Employers and government continue to fail in their duty to protect workers, especially against the primary route of transmission of Covid-19, airborne spread. Trade unions should therefore adopt specific policy and act to protect their members from airborne spread as a matter of urgency. A detailed look at the issues and the evidence.
- Background and the toll of Covid-19 on workers
- Official workplace guidance is seriously deficient
- Masks are “not needed with people you know”
- “They caught it outside the factory”
- Regulation and enforcement in the workplace are effectively absent
- Trade Unions should intensify the health and safety campaign against Covid
- Airborne mitigation measures
- Face masks – a vital part of airborne protection
- Air filtering units
- CO2 monitors
- Workplace and individual risk assessments
- Perspex screens don’t work
- Union health education campaign
- Public transport and shops
- There is no airborne transmission in health care, says IPC
- What if employers refuse to provide FFP2 masks and other airborne protections?
- Legal action will set a precedent
- Unions should provide their members with FFP2 face masks in the meantime
- Appendix – IPC guidance
- The Covid-19 pandemic continues to spread alarmingly across the UK:
- Despite the vaccination program, tens of thousands of people are getting infected every day and over a thousand people die each week. Since “Freedom Day” in July over 4 million people have been infected and over 20,000 have died.
- 1.2 million people have long Covid according to the ONS (Office of National Statistics).
- Many of these people will be workers and their families. Children are paying a very heavy price for a government policy of deliberate infection in schools, a totally misguided effort to achieve herd immunity in children.
- Hundreds of workplace outbreaks of Covid occur each week according to a recent union and TUC statement.
- It is the duty of employers to identify and assess risk in the workplace and put in place measures to reduce risk as far as possible. This should be done by following the “hierarchy of controls” approach – see above diagram. This document mainly considers engineering controls and PPE within the hierarchy of controls, but clearly all levels require assessment by employers.
- In most workplaces, protections against Covid are inadequate and regulation is absent:
- Keeping businesses running normally has always taken precedence over worker health and safety.
- There is over-reliance on handwashing and cleaning of surfaces in official guidance, putting responsibility for prevention on workers.
- We have known for some time that breathing in infected air is the main way Covid-19 spreads; protecting workers from airborne spread is therefore critical to controlling spread. This must and can only be done by government and employers. They have failed to do this.
- Regulation and enforcement of Covid measures in the workplace has effectively been non-existent; the HSE (Health and Safety Executive) has not brought a single prosecution against any employer in the 20 months of the pandemic.
- Under reporting rules, employers are the ones who decide if Covid infection occurred at work or if it occurred outside the workplace. Not surprisingly, workplace infections and deaths are massively under-reported according to a TUC report, and bear no relation to ONS figures for deaths of working age people.
- While there is a new education campaign aimed at the public about improving ventilation in the home, there is no mention of the importance of this elsewhere, especially in the workplace.
- The trade union movement should therefore urgently adopt an explicit program of airborne protections for all workers, with a clearly defined set of demands of employers in every workplace. These include:
- Respiratory face masks (FFP2 or better) to protect workers from breathing in the virus. Fluid resistant surgical masks (FRSMs) are not good enough.
- Monitoring of air quality throughout the workplace using carbon dioxide (CO2) monitors, to identify areas with poor ventilation where risk of airborne spread will as a consequence be high.
- The provision of air cleaning and filtering units to improve air quality in all spaces where ventilation cannot be improved to safe levels.
- All risk assessments – workplace and individual – must now include assessment of ventilation in all work and rest areas by means of CO2 monitoring.
- Employers must put forward concrete plans, including timescales, to address poor ventilation in the longer term.
- These demands are practical and deliverable (apart from major works to improve ventilation); they are also affordable by all employers. Most importantly the measures work, they are highly effective if applied properly and consistently. The demands can be negotiated at a local, regional and national level.
- A clear set of demands, which tackles the main airborne route of spread of Covid, will help Health and Safety reps in their role of protecting their colleagues at work. To date the circumstances they have worked in have made their jobs very difficult: inadequate and ill-advised official guidance, employer inaction and indifference, absent regulation and blaming of workers for infections.
- These demands for airborne protection are in addition to other Covid mitigation measures. Vaccination remains a very important measure but it must be accompanied by other measures, such as proper sick pay, social distancing and a functioning test and trace system. We have learnt to our great cost that no single measure on its own is enough, including vaccination; but without airborne protections we will fail to control the pandemic
- We need an educational program for H&S reps and union members about the importance of airborne transmission and the specifics of each of the demands, so they are well informed in negotiations with employers. There also needs to be clear, confident and ongoing messaging from the union nationally to all its members about the campaign. Vaccine hesitancy should also be part of the educational campaign, done in a supportive and not punitive way. No worker should lose their job for not having had the vaccine.
- In the event of employer refusal to meet these demands, unions should consider:
- Escalating matters through formal dispute procedures.
- As an interim measure, providing members who are essential workers with FFP2 (filtering face piece) masks, while pursuing action against the employer.
- The purchase of CO2 monitors for H&S reps to assess workplace air quality. While portable CO2 devices do not provide a comprehensive ventilation assessment, they are a reliable way of identifying high risk areas in the workplace for priority improvements.
- Pursue legal action against employers for failing to meet their obligations under the Health and Safety Act. The measures demanded would appear to satisfy the “reasonably practicable” requirement under the Act.
- Infection control guidelines for health and social care leave workers and patients at high risk
- Infection prevention and control (IPC) guidelines deny the existence of airborne transmission and health sector employers (apart from a few) have not implemented airborne mitigations. There is widespread concern and criticism of this position by health unions and the medical and scientific community.
- However, while the guidelines are clearly not fit for purpose, they state themselves that employers “should…… comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.”
- Health service trade unions should therefore bring these demands under the Health and Safety Act, and abandon efforts to persuade IPC to change its guidance.
11. The document below examines these issues in detail, as well as the practicalities of each of the demands. There is also an appendix at the end which looks at the IPC guidance.
Background and the toll of Covid-19 on workers
12. The UK government effectively abandoned all public health mitigations against Covid-19 on 19 July 2021, saying prevention of the disease was the “personal responsibility” of individuals. De facto UK policy towards Covid-19 is one of herd immunity through either infection or vaccination (or a combination of the two), while our children are being subjected to a deliberate policy of mass infection at school.
13. Immunity after Covid infection and vaccination is unreliable: it wanes over time and in many people is not sufficient to prevent re-infection or transmission of the virus to others. A third of the population remains unvaccinated. Herd immunity as a strategy is plainly failing and quite rightly was condemned by the WHO in July as “moral emptiness and epidemiological stupidity”. Moreover, our high transmission rates in a partly vaccinated population also constitute favourable conditions for further mutations of the SARS-CoV-2 virus, which may be vaccine resistant and/or more infectious.
14. The consequences of herd immunity have been a public health disaster: for the past two months, every week around 250,000 people are infected, over 6,000 people are admitted to hospital and over 1,000 people die from Covid-19. The ONS reports that 1.2 million people currently suffer from long Covid. In children the figures are shocking: almost 6% of children are currently infected, and 250,000 children were off school with Covid-19 in the week before the October half-term break. Thirty-eight children have died of Covid since May, with 12 dying in the month of October alone, the highest number since the start of the pandemic. 40-50 children are admitted to hospital every day and the ONS says tens of thousands of children have symptoms of long Covid. (There is some disagreement on the numbers of children with long Covid, but it is clear it is a major concern.)
15. The recent emergence of the Omicron variant exposes the folly of the herd immunity policy, as well as the myth we can vaccinate our way out of the pandemic. It is early days but Omicron is spreading rapidly where it has been found, and has the potential to evade vaccine protection. All measures against Covid-19 are needed to control the pandemic, especially airborne protections which are effective against all variants.
16. We know that essential workers, especially black and Asian essential workers, who are often in poorly paid, insecure employment and lacking basic rights like adequate sick pay, have paid a very heavy price during the pandemic. Black and Asian essential workers have over 8 times the risk of hospitalisation or death of white non-essential workers. Another study done in Birmingham University Hospital showed that housekeeping staff had the highest rates of Covid infection of all health care workers, and twice that of staff working in ICU. Outsourced workers, with few employment rights, low rates of unionisation, and inadequate sick pay are at particular risk.
17. Structural inequalities in social class and race are major determinants of who gets sick and who dies from Covid-19. Essential workers in food processing, transport and security have five times the death rate of managers and professionals, while black and Asian people have two to four times the risk of white people of dying from Covid. These effects are much greater than the effect of common underlying health conditions on Covid risk (like obesity, diabetes and asthma), with the exception of chronic lung disease and in particular learning disability which is very high risk.
18. The reporting system for Covid in the workplace is broken: employers decide if workers caught Covid in the workplace or not. Between April 2020 and April 2021 the ONS reported that 15,263 people of working age died from Covid. Around 75% of working age people are in employment. Employers reported that just 387 of these deaths occurred from infections in the workplace during this time.
19. Despite this ongoing toll on the nation’s health, and the likely rise in cases during the coming winter, the government shows no sign whatsoever it will do anything else to mitigate spread of infection in the workplace and protect workers.
Official workplace guidance is still seriously deficient
20. Official guidance for the workplace still over-emphasises cleaning of surfaces and handwashing, to combat “droplet spread” of Covid, and fails to emphasise the primacy of airborne transmission. While it now includes guidance on improving ventilation, and the use of CO2 monitoring for air quality, it proposes much too high a threshold for intervention. It says, “Outdoor levels are around 400 parts per million (ppm) and indoors a consistent CO2 value less than 800ppm is likely to indicate that a space is well ventilated. An average CO2 concentration of above 1500ppm when a room is occupied is an indicator of poor ventilation. You should take action to improve ventilation where CO2 readings are consistently higher than 1500ppm.” The guidance does also say that “Where there is continuous talking or singing, or high levels of physical activity (such as dancing, playing sport or exercising), providing ventilation sufficient to keep CO2 levels below 800ppm is recommended.”
21. It seems then that workers do not have the right to work in well-ventilated workplaces. Expert opinion from aerosol scientists and others clearly says levels greater than 800ppm require additional measures to improve air quality (see here, here, here, here, here and here). THE CDC in the United States also has 800ppm as its standard for safe CO2 levels; it does not say “Oh but for workers twice that level is OK”. The WHO limit for healthy air quality is 1,000ppm. The higher the level of CO2 in the air the more people breathe in other people’s expired air, which will contain virus if anyone has it (remember many people are infectious and asymptomatic). This relationship is also not linear, at CO2 levels of 800ppm 1% of air is rebreathed, at 1000ppm it is 1.5%, at 1,500ppm it is almost 3%, which is increasingly risky. It is not clear where the 1,500ppm figure in the guidance comes from; Professor Catherine Noakes, the UK’s leading expert on air quality and fluid dynamics said this: CO2 levels should “Ideally (be) below 800ppm and spaces over 1500ppm should be highest priority for mitigation”. The guidance however allows employers to ignore levels below 1,500ppm.
22. Government guidance then once more fails to protect workers. Doubling the threshold for action of CO2 in the air, is like saying that for drinking water, levels of phosphorous and nitrates, twice the safe limits are acceptable, or for food safety, it OK for businesses to compromise on Food Standards Agency regulations for food hygiene. No-one would find that acceptable; why then should workers have to risk breathing in air infected with Covid-19 every day, when we know how to provide them with clean air and have the means to do so?
23. The section on face masks in the guidance is particularly poor:
- It still refers to masks as “face coverings” endorsing a DIY, unscientific approach to this important mitigation measure.
- It minimises the effectiveness of masks, using phrases like “they may reduce the risk of transmission”, when we know they are highly effective, and “Businesses can encourage customers, visitors or workers to wear a face covering”, hardly a binding instruction or ringing endorsement.
- There is also no mention whatever of the relationship of airborne transmission and the standard or specification of mask required. We are well past the time when any face covering will do, there is now a well-established science to masks, in terms of the ability of the mask material to filter out aerosols 0.3microns in size or larger (where the virus is found), the fit of the mask around the face and mask comfort. We have known for some time that well-fitting respiratory masks are needed to protect the wearer and those around them from aerosol spread, especially from the greater infectivity of delta Covid. A well-fitting FFP2 or N95 grade (EN standard 149:2001 or better) mask is needed; they are readily available and cheap.
- The guidance also perpetuates misinformation about when masks are and are not required, when it states they should be worn, “…..in crowded and enclosed settings where they come into contact with people they do not normally meet.” This is simply wrong.
“Masks are not needed when you are with people you know” is misinformation
24. This unscientific and completely false theory has been touted by the government for almost 18 months, and says masks are not required when you are with “people you know” or who you “normally meet”. While it is correct that there is little benefit in wearing a mask in your home (unless someone has to isolate), for everyone else this is false and potentially risky. It was former Health Secretary Matt Hancock in July 2020 who first said masks are not needed when you share an indoor space like an office with work colleagues, because you know them and spend time with them. (This was part of the official narrative of “Covid-safe and Covid-secure” workplace being promoted at the time, when there were dozens of factory outbreaks occurring). This has been part of official guidance since and was repeated as recently as last month in parliament by Jacob Rees Mogg (shortly before a large Covid outbreak in parliament was announced). In fact, the opposite is true: the risk of transmission of Covid-19 depends on the amount of virus in the air and the time you spend in that space; therefore the longer you spend with other people in the same space, the greater the risk. It has nothing to do with how often you see them or how well you know them; the virus does not care who you know – if you provide favourable conditions for spread, like sharing an office or workspace for hours every day, where ventilation is not good enough, where there are no air filtering units, and people are unmasked, spread will occur. In fact, super-spreading of virus may well occur as happened at the DVLA which saw the biggest outbreak of Covid-19 in the country when 560 workers got infected in January and February 2021. One of the first epidemiological studies pointing to airborne transmission of Covid-19 was of an outbreak in a call centre in Seoul in March 2020, where 94 out of 216 workers in an open plan office, became infected within a few days from a single person with the virus. Those workers knew each other, they worked together every day.
This is dangerous misinformation and should be removed from official guidance and ministerial pronouncements. Workers need masks at work, in all spaces they share with other people, be they work colleagues and/or the public.
“They caught it outside the factory or workplace” is also misinformation
25. This is another example of harmful misinformation and a favourite response of employers and government when confronted by workers or unions about Covid outbreaks in the workplace. They say the workplace is safe, and workers must have caught it outside, in the community or sharing transport or smoking breaks with each other outside the premises. Public health officials have colluded in this blame culture, as in the Greencore outbreak. This conveniently blames workers for getting infected, but does not stand up to scrutiny. While it is true that the initial individual infection will have occurred outside, conditions inside the workplace, especially in food processing, offices, transport and many other sectors, are highly favourable for spread: workers being close together, spending long periods together, inadequate ventilation, no masks or poor quality of masks etc. There have been numerous studies now that have investigated large outbreaks in the workplace, which clearly show from the pattern of infection and from gene studies of the virus which infected workers, that spread occurred in the workplace, and not from outside.
26. One detailed study in Germany into a large outbreak in meat-packing plants and local communities in the west of the country showed conclusively that airborne spread in the factory was responsible, and that workers sharing transport or accommodation did not contribute to transmission. Other large workplace outbreaks include Greencore in Northampton in late 2020, and the huge outbreak at the DVLA mentioned above. In fact the reverse is the case, workers got infected at work and then took the infection back into their communities – this is a major driver for community infections.
27. It is obvious that current measures are failing; hundreds of workplace outbreaks are occurring each week. Handwashing and cleaning surfaces (so called “droplet” precautions) are failing to control spread, in fact the over-reliance on these measures distracts from the main route of spread. Until we put protection against airborne transmission at the centre of our efforts, our failure to control the pandemic will continue.
Regulation and enforcement are effectively absent
28. However, whatever official workplace guidance says, the absence of regulation and enforcement by HSE means that employers are free to do whatever they like, including ignoring the guidance, secure in the knowledge that there will be no consequences for them. As stated above no employer has been prosecuted to date for breaches of health and safety in the workplace, and consistent government rhetoric throughout the pandemic about “Covid safe” and Covid secure” workplaces, has facilitated the myth that workplaces are safe and workers get infected due to their own fault.
29. The issue of who is responsible for Covid spread and which measures are adopted to prevent it, is highly political. This quote from Professor Juan Luis Jimenez, one of the leading experts on aerosols, sums it up very well:
“Droplets and surfaces are very convenient for people in power – all of the responsibility is on the individual. On the other hand if you admit it is airborne, institutions, governments and companies have to do something.”
Trade Unions should intensify the health and safety campaign against Covid
30. A joint union statement on 23 October from the leaders of Unite, USDAW, Unison, the GMB, ASLEF and others, and Frances O’Grady, head of the TUC, criticised the government for it’s laid-back approach to the pandemic, and its refusal to implement additional measures to limit the spread of infections. It stated there were “hundreds of Covid outbreaks at workplaces being reported to health authorities each week.” Boris Johnson replied he saw no reason to take further measures.
31. In the face of indifference and deliberate inaction on the part of government and employers, the trade union movement should intensify its Covid health and safety campaign in the workplace, and make prevention of airborne spread its main focus. Millions of workers remain at risk this winter from airborne spread of the virus; fortunately, as set out in the summary (point 3 above) there are a number of practical steps unions could take themselves towards meeting this goal.
32. These measures are based on the fact that the primary route of transmission of Covid-19 is through the air, by people breathing in the virus into their lungs. The evidence for this is now overwhelming, and almost every day new research is published confirming this. Newly updated guidance from the government on how to stay safe and prevent the spread of coronavirus, is also now very clear on this:
“COVID-19 is spread by airborne transmission, close contact via droplets, and via surfaces. Airborne transmission is a very significant way that the virus circulates. It is possible to be infected by someone you don’t have close contact with, especially if you’re in a crowded and/or poorly ventilated space.”
33. Interestingly there is no evidence at all for droplet spread of Covid-19; the droplet theory has always been just that – an unproven theory, unfortunately long held by some infectious diseases doctors. This paper from over 20 of the world’s leading experts in the field, discusses in detail the origin of this “droplet dogma” and how this has hamstrung our understanding and response to transmission of respiratory viruses including Covid-19. Airborne mitigations are crucial if we are to protect workers; the measures proposed are straightforward and highly effective if done properly, they are deliverable and not expensive. They are discussed further below.
AIRBORNE MITIGATION MEASURES
a) Face masks – a vital part of airborne protection against Covid-19
34. As Covid-19 is a respiratory virus, overwhelmingly spread through the air; respiratory protection equipment (RPE), should be issued to all workers by their employers. The blue “surgical” mask is not good enough, and is not designed to protect against airborne transmission. These so-called “Fluid resistant surgical masks” (FRSMs) provide much less protection because the fit is poor: air escapes from the sides, around the nose and under the chin, meaning virus in the air is breathed into the lungs, or out into the surrounding air, without being filtered out. They are not designed to protect against airborne transmission.
35. A well-fitting FFP2 mask (EN standard 149:2001 or its equivalent), provides highly effective two-way protection against transmission of Covid-19. This means that at least 95% of virus containing particles 0.3 microns in size or larger are filtered out by the mask, both preventing virus from being inhaled (protecting the wearer), and from being breathed out into the surrounding air shared by other people (protecting others).
36. Mask fit is important to maximise protection, but it is not essential for everyone to have formal “fit testing” for FFP2 masks as is done in hospitals with FFP3 masks. This study in the US showed that 80% of people using N95 masks (FFP2 equivalent) without formal fit testing, achieved better protection than with a surgical mask. Simple instructions about how to achieve the best fit are sufficient; where greater levels of protection are required then a higher grade FFP3 mask and formal fit testing are probably needed.
37. Widespread mask wearing in countries like South Korea and Japan, have resulted in far fewer cases and deaths from Covid-19; while countries like the UK and US, where mask wearing has become politicised, and official mask policy is one of personal choice, continue to have very high numbers of cases and deaths. There are other factors involved in transmission clearly, but the effect of widespread mask wearing is striking and consistent. The huge spike in infections in Austria occurring now, is thought to be due to the removal of mask mandates and other mitigations everywhere except in Vienna, which has been affected least of all.
38. A study carried out on Covid wards in Addenbrooks Hospital in Cambridge has shown that providing RPE masks (FFP3 in this study) to health care workers, eliminated hospital acquired infection among staff, while a modelling study of universal wearing of facemasks on public transport in Seoul, indicates this would lead to a 95% reduction in transmission.
39. This measure could be implemented rapidly. Comfortable FFP2 or N95 masks are inexpensive and widely available. Many are disposable which are not good for the environment however. Personalised, re-usable masks are available, which can be re-used for many months by the same person.
b) Air filtering units
40. These are relatively cheap commercially (starting from about £150) and are highly effective (see 1, 2, 3 and 4 for example) in removing airborne virus from indoor room air. The technology is well-established, there are minimum specifications including the requirement for HEPA (high efficiency particulate absorbing) filters to remove from the air 99% of aerosols which are 0.3 microns in size or larger, which may contain virus. The device must be suitable for the size of the room (more than one may be required), in terms of the “clean air delivery rate” (CADR) for the space. For inadequately ventilated indoor spaces, air filtering units can add considerably to air quality; a simple formula can be used to give an equivalent in “air changes per hour” (ACH), which is how ventilation is assessed in a given room. (See also section on ventilation below on measuring adequacy.) Six ACH is considered a safe level, and can be achieved by a combination of ventilation and air filtering devices where necessary. CO2 monitoring where air filters are being used will not give an accurate picture of air quality – see below.
41. Air cleaning and filtering units are therefore an effective and very practical measure to improve air quality in the workplace. Assessing air quality fully can take time but there are likely to be poorly ventilated high-risk areas in many workplaces, which can be identified by checks with handheld portable CO2 monitors: any area with a sustained rise in levels (eg more than 15 mins) can be prioritised for air filtration while more detailed assessments take place. Air filtering devices are readily available, they are also portable and quiet to operate. They require limited maintenance but changing the filters needs to be done safely.
c) CO2 monitors
42. As discussed above the CO2 level in any space can be used as a proxy measure for ventilation. Outside air has a CO2 concentration of about 420ppm; an indoor level up to 800ppm is considered relatively safe as it implies sufficient air changes per hour (ACH) to prevent virus build up in the room. CO2 monitors are also relatively cheap (around £150 for a portable and accurate device); non-dispersive infra-red devices are preferred as they are more accurate. Some monitors are Bluetooth enabled and can download data of CO2 readings onto a smartphone app, giving an accurate picture of ventilation over the whole day or several days. Health and Safety reps could be issued with these allowing them to spot check which work spaces are well ventilated and which are high risk and require immediate improvements in ventilation and/or air cleaning.
43. Employers should carry out assessments using established methods for CO2 assessment of air quality (for example in the ventilation guidance from the HSE), but this process should not stop improvements in ventilation being made or the installation of air filtering units where workers occupy spaces where ventilation is obviously very poor. Note: CO2 monitoring is not reliable when air cleaning devices are being used, because air cleaners remove virus, but not CO2 from the air. However, background ventilation can be assessed with CO2 monitoring, and air filtration then added as necessary to give the equivalent ACH required for any given space.
44. Transmission of Covid-19 outdoors is very rare, almost all spread occurs indoors. Therefore the more outside air that circulates in an indoor space the safer it is. There is detailed guidance on improving ventilation for employers from the HSE. In some workplaces it may not be possible to improve ventilation sufficiently by simple measures e.g. opening windows and doors, or by maximising outside air intake through HVAC (heating ventilation and air conditioning) systems. There will be areas where ventilation remains poor, posing a risk for airborne spread; as described above these are easily identifiable by CO2 monitoring. HSE suggests a number of measures such as limiting occupation of poorly ventilated areas, and taking breaks to ventilate such areas. Appropriate air cleaning and filtering units should also be provided in such areas.
45. While improving ventilation by installing HVAC systems may be costly and take time in some workplaces, employers have a legal responsibility to provide clean air in the workplace. They should therefore also have plans in place as to how and when they will provide adequate ventilation in these areas in the longer term, while taking other measures in the interim such as providing FFP2 masks for workers and installing air filtering units.
46. It is important to take into account room occupancy when assessing ventilation; clearly the more people in any space, the more outside air ventilation is needed. In addition to ACH (air changes per hour) therefore, ventilation rates should also specify “litres per person per second” (l/p/s). HSE advises following the CIBSE recommendation for this, i.e. 10 l/p/s for Covid, which will provide good ventilation and keep CO2 levels below 800ppm.
e) Workplace and individual risk assessments
47. Risk assessments of all workers must now include airborne transmission risk of the virus, by reporting on air quality using CO2 monitoring of the adequacy of ventilation in all areas in the workplace. Workers have the right to clean air, free of coronavirus; air quality assessment is therefore applicable to all workers in all areas within the workplace.
48. These do not protect against airborne spread of Covid-19. They are useful to protect against spray from coughs and sneezes for public facing front-line workers, eg in buses and taxis, receptionists and tellers in shops. But if used in open plan offices in fact they may increase risk because air flow around them causes negative pressure behind the screen, which draws in air, which may contain virus. The same is true of plastic face shields – worn without a mask they will not protect against airborne spread. Where screens are in place ventilation should be good; screens should never be a substitute for a properly ventilated work environment.
Union health education campaign
49. One of the biggest failings in the government’s handling of the pandemic has been the health education campaign about how the virus is transmitted and how people can best protect themselves and their families, other workers and their communities. The very belated recognition of airborne spread of Covid-19 and the ongoing failure of government messaging to put airborne transmission front and centre of its health education message has been disastrous, leading to much higher rates of infection, hospitalisation and deaths than necessary.
50. Because of official emphasis on contact and surface spread, a majority of people still believe that handwashing is the most effective measure against Covid-19. A survey done by Opinium in late October 2021 showed that almost two-thirds of people did not know that ventilation is an effective way to reduce the spread of the virus. If the public are not told the virus spreads mainly through the air, and the most likely way of getting infected is by breathing the virus into your lungs, they will not know how to reduce their risk of infection.
51. A Canadian Professor of Medicine, Andrew Morris, puts this point very well in a recent interview about Covid mitigation measures:
“….vaccines needs to remain numero uno. When it comes to addressing transmission, ….. the priorities are clear: Masking, ventilation and (air) filtration, rapid tests, and better flexibility for working and schooling, including sick pay. It’s time to “get rid of low-value stuff.” That means we need to de-emphasize cleaning, physical barriers, and hand hygiene.” These things may help, …. but not nearly as much as the clear strategies that we know, scientifically, are effective.
There are those, including in public health roles across the country, who would argue that we must continue the incessant hand-washing and putting up plexiglass barriers out of an abundance of caution. But that’s not science. Science asks us to test — and to pursue what works, and drop what doesn’t. In effect, what governments across this country are asking us to do is to invest faith in these strategies. If cases go up, it’s because we’re not washing our hands well enough. If cases go down, it’s because we’re washing our hands more. This isn’t science. It’s not even pandemic theatre. It’s superstition. And it’s not harmless. “It diverts energy from other higher yield interventions,” Morris says. It can also muddy something that we have sorely lacked for the past two years: Clear messaging, (which) can be as simple as “stay home if sick, breath clean air — and wear a high-quality mask if you can’t.” We do not have that clarity.
What’s more, we are risking COVID-19 fatigue. Rather than focusing on strategies that work, and ditching ones that don’t, we are just stacking advice to the ceiling. Regular people no longer have a sense of what’s effective, and what’s useless. Some still wear masks outside. Others are still pressure washing their groceries. Some think face shields are more effective than masks. (They are not.) We’ve had a truly miserable two years. But it hasn’t been for naught: We know what works. We know what doesn’t. (We need to) ditch the latter and focus on the former.”
52. Our government has engaged in exactly the practices that Professor Morris condemns: mixed messaging throughout the pandemic. Its abandonment of most mitigations against Covid-19 in mid-July, its ridiculing of mask wearing in parliament recently, the refusal by the prime minister to wear a mask at COP26, and shockingly going maskless while visiting an NHS hospital, all contribute to minimising the perception of risk by the public and a fatalistic view that there is not much that can be done to prevent infection anyway. It also leads to some people rejecting mask wearing and other measures.
53. The general public overall however, as we have seen throughout the pandemic, seem to have a much more sensible view of risk than the government. A recent YouGov poll reported that in England a large majority of people support mandatory masks on public transport and in shops and say that social distancing rules should be reintroduced in pubs and restaurants. The majority of the public are therefore receptive to health education messaging about Covid.
54. These views are likely to be representative of workers and trade unionists, who, if given the correct information about how Covid-19 is mainly spread and that preventive measures really do work and greatly reduce risk, are likely to respond positively and adopt these. The trade union movement through its publications and communications with its members, is well placed to continue to put out a clear and consistent message that airborne spread is the primary means of transmission, which specific airborne mitigations are needed and that when these are properly implemented they can be highly effective. We also have a well-established network of Health and Safety reps and Shop Stewards who could further this message at a local level for members in branches.
55. There may be some mask scepticism or hostility among workers. Clear explanation of why they are needed, how they work and their effectiveness coming from their union may change that. The approach should be supportive and ongoing.
Public transport and shops
(Note: the government have now taken this step due to the threat of Omicron)
56. While improvements have been made, train, bus and taxi drivers are front-line staff, and have paid a heavy price during the pandemic. They and the travelling public, many of whom are workers, remain at significant risk particularly when travelling at rush hour to and from work. When they are over-crowded, air quality in trains and buses quickly becomes unsafe; random measures of CO2 levels on crowded trains show levels up to three times safe levels. Crowded train carriages with half of passengers unmasked is a common sight these days. These are very favourable conditions for viral spread. Public transport operators have a legal duty to provide safe travel conditions for passengers; improvements in ventilation are urgently needed. It would also be straightforward to establish what level of occupancy is safe in buses and trains, allowing limits to be imposed to keep the air quality at safe levels.
57. Mask wearing on public transport and in shops urgently needs to be made mandatory again. If everyone, including transport workers wears a FFP2-type mask which provides respiratory protection, rail and bus workers would be better protected, and the travelling public would also be at significantly less risk. This modelling study from Korea states that transmission would reduce by nearly 95% with mandatory mask wearing, and by 98% if social distancing on transport were imposed as well.
58. Shopworkers are essential front-line workers. ONS figures for occupation-related mortality from Covid-19 indicate an elevated risk for essential workers including those in retail, distribution and processing. The British Medical Journal reported in October 2020 that those in customer-facing roles in grocery stores are 5 times as likely to test positive for Covid as their colleagues in other positions. There is therefore the same need to ensure good ventilation and provide air cleaners where necessary, and for staff to be provided with FFP2 face masks to protect them against airborne spread. There is a need for mandatory mask wearing by the public in shops, which by definition are enclosed indoor spaces. As discussed above Perspex screens offer no protection against airborne spread, and should not be used as a substitute for other protections.
There is no airborne transmission in health care, say infection control authorities
59. There is a particular problem for workers in the health and social care sectors when it comes to airborne protections against Covid-19. Remarkably, the recently updated Infection Prevention and Control (IPC) guidelines say that Covid-19 spread occurs only through “droplets”, and it is not an airborne infection, apart from so called “aerosol generating procedures” (AGPs). The guidelines are issued jointly by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, NHS National Services Scotland, UK Health Security Agency (UKHSA) and NHS England as official guidance, published on their behalf by UKHSA.
60. The guidelines will be discussed further in the appendix but in summary:
- There is broad consensus in the medical and scientific community that the guidelines are fundamentally flawed and not fit for purpose. In fact they are dangerous.
- IPC is increasingly isolated in its view that airborne transmission does not occur; its policy also directly contradicts that of Health and Education Departments and the overall government message on transmission of Covid-19.
- The notion of AGPs (central to IPC guidance) is now thoroughly discredited, to the extent that there are calls from experts to stop using the term altogether.
- IPC’s policies have failed comprehensively to protect health and social care workers, and there has been wholesale failure to keep patients safe from getting infected with Covid-19 in our hospitals. This is an indictment of current infection control policy and a national scandal.
- A number of NHS Trusts have bypassed IPC guidance and issued their staff with respiratory PPE, but the majority still adhere to it.
- Health workers, like ambulance staff, continue to be sent into very high risk “red zone” situations, wearing only surgical masks.
- The guidelines are based on factual errors which defy the laws of physics of airborne particles.
- Concerted efforts for well over a year to get IPC to change, by health trade unions, numerous health organisations and experts within the medical and scientific community have proved futile.
61. Tactically therefore, the health unions should abandon efforts to persuade IPC to change its guidance, and now demand airborne protections directly from the employer under the Health and Safety at Work Act. As this article in the Health Service Journal makes clear when it comes to worker health and safety, the buck stops with the employer, the Chief Executive of the NHS Trust. And all official guidance, as well as IPC guidance, make it clear that employers are expected to comply with this law, whatever guidelines say. The HSJ article states, “These guidelines were established primarily to protect against the spread of infection – not to ensure the safety of the workforce….. Preventing infection of staff is a part of the guidance, but not its main objective. When it comes to the safety of staff, there is a higher law that employers ignore at their peril”, i.e. the Health and Safety Act.
What if employers refuse to provide FFP2 masks and other airborne protections?
62. As stated several times already, the Health and Safety at Work Act, puts a duty on employers to provide a safe working environment and protective equipment for all workers. We know that Covid-19 is an airborne disease, and that poorly ventilated spaces are high risk for transmission. This now widely accepted including by government. Employers need to act therefore. Apart from installing ventilation systems, the other measures to limit airborne transmission are not costly and can be implemented more quickly. These would appear to fall within the scope of the act, i.e. they are affordable and “reasonably practicable”, and we should demand employers provide these as a matter of urgency.
63. The union should pursue airborne protections with the employer through all available procedures and mechanisms. Unions should develop clear, specific guidance on airborne protections for H&S reps and shop stewards to negotiate with employers. Sector wide negotiations should also take place. If employers refuse the union should escalate matters through formal dispute procedures, as well as take legal action.
Legal action will set a precedent
64.There may well be a need for legal action on this issue; for example a case on behalf of union members (e.g. a local branch, or perhaps at a sectoral level nationally) against employers who refuse to provide airborne protections. Clearly specialist legal advice is needed but on the face of it, the union case is a strong one: airborne transmission is widely accepted now, including by government, and the H&S Act is clear that safe working conditions must be provided by employers, which means mitigating risk of airborne transmission. The HSE states that “The law says employers must make sure there’s an adequate supply of fresh air (ventilation) in enclosed areas of the workplace. This has not changed during the pandemic.” There are many medical and scientific experts, as well legal experts in health and safety law, who the union could call upon in such a case. The legal responisbilities of NHS Trusts is clearly stated in this article from Professor Raymond Agius and Diana Kloss, barrister. The article makes clear that health and safety law is fit for purpose but workers are getting infeted because it is being ignored in the workplace.
65. If employers defend the action, they would have to make the case that airborne transmission does not pose a risk in the workplace. This is an untenable position, because quite apart from the large amount of evidence to the contrary, the Education Department is taking measures to mitigate airborne transmission in schools, the Department of Health and Social Care has just launched a major health education program about the importance of improving ventilation in the home during the festive season, using video clips of people emitting large amounts of virus-containing aerosols into room air, and recent general government guidance says “Airborne transmission is a very significant way that the virus circulates”. Airborne transmission stopping at the workplace front door is not a viable defence.
66. If legal action is successful, it would set a precedent nationally, meaning all employers would have to provide the necessary airborne protective measures. Potentially this could have a huge impact on worker health and safety against Covid-19 nationally.
Unions should provide their members with FFP2 face masks in the meantime
67. Clearly the provision of all protections in the workplace is the responsibility of the employer, including RPE against airborne spread. However if employers refuse to provide this, workers remain exposed to significant risk of Covid and all its consequences. We suggest that in the short term, unions should consider providing FFP2 masks to all their members who are essential workers and at most risk. Unit costs of disposable FFP2 masks are under £1. They can be re-used over several days as long as they are not soiled or wet, and the seal around the face remains intact.
68. The Union will be seen in a very visible way to be actively protecting its members against a workplace hazard, which will enhance is standing among workers. The masks could be branded with the Union logo and a suitable message, e.g. “Protecting our members against Covid-19 in the workplace”.
69. This is likely to generate media interest which will draw attention to the failure of employers and government to provide airborne protections for workers.
70. The union, as an employer, should at the same time provide FFP2 masks for all its officers and administrative staff.
- As stated above UK infection control guidelines are not fit for purpose. IPC authorities are increasingly isolated in their view that Covid-19 is spread by droplets and not through the air, a position which is directly contradicted now by official government policy. What follows is a more detailed look at the issues summarised above in section 56, which demonstrates how unscientific, out of touch and indeed hazardous the guidelines are for health workers and patients.
- There is widespread consensus that the guidelines are fundamentally flawed and not fit for purpose. Many expert scientists and health professionals have spoken out publicly about them, and repeatedly asked for them to be changed. The Royal College of Nurses calls the guidance “fundamentally flawed”, while the British Medical Association wrote to the prime minister in February 2021 along with 16 health organisations, stating the guidance needs revision as it fails to take into account airborne spread or recommend airborne mitigations. To date 26 different health organisations have called for airborne protections for staff, to no avail.
- IPC is isolated in its view that airborne transmission does not occur. The Department for Education is putting in place airborne mitigations (CO2 monitors and air filtration units) in schools and the Department of Health and Social Care has just embarked on a major health education drive for the public to improve ventilation in their homes over the festive period to limit airborne transmission. Newly updated guidance from the government says airborne transmission is a very significant way that the virus circulates. The idea that airborne transmission occurs everywhere else, but stops at the hospital front door is ludicrous.
- IPC’s belief that airborne spread is only a risk from certain aerosol generating procedures (AGPs) has now been thoroughly discredited by numerous clinical studies. Not only do so-called AGPs not constitute additional risk, a patient with Covid who is actively coughing produces far more aerosols. Experts are now openly calling for us to stop using the term AGP altogether. This review article in the Lancet states:
“We propose an end to the term aerosol generating procedure, as it is neither accurate (aerosol is not generated above a cough for many of these procedures), implies aerosol emission is only from specific procedures (rather than being generated during normal respiratory events), potentially misidentifies the source of infection risk, and applies a binary definition to a situation that is more complex. Instead, we propose that clinicians follow an evidence-based framework that accounts for the major drivers of risk, with a focus on physical exposure to patients with suspected or confirmed COVID-19 as the critical component.”
- There is widespread dismay and frustration by health trade unions, numerous health organisations and large sections of the medical and scientific community at the refusal of IPC to amend the guidance. Concerted efforts for well over a year to get IPC to change have proved futile, despite overwhelming evidence of airborne transmission, and the multiple criticisms of the failings of the guidelines from clinicians and scientists.
- In practice IPC’s policies have failed comprehensively to protect health and social care workers – more than 1,500 of whom have died from Covid, according to former Health Secretary Matt Hancock, and over 120,000 health workers and 30,000 social care workers have long Covid according to the ONS. These figures predate the onset of delta Covid, which is more infectious and can lead to more serious disease; the figures now are therefore likely to be higher, despite most HCWs now being vaccinated.
- There has also been wholesale failure to keep patients in hospital safe from Covid infection. Tens of thousands of patients have been infected while they were in hospital for other health conditions. During the terrible second wave last winter, an average of 20% of Covid infections were hospital acquired; this dropped substantially over the summer, but the rate is now over 8% and rising.
- Over 11,600 patients have died from hospital acquired Covid-19 infection, according to a recent article in the Daily Telegraph. This is an indictment of infection control in our hospitals and a national scandal.
- An NHS spokesperson said in response to the Telegraph article that staff had “rigorously followed UK Health Security Agency (formerly PHE) infection prevention control guidance”. No doubt this is true, therefore the inescapable conclusion is that it is the guidance which is comprehensively failing to protect staff and patients. Until we have guidance which accepts the predominance of airborne transmission, and that this is a risk everywhere in our hospitals, thousands more patients will get infected with Covid in hospital and many will die. Health workers will also continue to get infected and some of them will die. More handwashing and surface cleaning is futile while no measures are taken against air infected with Covid-19 from patients and staff who have the virus. Wherever there is shared air, there is risk of transmission, and this includes non-clinical areas such as staff rest rooms, offices, change rooms, storage areas, reception and waiting areas etc.
- To date seventeen NHS Trusts are known to have gone beyond the guidance and issued their staff with respiratory PPE to protect them and patients against hospital acquired infections. The great majority of Trusts (there are 223) have not. As this study comparing hospital acquired infections in the different trusts shows, the wearing of respiratory protective equipment by staff in contact with Covid patients, compared with wearing surgical masks, significantly reduces hospital acquired infections.
- The same “droplet-not-aerosol” IPC guidance also applies to ambulance staff, i.e. they must wear surgical masks and not respiratory masks. Ambulance workers are probably one of the most at-risk groups of health workers: they enter the homes of sick patients who are known to be Covid positive, who are often actively symptomatic (e.g. coughing and therefore producing large amounts of aerosols with virus into the air), and they are in the earlier stages of the disease which we know is the time of greatest Covid infectivity. It is hard to imagine a scenario which is more high risk “red-zone” than this, yet staff are still issued poorly fitting surgical masks as standard. Unsurprisingly in February 2021 the GMB union reported that one third of ambulance staff had been infected; it is likely that many more will have been since the onset of delta Covid.
- IPC guidance also gets the basic physics of aerosols wrong. It states that only aerosols particles 5mm (microns) in size or smaller remain airborne. This is wrong – particles up to 50-100mm can remain suspended and travel long distances through the air. The bottom line is that the laws of physics greatly favour airborne transmission over droplet transmission – see here for a detailed explanation.
- So glaring has been IPC’s intransigence on airborne transmission, there is now a growing literature being published on the matter, examining why this may be happening. This recent paper is an interesting review of reasons, pointing to historical errors, scientific vested interests, ideological manipulation and do-the-minimum policy making, while the paper in point 32 above gives an international perspective of the origin of droplet-dogma and how it continues to bedevil current policy.
J Fluxman November 2021