an hour and can cause facial irritation. PAPRs would be better, such as the PeRSo (Personal Respirator Southampton) developed by Southampton University in the height of the pandemic.

A fan pumps air through a high-grade HEPA filter worn on the belt and pipes it to the hood, providing a flow of purified, cooling air over the face. These devices are suitable for everyone regardless of gender, race or religion, and, because they are not tight-fitting, wearers do not have to undergo a ‘face-fit test’.

They also aid better communication with the patient compared with the FFP3 respirators or surgical masks as patients can see the HCW smile, lip-read, etc.

Images: Ric Gillams Photography, with permission from Professor Elkington. 

Although FFP3s still have a place for short, ad-hoc exposures to infectious patients, this is the way forward for future pandemics.

13 March 2020: A crucial day in the pandemic

HCWs who are left languishing with serious Long Covid conditions may feel that they have been badly let down by the above-mentioned failings and they may also wonder why the Health and Safety Executive (HSE), the statutory body responsible for health and safety management in the UK, allowed this to happen.

While not seeking to excuse the HSE’s failure to enforce the law in relation to PPE during the pandemic, the answer may lie in events up to a decade earlier when their requirement for healthcare workers to be protected with efficient respiratory protection was over-ruled by Government’s Health Departments who clearly had no respect for the HSE’s authority or the laws they sought to enforce.

Some insight into the background of this is revealed by a document recently released into the public domain by the UK Covid-19 Inquiry. This relates to an email dating back to January 2020 between two of the most prominent people who steered the country through one of the most crucial days of the pandemic.

The day was 13 March 2020 when two key events occurred:

• The NHS downgraded respiratory protection from RPE, such as FFP3 respirators, to flimsy surgical masks (which do not provide respiratory protection).
• The status of Covid-19 as a high consequence infectious disease (HCID) was revoked.

The two people involved were the then Deputy Chief Medical Officer, Professor Jonathan Van Tam, who, on 12 March 2020, had sent the new '4-Nations IPC guidance version 1.0' to the NHS and Public Health England, downgrading FFP3 to RPE; and Professor Tom Evans, Chair of the Advisory Council on Dangerous Pathogens (ACDP), the expert body that provides Government with advice about pathogens, who confirmed to Professor Van Tam that his committee no longer considered that Covid-19 should be classified as a HCID.

The email reveals that Professor Van Tam had personally advised the Department of Health on RPE since 2004. During this time, HSE had, quite properly, adopted the legal position that in the event of a pandemic HCW's safety must be assured by the wearing of efficient and properly certified RPE.

HSE had made it very clear that surgical masks were not classed as PPE and that they would not provide HCWs with adequate protection in a pandemic.

So although the HSE were demanding a maximum level of respiratory protection for HCWs, Professor Van Tam states very clearly that this was “neither affordable nor practical for pandemic stockpiling”. Therefore, Government policy was to ignore the representations of the HSE. They only established the stockpile with a quantity of RPE that they believed would be needed for use in intensive care units and when certain 'aerosol generating procedures' were carried out. Everyone else, from paramedics through to doctors, nurses and all healthcare staff working in high-risk settings, such as A&E and general wards with Covid patients, would only be given the flimsy surgical masks for their 'protection'.

The decision to set up the PPE stockpile on this basis was made in 2009 when the original stockpile was established after the swine flu outbreak, only a few months after the HSE had completed their research into PPE for pandemics confirming the unsuitability of surgical masks and asserting their requirement for RPE to be used in pandemics.

In 2016, the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) established a subcommittee to provide the then Department of Health with scientific and clinical advice in order to set policy on the emergency PPE stockpile, with particular focus on the provision of respirators versus surgical masks.

The subcommittee, co-chaired by Dr Ben Killingley and Professor Jonathan Van Tam, advised the Department of Health that FFP3 respirators should only be provided for aerosol generating procedures, intensive care units and high dependency units. Crucially, the subcommittee specifically advised against the use of FFP3 respirators for other hospital settings (general wards, A&E, etc), ambulance staff and for social work.

Therefore, it came as no surprise when the pandemic reached the UK that HCWs caring for highly infectious patients in general wards, A&E, ambulances, etc, were denied the RPE that they so richly deserved as they put their lives on the line for us.

There simply wasn’t enough of the right types of RPE to go round due to flawed thinking and penny-pinching by the key decision makers.

A golden opportunity missed

Returning to the main theme of this blog, that same NERVTAG subcommittee had every opportunity to advise the Department of Health and Social Care that the stockpile of respirators should contain RPE that would be suitable for HCWs of all genders, ethnicity and faiths.

Another email released by the UK Covid-19 Inquiry reveals that subcommittee members were well aware that “not all devices [respirators] fit all face shapes and sizes” and “Face size and shape may vary across the world”. Given the NHS employs men and women and is a diverse community of different ethnicities and faiths, it would have been sensible to recommend to the Department of Health and Social Care that they should take this factor into account when considering their pandemic stockpile.

The future...

If we were to face another pandemic, will we have an adequate stockpile of suitable RPE and ‘in-house’ manufacturing capacity to support all our health and social care workers for the duration? 

Have lessons been learnt?