Debate about PPE in the UK at the moment seems to centre around distribution and supply. Both are important but what is equally important is which type of PPE is being allocated where – to the people caring for Covid patients.
Health workers working in Covid positive wards – right now – are wearing Basic PPE, which is not sufficient to protect them from infection.
On 2 April, the government announced that they were ramping up efforts to get coronavirus testing to frontline NHS workers. Good thing. But the tag-line was “so that they will be able to get back to work”, and – without the PPE they need to protect them – it feels like sending lambs to the slaughter.
The official recommendations for health workers in every context other than in acute care (ICUs) or when performing aerosol generating procedures (when fine droplets are exhaled), is a fluid-resistant surgical mask, pinny and gloves. The recommendations were updated 7 April to include goggles.[1]
The recommendation remains that in all other contexts working with possible or confirmed Covid-19 cases, key healthcare workers should be wearing only fluid-resistant surgical masks.
Surgical masks are designed to contain any contagious molecules the wearer breathes out. They are not designed to stop particles from entering the body of the wearer – although they will do that to some degree.
The story of why the recommendations have changed goes like this:
Public Health England (an agency within the Department of Health, not part of the NHS) changed their guidance towards the end of March.
Earlier in the month, they had said that health workers should be wearing FFP3 respirator masks and full gowns when working with covid positive or suspected positive patients.
However, on 19 March, they downgraded the threat of the virus saying: “Covid-19 is no longer considered to be a High Consequence Infectious Disease”.[2]
Consequently they were able to revise their guidance about protection, saying that full PPE was no longer needed. [3] Separately, however, health practitioners and managers were told that this was for practical reasons, because stocks were not available.
This guidance was echoed by the World Health Organisation who, it is thought, feared that if they continued to recommend full PPE, and countries could not equip their health workers accordingly, some frontline workers might refuse to carry on working in situations that even the WHO thought dangerous.
That “Covid-19 is no longer considered to be a High Consequence Infectious Disease”[2] is jaw-droppingly at odds with evidence from across the globe.
It is also patently clear that if FFP3 masks and full gowns were needed to stop coronavirus molecules in the middle of March, they are still needed now.
Supply is also an issue of course. We have seen on social media how doctors and nurses are making their own kit. Groups of people are crowdfunding to make visors for frontline staff. Health workers themselves are improvising with sheets of acetate, a stapler and sticky tape.
Doctors are sharing tips:
– If you have a single use full mask, that you’re using every day, try heating it up in the oven when you get home (60oC) for 2-3 mins.
– If you can get hold of a builder’s mask (not easy to come by and the particle rating won’t be high enough but …) you can try doubling it up with a surgical mask. Better than nothing …
Despite the provision of an NHS PPE helpline for staff and despite the government’s promise to give the NHS “whatever it needs” – frontline health workers (outside ICUs), are in face to face contact with, and caring for, covid positive patients – with inadequate, and in some cases no, PPE.
When calling the National Supply Distribution Response PPE order line, some health workers have been told that they will need to order full PPE from other suppliers or, if they have been able to place an order, equipment doesn’t in fact arrive.
There are also some reports[4] that health workers who voice their concerns about the lack of PPE, are being told by their managers to keep quiet and present a professional front.
A national and laudable effort has been made to manufacture ventilators. Why is the same effort not going into making the kit necessary to protect NHS workers?
Finally, the jury is out on viral load (in other words, the more you’re exposed, or the more of the virus enters your body, the worse the attack).[5] There is some evidence from Italy but it seems now that the high infection and death rate among Italian doctors and nurses treating covid patients, may have been due to lack of PPE when the outbreak started.
Which means that, whichever way you look at it, health workers are at increased risk of becoming seriously ill and dying with coronavirus – a situation which could be radically reduced if they were equipped with full PPE.
from The International Council of Nurses [6]:
“Nurses are the frontline in the fight against COVID-19 … and they have been working non-stop to care for these very sick patients, many of whom … require complex 24-hour care.
“Of course nurses are stepping up and answering the call for help, but they are not superheroes or angels: they are women and men who have children and families and friends and responsibilities, and they must be protected from the risks that caring for patients with COVID-19 poses.
“They must be tested for the virus and have the PPE they need so that they can carry on their duties without fear for their own safety and that of their families.
“It is unacceptable for them to have to work without sufficient protection and governments must put robust supply chains in place now.”
[1] Recommended PPE for healthcare workers 9-4-20. Taken from GOV.UK PPE guidance, updated 7 April 2020:
Working in an inpatient, maternity, radiology area with possible or confirmed case(s) – direct patient care (within 2 metres)
or
Working in an inpatient area with possible or confirmed case(s) (not within 2 metres)
or
Working in an emergency department/acute assessment area with possible or confirmed case(s) – direct patient care (within 2 metres)
or
All individuals transferring possible or confirmed case(s) (within 2 metres)
or
Operating theatre with possible or confirmed case(s)
or
Labour ward/area – 2nd/3rd stage labour vaginal delivery (no AGPs2 ) – possible or confirmed case
or
Inpatient care to any individuals in the extremely vulnerable group undergoing shielding
workers should be given a “fluid-resistant (type IIR) surgical mask”.
ie, health workers working on Covid positive wards, are wearing only Basic PPE:
surgical mask, gloves, pinny
It is only if the health worker is :
Performing a single aerosol generating procedure on a possible or confirmed case in any setting outside a higher risk acute care area
or
Working in a higher risk acute care area with possible or confirmed case(s).
that they should be wearing a “filtering face piece respirator”.
[2] Government guidance, 19-3-20.
[3] Public Health England guidelines, 1-4-20.
note: the graphic of the face mask on the left makes it look very similar to the full mask on the right. It is in fact (as labelled) simply a fluid resistant surgical mask.
[4] health workers warned not to discuss lack of PPE.
[5] Effect & relationship between, viral load / infectious dose / severity of symptoms. See also the New Scientist.
[6] International Council of Nurses: The high proportion of healthcare workers with COVID-19 in Italy is a stark warning to the world: protecting nurses and their colleagues must be the number one priority. See also European Centre for Disease Prevention and Control guidance ref PPE, February 2020:
