Calls for change to PPE guidance to protect against airborne COVID

Fresh Air NHS, Patient Safety Learning and the Safer Healthcare and Biosafety Network are calling for urgent change to the UK government’s guidelines on Personal Protective Equipment (PPE), saying they are failing to adequately protect healthcare workers against the airborne nature of the COVID-19 virus.

The groups say that all staff caring for COVID-19 patients should be provided with airborne PPE (i.e. FFP3 respirators) to protect them from the airborne nature of the virus, not just staff on the intensive care unit (ICU).

Dr David Tomlinson, a member of Fresh Air NHS, said: “The response from medical and political leaders to repeated pleas from the healthcare sector for better protection has been inadequate, unsafe, and unlawful. It appears that the authors of infection prevention and control (IPC) guidance are accepting greater staff infection risk because they do not want to admit that they were wrong in removing airborne protection for non-ICU healthcare workers in March 2020, with the consequent financial exposure from the likely many cases of preventable death and/or disability resulting from workplace-acquired COVID-19.

“Instead, IPC guidance authors continue to emphasise the need for ‘local risk assessment’; a move clearly intended to shift legal responsibility for PPE decision making onto individual NHS Trusts. However, their guidance remains without a scientifically valid risk assessment method, since airborne transmission risk is restricted to a small group of so-called ‘aerosol generating procedures’ (AGPs) – a concept now recognised to be invalid, since a single cough has been shown to produce ~500 times greater aerosols than intubation, historically believed to be one of the highest risk AGPs.

“Healthcare organisations including the British Medical Association and Royal College of Nursing representing hundreds of thousands of members, and Fresh Air NHS, have all been repeatedly calling for better ventilation and airborne PPE for all COVID-19 facing HCWs. Our serious safety concerns are being ignored; it feels like we were screaming into a vacuum. No one is listening. No one is taking responsibility.”

In March 2020, UK PPE guidance for COVID-19 facing HCWs was downgraded, from requiring airborne protection for all staff, to only those in areas where AGPs were commonly performed – mainly the ICU.  To-date, approximately 1,500 UK health and care workers have died from COVID-19, with non-ICU HCWs experiencing far greater risk of infection than their better protected ICU colleagues. 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.

Helen Hughes, chief executive of Patient Safety Learning, said: “Providing enhanced PPE to everyone working in non-ICU COVID-19 wards would offer much-needed reassurance that our leaders are committed to protecting both patients and staff from avoidable infection and the associated consequences.

“The lack of recognition of the airborne nature of COVID-19 transmission from the UK government puts at risk the safety of healthcare staff, their loved ones and patients. 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.”

On Tuesday 29 June 2021, research released as a preprint by a team from Cambridge University Hospitals NHS Foundation Trust, demonstrated that the quality of face masks makes a huge difference to the risk of SARS-CoV-2 infection at work.  Following a local policy change from surgical masks to FFP3, the previously noted 47-fold greater risk of SARS-CoV-2 infection amongst HCWs on COVID-19 ‘red’ versus ‘green’ wards, was completely eliminated.

Frontline healthcare staff have undoubtedly been disproportionately affected by COVID-19 infections. It has also become clear that a significant number of in-patients who had COVID-19, acquired the virus whilst in hospital. Failure to account for the known peak infectious viral shedding early during COVID-19, ineffective standards for hospital ventilation and most importantly, inadequate guidance and provision of PPE, created a ‘perfect storm’ for greater infection risk amongst non-ICU HCWs.

Only 15 NHS Trusts currently provide FFP3 respirators to non-ICU HCWs: the rest remain exposed to SARS-CoV-2 variants demonstrating important vaccine escape and associated with greater COVID-19 disease severity.

The groups say that as we enter a third wave of infections, for the NHS to recover and care not only for those with COVID-19 but also the millions awaiting treatment, it is essential that we have a healthy workforce. The way to achieve this is to immediately change COVID-19 IPC guidance and require airborne PPE for all COVID-19 patient care, bringing with it an end to workplace-acquired COVID-19.