Statement on urgent need to update Public Health England (PHE) and Infection Prevention and Control (IPC) guidance on coronavirus infection prevention and control to reflect what has been learned about the importance of aerosol transmission

At the start of the pandemic it was thought that spread of coronavirus was through large droplets travelling over a relatively short distance or by fomites contaminating hands and mucous membranes. The danger of aerosol spread was recognised, but thought to be limited to ‘aerosol generating procedures’ (AGP) such as intubation. For this reason, high grade face masks (FFP3 or N95) were only recommended for staff exposed to AGP (1).

The denial of aerosol transmission of virus  (2) always sat uncomfortably with the acceptance that so called AGP represented a risk. It is now known that aerosols are generated by talking, shouting, singing, coughing and sneezing and are an important form of viral transmission.  Official Infection Prevention and Control (IPC) guidance [3] is now seriously lacking on the issue of AGPs: several studies [4] [5] [6] indicate that many of the “classic” AGPs (like intubation) produce little in the way of aerosols and that an actively coughing patient may be much more infectious than those undergoing various AGPs.  Moreover, patients with Covid-19 requiring AGPs are likely to be sicker and later on in their illness course, and will therefore produce much less aerosolised virus than patients who have just become symptomatic, when infectiousness is known to be at its greatest.

In fact, coronavirus can be spread over large distances, for example in food processing plants (7) or in restaurant settings. Studies in health workers of SARS-CoV-2 antibody status (signifying past infection) (8) strongly suggest that high level PPE (including high grade masks) is effective in preventing infection, and that use of surgical type fluid resistant masks is inadequate in situations where staff are in close contact with symptomatic patients such as on hospital wards.  

In addition, ventilation in enclosed and crowded workspaces is clearly an important risk factor in spread, yet there is little specific advice to manage this risk other than keeping windows open. This is a particular concern in workplaces and schools where maintaining social distancing is difficult; currently the highest rate of new infection is among secondary school children.  The fact that a recent update of official IPC guidance does not mention aerosol spread at all (outside of AGPs) is inexplicable, given that this was after Public Health England recognised this route of transmission over two month ago.  This puts tens of thousands of health and social care workers at potential risk in hospitals, primary care settings and in care homes, as well as the patients they care for.

The pandemic is far from over, with more than 600 health and care workers already having died, and an overall death toll in the UK equivalent to one international airplane crash killing all passengers every day for nine months. Although vaccine development gives some cause for hope, important unknowns remain how many people will receive/accept vaccination and how long this process will take, whether vaccination will prevent transmission and therefore achieve herd immunity, and how long protection might last. There is therefore every reason to hone non-pharmacological interventions in order to reduce further loss of life. We therefore call upon PHE and the Department of Health and Social Care to recognise an urgent need to update guidelines on COVID-19 prevention and control in the light of what is now known about aerosol transmission. This should include upgrading type of masks worn (9) and advice on how to maintain and monitor effective ventilation.

References

  1. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control
  2. https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations
  3. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/910885/COVID-19_Infection_prevention_and_control_guidance_FINAL_PDF_20082020.pdf

BAME frontline workers should also get priority for Covid-19 vaccine

Evidence shows that those of BAME origin are amongst those at highest risk of infection and death  from COVID 19. People of BAME origin often work in low paid employment in jobs where it is not possible to work at home such as cleaners, carers and bus drivers. These are also jobs which put workers in close, protracted contact with the public. Doctors in Unite believe that when a safe vaccine against COVID 19 becomes available that those in such high risk roles should be prioritised to receive it and they should be recognised as front-line staff.

In the NHS, it is usual for low paid jobs to be contracted out to private corporations and these outsourced workers, for example in NHS domestic services and portering,  do not get treated on a par with directly employed staff. While it has been shown that clinical staff in intensive care units have been well protected against Covid 19 with high quality risk assessment, PPE, air purification and more, other front line clinical workers, especially outsourced BAME workers, have had high mortality.  

In addition, public facing workers of BAME origin often live in overcrowded, multi-generational households. Potential exposure to COVID 19 at work not only puts them at risk, but their extended families.

Doctors in Unite believes that these high risk, front-line workers should be among those at the front of the queue to receive a safe COVID 19 vaccine,  and applauds the International Workers of Great Britain for their  groundbreaking court victory over health-and-safety protection for workers in the gig economy.

See article here on IWGB’s court victory here: https://morningstaronline.co.uk/article/b/union-hails-groundbreaking-court-victory-over-access-to-ppe-for-gig-economy-workers

Mass testing in Liverpool – more questions than answers

Doctors in Unite sent the letter below to Professor Allyson Pollock and colleagues, in support of their letter to Liverpool MPs questioning the rationale for mass testing of the people of Liverpool. A link to their letter, and a BMJ blogpost by Dr Angela Raffle, Consultant in Public Health appears below our letter.

9th November 2020

To: Allyson Pollock, Professor of Public Health, Newcastle University;  Anthony J. Brooks,  Professor of Genomics and Bioinformatics, Leicester University; Louisa Harding-Edgar, General Practitioner and Academic Fellow in General Practice, Glasgow University;  Angela E. Raffle, Consultant in Public Health, Honorary Senior Lecturer in Public Health, Bristol Medical School Department of Population Health Sciences, University of Bristol;  Stuart Hogarth, Lecturer, Department of Sociology, University of Cambridge. 

CC: Dr Matt Ashton, Director of Public Health, Liverpool.

Dear Allyson, Prof Brooks, Dr Harding-Edgar, Dr Raffle and Dr Hogarth,

Doctors in Unite would like to support your letter expressing concerns about the mass testing for COVID 19 in Liverpool.

We are surprised that Dr Ashton, Director of Public Health for Liverpool is enthusiastic about the pilot and would be interested to hear his reasoning.  If there is more detailed information which has led him to this conclusion, that we are not party to, we would be willing to reconsider our position in the light of any such evidence.

We believe that there is a place for testing of a sufficiently-sized random sample of individuals if it is to determine more accurately the prevalence of COVID 19 in society, in fact we called for this early on in the pandemic, it is in place nationally and could usefully be augmented to generate local results. However opening the testing to everybody detracts from the randomness of the sample, which becomes self-selected, and creates a significant issue of false negative test results which needs to be considered.

Mass testing with the aim of suppressing the virus, without adequate Test, Track, Trace, Isolate and Support is in our view unlikely to be successful. As you point out even a very small false positive rate will mean that people who are not infected will be told to self-isolate and there will be a larger number of these individuals and their families the more people who are tested.  Without income protection many people are likely to decline to be involved.

We believe that the Westminster Government response to the COVID 19 pandemic has been appalling and that many lives have been unnecessarily lost. It is time for the Government to abandon their populist approach and to start to be led by the science.

Best wishes

Dr Jackie Applebee, Chair, Doctors in Unite

Letter to Liverpool MPs:

https://allysonpollock.com/?page_id=3345

BMJ blogpost by Dr Angela Raffle

One Stop Shops – trick or treat?

The media recently highlighted the fact that NHS England has announced:

The NHS is set to radically overhaul the way MRI, CT and other diagnostic services are delivered for patients . . . . Community diagnostic hubs or ‘one stop shops’ should be created across the country, away from hospitals, so that patients can receive life-saving checks close to their homes. The centres could be set up in free space on the high street or retail parks.”

“The need for reform of NHS diagnostics was recognised in the Long Term Plan” – so begins the recent report by Professor Sir Mike Richards, ‘Diagnostics. Recovery and Renewal’.

The key recommendations are:

  • Acute and elective diagnostics should be separated wherever possible to increase efficiency.
  • Acute diagnostic services (for A&E and inpatient care) should be improved so that patients who require CT scanning or ultrasound from A&E can be imaged without delay. Inpatients needing CT or MRI should be able to be scanned on the day of request.
  • Community diagnostic hubs should be established away from acute hospital sites and kept as clear of Covid-19 as possible.
  • Diagnostic services should be organised so that as far as possible patients only have to attend once and, where appropriate, they should be tested for Covid-19 before diagnostic tests are undertaken.
  • Community phlebotomy services should be improved, so that all patients can have blood samples taken close to their homes, at least six days a week, without needing to come to acute hospitals.

Motherhood and apple pie

On the surface of it, these are laudable aims that have been welcomed by hospital bosses. The COVID-19 pandemic has had a devastating effect on management of non-covid conditions with, for example, a 75% reduction in cancer referrals and a reduction in 210,000 imaging procedures each week. Before the pandemic there were 30,000 patients who had waited longer than 6 weeks for a diagnostic test, a figure that has now increased to 580,000. Urgent consideration must be given both to how the NHS is put back on its feet and how it addresses the huge backlog of problems as well as the ongoing pandemic. There is logic in separating acute and non-acute service provision into covid and covid free areas, and who could object to patients having convenient and rapid access to the best available technology? This does of course depend on many factors, not least having an efficient coronavirus testing system at some point in the future, but raises other crucial issues.

Where will the staff be found?

The plan as set out requires the recruitment of around 11,000 staff including 2000 radiologists, 500 Advanced Practitioner radiographers, 3,500 radiographers, 2,500 assistant practitioners, 2,670 administrative staff and 220 physicists. Bear in mind the current staffing crisis on the NHS, with around 140,000 vacancies across the board exacerbated by low pay and workplace stress. Cancer Research estimated that staff would need to double by 2027 to meet demand, with one in ten posts in diagnostics unfilled at the start of the pandemic. Furthermore, massive investment in equipment will be needed. The report points out that in relation to the 20 other countries making up the Organisation for Economic Cooperation and Development, the UK ranks bottom for CT and 3rd from last for MRI scanners. The Clinical Imaging Board claims that nearly 30 per cent of the UK’s MRI stock is at least ten years old, with no replacement plans for almost 40 per cent of systems more than seven years old.

All that’s left to find – money and staff

The last settlement for the NHS was £20.5 bn, which over a five year period amounted to an annual increase in budget of 3.4%. This did not include funding for training and employing the staff of the future. Most commentators thought a minimum 4% increase in funding was needed, and the Office for Budget Responsibility put the figure at 4.3% in order to meet increasing demand. COVID-19 has now blown all these estimates out of the water with the additional costs of restarting and sustaining the service, dealing with COVID-19 long term and developing and implementing a workforce transformation.

Private sector – the spectre lurking in the wings

In Simon Stevens’s letter to health care providers in July this year, he mandated:

Ensuring that sufficient diagnostic capacity is in place in Covid19-secure environments, including through the use of independent sector facilities, and the development of Community Diagnostic Hubs and Rapid Diagnostic Centres”.

As pointed out in The Lowdown in a comment on diagnostic hubs:

“References . . . to high street and retail park sites are possibly of no real concern – perhaps they’re more about exploiting cheap-to-rent locations during the pandemic-driven economic recession than a push to link-up with high-profile brand sponsors – but the well-established presence of private sector interests operating in the diagnostic and pathology arena suggests there may be rich pickings on offer somewhere in the hub programme, if only until the backlog is cleared”.

In fact the privatisation of diagnostic and laboratory facilities is already well underway. There is no comfort here in Professor Richard’s report which even cites as a case study:

The East Midlands Radiology Consortium (EMRAD) was launched in 2013 to create a common digital radiology system. Pioneering work led to the development of a Cloud-based image-sharing system through which the seven NHS trusts involved in the partnership could share diagnostic images, such as X-rays and scans. In 2018, EMRAD formed a partnership with two UK-based AI companies, Faculty and Kheiron Medical, to help develop and test AI tools in the breast cancer screening programme in the East Midlands.”

There is no mention of the fact that EMRAD paid £30m for the picture archiving and communication system from GE Healthcare but refused to pay full service costs until GE sorted out chronic problems causing a dangerous backlog of CT and MRI images.

Like many of the aspirational service developments contained within the Long Term Plan, ‘one stop shops’ could offer real value to patients. As the report by Professor Richards recognises:

These new services will require major investment in facilities, equipment and workforce, alongside replacement of obsolete equipment. Training of additional highly skilled staff will take time but should start as soon as possible. International recruitment should be prioritized.”  

This is no small ask and needs to be part of a generous new funding settlement for the NHS by government.  This should be an investment in the NHS as a public service rather than a source of rich pickings for private companies.

This article was written by John Puntis for Keep Our NHS Public

Doctors in Unite support Independent SAGE’s emergency 10-point plan to stop a national lockdown

We sent the following message today, 20 September 2020, to Independent SAGE:

“Doctors in Unite fully endorse Independent SAGE’s emergency ten point plan to avoid a national lockdown. [The plan can be found here: https://www.independentsage.org/wp-content/uploads/2020/09/Emergency-Plan-PUBLISHED.pdf ]


Experience from other countries such as Germany, South Korea and Japan has shown that if the correct measures are adopted the case rate of COVID 19 can be substantially reduced and unnecessary deaths prevented. Equally these proposals are not alien to the United Kingdom as virtually all of the recommendations are already policy in our devolved administrations.

However, despite governing one of the richest countries in the world, Boris Johnson and the Tory Party callously ignore what can be done and what needs to be done and instead throw billions of pounds at private sector providers such as Serco, Sitel and Deloitte whose national “test, trace, isolate and support” programme is demonstrably unfit for purpose, and is contributing to the current alarming rise in Covid-19 infection.

Doctors in Unite call on the Tory Government to take off their ideological blinkers and to listen to the experts and people on the front line, to give the NHS and Public Health the tools they need to crush the virus and to immediately adopt i-SAGE’s emergency ten point plan”


We did suggest an amendment to point 2 of the plan which says there should be “no return to workplaces until they are certified Covid-safe”. It is very difficult to make any indoor space completely Covid-safe and the Health and Safety Executive (HSE) has suffered swingeing cuts over the last decade to the point where it is unable to fulfil its statutory duties in the workplace. We suggest therefore that there should be no return to the workplace “until it has been fully risk-assessed”, which will allow for trade union and worker involvement in ensuring that workplaces are as safe a possible.

Speech by Dr Jackie Applebee, Chair of Doctors in Unite to the BMA Annual Representative Meeting, 15 September 2020

Dr Applebee proposed the motion by TOWER HAMLETS DIVISION of the BMA: That this meeting, in response to COVID 19, demands that government:

i) ensure that workers are not under pressure to attend work either for financial or workforce reasons while they are unwell or self-isolating and at risk of inadvertently passing on the disease;

ii) provide the equivalent of day-one statutory sick pay to those on zero hours contracts;

iii) allow the NHS to requisition private health care facilities to accommodate effective COVID-19 treatment and quarantine provision if needed;

iv) ensure workers are paid in full while they are unwell or self-isolating.

With respect to point iii)

The COVID 19 pandemic has surely blown the myth that private is good and public is bad.

We have heard repeatedly today how the NHS has stepped up to the plate to deal with the crisis, though years of an unprecedented funding squeeze has led to the collateral damage that Chaand (Dr Chaand Nagpaul, Chair of the Council of BMA) referred to earlier of  those whose other health needs could not be met due to the lack of slack in the system.

On the other hand outsourcing to the likes of Deloitte and Serco has led not to the world beating test trace isolate and support system trumpeted by Boris Johnson, but a wholesale fiasco where people are having to drive miles to get a COVID test and where, despite the billions spent, the global multinationals cannot do as well with contact tracing as the very poor relation that are local public health departments.

Private hospitals were handed hundreds of millions back in March to increase capacity to deal with COVID 19 but they were largely unused, gifting a nice windfall to their shareholders at a time when their usual work had all but dried up.

Now they are likely to commissioned to help with the backlog of NHS care. Don’t get me wrong the backlog needs to be cleared, patients need their treatment, but the private sector should not be able to profit from this. They should be brought into the NHS family and their activity now should be offset against the money they were given in March. There must be value for public money spent.

The fact that the NHS had to shut down everything except dealing with COVID in March is a stark illustration of the chronic underfunding and that there has to be spare capacity inbuilt into the system to deal with crises. The extra money thrown at the system should have been thrown at the NHS not the private sector.

With respect to points i), ii) and iv):

If we are going to crush COVID, really get on top of it, we need people to be able to afford to stay at home and isolate if they are in contact with an index case. If there is enough money in the economy to subsidise eating out there is surely enough to guarantee that if someone is in quarantine that they are paid in full.

Many of the lowest paid, for example cleaners, refuse collectors and care workers, many of whom have looked after patients with COVID, often of precarious zero hours contracts, cannot work from home, and to make ends meet many of them have two jobs. They need to be reassured that they wont’ lose out financially if they stay off work otherwise they will have no choice but to go in and the virus will continue to spread.

Covid is with us but Government could do so much more to minimise it’s devastating impact.

The pandemic has surely underlined the huge value of publicly funded, publicly provided health service which is free at the point of delivery and the demonstrated the dedication of the staff who work within the NHS and Social Care.

As has been said today already, we have an opportunity to reshape the future, it’s up to us whether we grasp the nettle.

Please support this motion in all it’s parts.

The Motion was passed with overwhelming support from delegates