Infection control guidance that begs a lot of questions

During the pandemic we are all living through, vaccines have been a triumph of scientists and medics. Vaccines have saved millions of lives, and we should all be grateful to the medics who have played their part in this. By contrast, the senior medics responsible for infection control in hospitals have, in my opinion, had a much less good pandemic. A year ago and a few months ago, I wrote about how the guidance on the wearing of masks by healthcare workers did not seem to be consistent with what we knew about how respiratory diseases, such as COVID-19, spread.

And by we I include the Health and Safety Executive (HSE) agency, who 14 years ago commissioned a report on masks and flu. The HSE is the relevant UK government agency that regulates masks and health and safety protection at work, eg of a nurse or doctor from catching a dangerous disease such as COVID-19. The HSE report from 14 years ago concluded, correctly I think, that you want proper masks such as FFP2 and FFP3, not surgical masks, for flu. I think the same applies for COVID-19, which as far as we know spreads in very similar ways to flu. Given this I was pretty astonished to read in the Byline Times of correspondence between a senior Health and Safety professional, David Osborn, and the Chief Executive of the HSE. The correspondence is fiery stuff.

Then I locked at the guidance for infection prevention and control, which appeared in the correspondence. As updated on 15th March 2022, the guidance for infection control includes some, to me, surprising statements (guidance is on this webpage – at time of writing, early April 2022):

  • RPE [Respiratory Protective Equipment] (FFP3 masks) are recommended when caring for patients with suspected and confirmed seasonal respiratory viruses including SARS-CoV-2 when carrying out AGPs [Aerosol Generating Procedures*]
  • RPE (FFP3 masks) are recommended when caring for patients with a suspected or confirmed infection spread predominantly by the airborne route (during the infectious period). Note that ‘predominantly’ has been added to clarify this. See section 6.5.6
  • PPE (including FRSM [Fluid Resistant Surgical Masks]) are indicated when caring for patients with suspected and confirmed seasonal respiratory viruses including SARS-CoV-2

Note that the second bullet point refers to “spread predominantly by the airborne route”. It is I think accepted by HSE, that FFP3 masks protect from airborne viruses and bacteria, while masks, what they refer to as FRSM – Fluid Resistant Surgical Masks – do not. So the first strange thing is that it is a bit weird that you apparently only need to wear the type of mask that protects you from airborne diseases, when the disease spreads “predominantly” by that route, and not say if 50% of the spread is via that route, and 50% via another route. That does not seem safe or wise to me.

The second strange thing is in the third bullet point: They don’t classify COVID-19 as spreading predominantly via the airborne route. I would say this is not right, and certainly there is a lot of evidence for airborne transmission of COVID-19, which has been published and debated.

I think David Osborn’s basic point is as follows. The NHS has a duty of care to protect its staff and patients from dangers. COVID-19 is obviously a danger, and there is considerable evidence that it spreads via the air. Then the NHS should use precautions against airborne hazards, which means FFP2/FFP3 masks, not surgical masks. The NHS is not doing so, the medics that draw up the guidance seem very keen to stick to surgical masks, in defiance of the evidence. This is not acceptable, and the HSE as the relevant UK government agency, should enforce the use of FFP2/FFP3 masks in the NHS – for staff working with patients who have or are suspected to have COVID-19. The HSE is not doing this, hence the correspondence from David Osborn.

I think this is a very valid point. The guidance – for reasons I don’t understand – is not consistent with what we know of COVID-19 transmission. And it is disappointing that the NHS is not correcting the guidance, and that the HSE is not telling them to improve. Although I don’t know the thinking behind the guidance, the correspondence between the HSE Chief Executive and Osborn is worrying, at one point the Chief Executive says: “HSE cannot start
an investigation based purely on an opinion, especially one which is not shared by our
scientific advisers and the many eminent physicians and scientists comprising the UK
IPC Cell”. This should not be about anyone’s opinions, shared or not, it should about our data and models for COVID-19 transmission. Also, eminence has nothing to do with this.

* The data on AGPs is also very sketchy, as discussed in another blog post.

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