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

COVID-19 update 7 September 2020 – still stumbling along

A review of where the UK is in its response to the Covid-19 pandemic

1. Policy failure

Richard Horton, editor of the prestigious medical journal ‘The Lancet’, described the management of COVID-19 as the “greatest science policy failure for a generation” in his book on the pandemic. Currently the numbers of newly diagnosed patients are steeply rising with many wondering if the government has completely lost its grip. So – four months after Johnson showed his remarkable grasp of the scientific narrative by declaring: “If this virus were a physical assailant, an unexpected and invisible mugger (which I can tell you from personal experience it is), then this is the moment when we have begun together to wrestle it to the floor” –  where do things stand?   

2. Increasing number of positive test results

In July, the lowest number of daily new positive tests recorded was 574; by 6th September 2020, this had risen alarmingly to nearly 3000 on each of two successive days, showing a sudden increase of around 50% just as schools were reopening and more workers being coaxed back into workplaces. Over the preceding few weeks, European countries such as France, Germany, Spain and the Netherlands had all seen a sharp rise in new cases, with 40% being in the younger age group. In the UK, the change in new diagnoses from predominantly elderly people to the young was even more apparent, with two thirds being in this demographic, including the steepest increase seen in 10 – 19 year olds accused of not observing social distancing.

3. Disillusionment

Meanwhile those with symptoms were often being told they will have to drive long distances, sometimes over a hundred miles, just to get a test. For many, this is simply not feasible, while for those who do make such a journey there is the risk of spreading infection further. At the same time statisticians have started to model the effects of NHS winter pressure combined with a second peak of coronavirus and predict that more than 100 acute hospital trusts will be operating at or above full capacity. A survey by the Doctors’ Association UK found that over 1,000 doctors were planning to quit the NHS through disillusion with the government’s management of the pandemic and frustration over pay. Recent national demonstrations calling for pay rises suggest many other NHS staff share these concerns and are prepared to take action.

4. Coronavirus endemic in some cities

A new public health report leaked to the press highlighted that COVID-19 was entrenched in some northern cities, and that case numbers had never really fallen to low levels during initial lockdown. This situation was strongly associated with deprivation, poor and overcrowded accommodation and ethnicity. New cases diagnosed per 100,000 population/week varied widely round the country at 98 in Bolton (topping the league), 37 in Manchester, 29 in Leeds, and only 3 in Southampton. The implication was that local lockdown measures were not likely to be any more effective in suppressing new infections and that there was an urgent need for a new strategy including better and locally tailored responses. These should include effective ‘find, test, trace, isolate and support’ (FTTIS) systems under the control of local authorities, many of which are in despair over their poor funding, and the hopeless performance of national ‘test and trace’.  Given over at huge cost to the private companies Serco and Sitel, these are still only successfully contacting 50% of contacts of known cases, a figure that, according to the official Scientific Advisory Group for Emergencies, should be at least 80%, with all these contacts then going into isolation.  

5. Broader lessons

Other lessons to be learned relate to financial support for workers and isolation of those living in overcrowded housing. It is simply no good (i.e. it is ineffective as an infection control measure) to expect low paid workers often with little or no financial reserves to self isolate for two weeks with either no pay or derisory statutory sick pay – full pay must be given by employer or government. In addition, people in densely packed housing cannot effectively self isolate, and as in some other countries, need to be temporarily housed in suitable alternative accommodation. This might be reopened hotels, or the almost unused Nightingale hospitals for those with mild symptoms.

6. is london different

One question of interest is why figures have not jumped up in London where the number of new cases in different areas is between 6 and 18/100,000/week. Possible explanations are that London was initially hit very hard by COVID-19 and as a result people have remained more cautious. For example, many Londoners who are able to work from home have decided not to heed government advice to return to office buildings. Geographical disparities in numbers of cases probably also reflect the fact that in northern cities such as Bradford, Oldham, and Rochdale, there is a relatively higher proportion of the workforce in more public facing roles such as the National Health Service, taxi services, take away restaurants, etc. Antibody testing (carried out regularly on samples of the population) also indicates that something like 17.5% of Londoners have been infected compared with 5-7% in the rest of the country. Although this is far from ‘herd immunity’ (which would require about 70% of the population to have been infected) it may mean that rapid increases in numbers of infection is at least initially delayed.

7. Airborne spread

There is now considerable support for the idea that an infected person can spread the virus over long distances through the atmosphere, although at the early stage of the pandemic this notion was rejected (hence the 2 meter social distancing advocated as being safe). There is an increasing body of evidence  confirming aerosol spread of virus, and this is well illustrated in food processing plants. Detailed investigation of the huge German meat factory outbreak showed spread of virus came from a single worker in the factory, with infection transmitted over 8 meters and more, and did not represent community acquired infection being brought in simultaneously by a large number of employees. The implication is that environmental conditions and effective ventilation are crucial to preventing spread of COVID-19, but unfortunately government guidelines as yet do not acknowledge this issue or provide appropriate guidance – a clear example of following far behind the science.

8. Treatments

Government strategy is reliant on the development of effective treatments and a vaccine; this in part explains the half-hearted approach to contact tracing. Lessons learned in the pandemic have reduced the numbers of patients that die once admitted to hospital, and this relates to use of oxygen delivery via a tube in the nose rather than one in the windpipe requiring the patient to be paralysed with drugs and breathing performed by a ventilator machine. Studies have also shown that giving a powerful anti-inflammatory steroid drug improves survival. As the number of patients has fallen considerably, less pressured staff also have more time to give better quality care. There is no basis for the suggestion that coronavirus has become less virulent; if it were to mutate, there is also the possibility it may become more rather than less harmful. The most likely explanation for rising case numbers overall with little change in hospital admissions and deaths is the fact that new cases are now predominantly in younger, fit people, who are much less likely to develop severe disease.

9. Vaccine

A vaccine is being presented as a ‘silver bullet’ that is just around the corner, however this is not the right message to give. There are estimated to be 170 research teams working on developing a vaccine, and nine products have reached large scale trials. To frame vaccine development as some kind of race increases the risk that a vaccine which is not very effective or has serious side effects will be rushed into use and public trust destroyed as a consequence. This would be hugely damaging and illustrates the importance of good public health messaging and the imperative of not compromising on safety through political pressure to deliver or the thirst for company profit. More important to bear in mind, there has never been an effective vaccine against a coronavirus just as there has never been an effective vaccine developed against HIV.

10. Fairy tales and reality checks

The Westminster government continues to choose to stumble on through the pandemic in the hope that a vaccine or effective treatment will arrive like a knight in shining armour, effect a rescue and bring us back to what was once normality. There is precious little reason to think that this is a sound strategy. Its cavalier approach to managing this unprecedented health emergency has included closing down Public Health England on spurious grounds – likened to taking the wings off a malfunctioning  aeroplane in mid-flight in order to ensure a safe landing. Basic demands from the public must continue to be for an effective FTTIS system, nationally coordinated but locally delivered and aimed at complete disease suppression; much improved testing, including local testing units and rapid turn around of results; investment in NHS infrastructure and ending the obsession with inefficient and expensive private contracts; honesty and transparency to win public trust and unite the young and old in a common purpose. Sadly, a conservative government characterised by antagonism to public services and one that prioritises business interests over public health is unlikely to be either self critical and learn from experience or to implement positive changes such as those outlined above. The price for wearing such ideological blinkers will be more suffering and more economic damage as COVID-19 once again inevitably spreads like wildfire through our communities. Perhaps it is only a massively increased death toll that will make it change course.

THE ROLE OF AIRBORNE SPREAD IN FACTORY OUTBREAKS OF COVID-19

Workers and local communities are not to blame; responsibility lies with employers, regulatory agencies and government

Summary

It seems nearly every day there is another outbreak of Covid-19 in Britain’s factories, in the food processing industry, in the garment industry and elsewhere.  It is increasingly clear that working conditions in the factories are largely responsible for the outbreaks, in particular by means of airborne spread of Covid-19.  In contrast spread between workers outside the factory and in local communities plays only a small part.  The timing, circumstances and pattern of the outbreaks, points to them being typical “super-spreader events”, caused by airborne spread of the virus within the same enclosed indoor space of the factory, from one or two infected individuals to large numbers of other workers.  The actions of workers themselves play only a minor role in these outbreaks; the task before us is to urgently take measures to address the airborne route of spread, not only in factories but in all workplaces and schools, if we are to reduce outbreaks.   

The spread of Covid-19 in indoor spaces is extremely difficult to prevent entirely.  There is in reality no such thing as a “Covid-safe” workplace or school, unless transmission in the community is eliminated.  The rate of community transmission will determine what happens in our workplaces and schools and a national “Zero Covid” strategy is therefore essential.  We can make indoor spaces safer by hygiene measures, distancing, wearing masks and proper ventilation.  We should be spending as much time talking about ventilation as we do the other measures.  The Health and Safety Executive, the Food Standards Authority and other regulatory authorities have a crucial role in ensuring this is done properly; so far we have heard very little from them during the whole of the Covid-19 pandemic.

This briefing discusses airborne spread and the lessons we need to learn from super-spreading events which have occurred here and in other countries.  This is all the more urgent as we head into autumn and winter when we all move indoors to a much greater extent. 

Contents

  1. Airborne spread of Covid-19
  2. Greencore outbreak
  3. Tönnies meat packing plant study
  4. Preventive measures taken by Tönnies and lessons learned
  5. Growing evidence and consensus around aerosol spread
  6. Workers and local communities are being scapegoated for factory outbreaks caused by airborne spread
  7. Epidemiological studies
  8. A trade union programme
  9. Doctors in Unite
  10. References

1. Airborne spread of covid-19

The British Medical Journal published a leading article on 22 August on airborne spread of Covid-19  [1], which summarises what is now very convincing evidence for aerosol transmission through the air.  The article says that current official guidance, which says transmission occurs only through contact and droplet spread and that aerosols are produced only during so called “aerosol generating procedures” in hospitals, does not withstand scrutiny, and gets in the way of much needed measures to combat the virus.  The authors state, “Heavy breathing, coughing, talking, and singing all generate aerosols……This has important practical implications for infection control, the prevention of outbreaks and superspreading events, and for the new social behaviours that are being implemented in an effort to control the pandemic.”  

The article states that airborne spread is now the plausible cause of super-spreader events, and it seems very likely that several outbreaks here in the UK, for example Greencore in Northampton, the garment factories in Leicester, meat and poultry packing plants in Wales and West Yorkshire and Coupar Angus in Scotland have been just such events.  It is striking that according to press reports, in some of the outbreaks employers insist they have been fully implementing all recommended workplace safety measures. Greencore is a case in point: the company stated, “All of Greencore’s sites have wide-ranging social-distancing measures, stringent hygiene procedures and regular temperature checking in place”.  Yet nearly 300 people working there were still infected. 

2. Greencore outbreak

It is instructive to look at the Greencore outbreak in some detail, to ascertain how the virus spread.  It is unlikely that a large number workers breached handwashing and distancing measures at the factory all within a few days, especially as management says they are so careful.  It is also implausable that community transmission carried infection into the factory to such a large extent.  This would mean a large number of discrete, small outbreaks in the community all at the same time, and very many more cases in the community outside the factory, which does not appear to have happened.  In fact, the BBC reports [2] that “Testing data and analysis from the Joint Biosecurity Centre shows the spike is “almost solely down” to the outbreak at Moulton Park-based Greencore, which employs 2,100 people”.  The timing of the outbreak indicates instead a typical super-spreader event.  The graphs below demonstrate this clearly; one is of the Greencore outbreak: there was a low and steady number of cases in the Northampton area until mid-August when there was an abrupt jump in cases – over 200 within 3 days; a typical super-spreader pattern.  The second graph is of the super-spreading event in a call centre in Seoul in March 2020, and shows a similar pattern: 94 out of 216 employees working in an open plan office on the same floor became infected over a few days in this outbreak.

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Seoul call centre outbreak early March 2020 Source: Park et al, Emerging Infectious Diseases CDC https://wwwnc.cdc.gov/eid/article/26/8/20-1274-f1

We have appended below a press photograph of the Greencore factory floor: assuming this accurately portrays current working conditions, there are lots of people sharing the same, indoor space for many hours at a time each day.  We have no information about the ventilation in the factory, but food processing plants are usually kept cool for hygiene reasons, and colder temperatures favour the survival of the SARS-CoV-2 virus.  The ventilation often also involves recirculation of colder air in such plants, at least in part, rather than complete air changes with fresh outside air.  Even with several air changes per hour it seems that some live virus can still be present in the air indoors (see below).  And the direction of ventilation and air flow within the space is also important; it may carry the virus from an infected worker towards others. This is thought to have happened in the well documented restaurant outbreak in Guangzhou. [13]  

We do not know if the photograph reflects recent practise, but if so, the lack of mask wearing is striking. Greencore workers told the local press they were “terrified” of being required to work while they awaited test results for Covid-19, and were told it was up to them if they wanted to wear a face mask or not. [14]

3. Tönnies meat packing plant studyIt is helpful to look at a detailed study of a similar super-spreading event also in the food processing industry – at the Tönnies meat packing plant in Germany in June. [3 – not peer reviewed as yet]. The study analysed a range of possible factors involved in the outbreak, including the timing of infection events, spatial relationship between workers in the meat processing plant, climate and ventilation conditions, sharing of living quarters and transport, and performed full viral genome sequences (i.e. genetic fingerprinting) from virus recovered from PCR-confirmed SARS-CoV-2 cases. The viral sequencing established that spread was from a single index case within the factory to other workers, and not from multiple entry points by different workers bringing infection into the plant.  It also established that shared accommodation and transport did not play a material role in the outbreak.  Over a 3 day period, 29 workers out of 147 who worked the same shift as the index case became infected before the index case was quarantined.  60% of workers within an 8m radius of the index case became infected.  In addition, before the workers caught in the first outbreak were quarantined, they had had contact with others elsewhere in the factory, which led to a secondary outbreak leading to over 1500 workers becoming infected in the Tönnies factory overall.  This led to a lockdown of a large area in the North Rhine-Westphalia region in western Germany.

3. Tönnies meat packing plant study

It is helpful to look at a detailed study of a similar super-spreading event also in the food processing industry – at the Tönnies meat packing plant in Germany in June. [3 – not peer reviewed as yet]. The study analysed a range of possible factors involved in the outbreak, including the timing of infection events, spatial relationship between workers in the meat processing plant, climate and ventilation conditions, sharing of living quarters and transport, and performed full viral genome sequences (i.e. genetic fingerprinting) from virus recovered from PCR-confirmed SARS-CoV-2 cases. The viral sequencing established that spread was from a single index case within the factory to other workers, and not from multiple entry points by different workers bringing infection into the plant.  It also established that shared accommodation and transport did not play a material role in the outbreak.  Over a 3 day period, 29 workers out of 147 who worked the same shift as the index case became infected before the index case was quarantined.  60% of workers within an 8m radius of the index case became infected.  In addition, before the workers caught in the first outbreak were quarantined, they had had contact with others elsewhere in the factory, which led to a secondary outbreak leading to over 1500 workers becoming infected in the Tönnies factory overall.  This led to a lockdown of a large area in the North Rhine-Westphalia region in western Germany. 

The diagrams below are reproduced from the study and show:  A: the distance between the index case (B1) and spread to other workers; diagram B shows the relationship of distance to infection risk and diagram C shows that spread within the factory was the cause of the outbreak and not shared accommodation or car pools.  A full description of these findings is in the paper at reference [3].

It is worth quoting from this study at length:

“Aerosols are believed to be particularly important in cases where a single source transmits the virus toa large number of individuals, so-called super spreading events. Whereas droplets typically travel no farther than 2 m, aerosols can stay in the air for prolonged periods of time and may deliver infectious viral particles substantially beyond 2m distances, especially in indoor settings with low fresh air exchange rates. Factors such as temperature, humidity and air circulation are thought to significantly influence stability and transport of droplets and aerosols and consequently transmission efficiency.

Meat processing plants have recently emerged as hotspots of SARS-CoV-2 around the world. This is thought to result not only from operational practices (e.g. close proximity of workers in the production line combined with physically demanding work that promotes heavy breathing), but also from sharing of housing and transportation that may facilitate viral transmission. The requirement to operate at low temperature in an environment with low air exchange rates is another factor that may promote spread of the virus among workers.

Transmission occurred in a confined area of (the) meat processing plant in which air is constantly recirculated and cooled to 10°C. ……. Analyzing housing and commuting parameters, along with spatial and climate conditions in the work area, this study provides evidence that transmission occurred over a radius of at least 8 meters around the index case…… Physical work and relatively low fresh air exchange rates together with continuous re-circulation of cooled air may have favoured the transmission of SARS-CoV-2…

The universal point of potential contact among all cases was work in the early shift of the beef processing plant. The shift comprises 147 individuals, most of whom work at fixed positions in a conveyor-belt processing line……

….. while some secondary infections may have occurred within apartments, bedrooms or carpools, our collective data strongly suggest that the majority of transmissions occurred within the beef processing facility, with (index) case B1 being at the root of the cluster.

Our findings indicate that a physical distance of 2 meters does not suffice to prevent transmission in environmental conditions such as those studied here; additional measures such as improved ventilation and airflow, installation of filtering devices or use of high-quality face masks are required to reduce the infection risk in these environments.

Our findings suggest that the facilities’ environmental conditions, including low temperature, low air exchange rates, and constant air re-circularization, together with relatively close distance between workers and demanding physical work, created an unfavourable mix of factors promoting efficient aerosol transmission of SARS-CoV-2 particles.

It is very likely that these or similar factors are also responsible for current worldwide ongoing outbreaks in other meat or fish processing facilities. The recurrent emergence of such outbreaks suggests that employees in meat or fish processing facilities need to be frequently and systematically screened to prevent future SARSCoV-2 outbreaks. Furthermore, immediate action needs to be taken to quarantine all workers in a radius around an infected individual that may significantly extend beyond 2m.

In contrast to work-related exposure, shared apartments, bedrooms, or carpools appear not to have played a major role in the initial outbreak described in this study. Nevertheless, later viral transmission within shared living quarters or work rides very well may have been a confounding factor in context of the second, larger outbreak occurring one month after the first outbreak. Our genotyping results are fully compatible with the hypothesis that this second outbreak was seeded by cases related to the initial cluster.

The significance of this study is imminent for the meat and fish processing industry but might well reach beyond these industries, and points to the importance of air quality/flow in confined spaces to prevent future superspreading events

Common operational conditions in industrial meat processing plants promote the risk of SARS-CoV-2 superspreading events. Additional measures such as improved ventilation, optimized airflow management, installation of filtering or ultraviolet light devices or the use of high-quality face masks are required to reduce the infection risk in these environments.”

Community spread and spread among workers outside the factory have been pointed to as the cause of the Greencore outbreak.    This seems to be mere supposition rather than any evidence-based assessment for such spread.  The Tönnies study involved a similar group of workers, i.e. workers sharing accommodation and transport, and specifically looked at these issues and disproved them as the reason for the outbreak.  There is a lack of awareness and therefore no consideration of the role of indoor aerosol spread driving factory outbreaks, which perhaps explains why the press, public and even health experts look for possible explanations outside the factory gates.

4. Preventive measures taken by Tönnies and lessons learned

The study reports that the company took the following measures after the outbreak:

  • Hygiene regulations and one-way traffic in hallways were reinforced.
  • An internal multi-lingual information campaign was started to raise awareness for all staff of prevention and self-detection of early COVID-19 symptoms.
  • Temperature checks were set up to check all employees entering the building.
  • Workers were made aware of the availability of testing and were motivated to report any events where they see themselves being at risk. Staff were tested based on self-reported symptoms, possible contacts to other infected persons, returning to work after more than 96 hours absence from work, or possible work place contact with infected colleagues.
  • Work place assessments were performed to see if it was possible to extend distances between workers.
  • Simple one-layer face masks were made compulsory.
  • Regulations to prohibit rotation between working places were imposed.  (Shift workers were employed by an outsourcing company who had changed their workplaces according to demand by the employer.)
  • Measures in the canteen were imposed to reduce physical contact and to ensure that workers would spend their break times exclusively with workers from their own shift.
  • Implementation of the measures was audited within a month by unannounced inspections of the Occupational Health and Safety Experts of the competent authority. 

There are a number of important lessons from this study:

  • Airborne spread is particularly important in super-spreader events;
  • Aerosols can carry virus much further than 2m indoors;
  • Temperature, humidity and air circulation (fresh air exchange rates) significantly affect stability and transport of droplets and aerosols and therefore transmission;
  • Close proximity of workers on the production line doing physically demanding work and therefore breathing heavily also facilitate transmission. (Other studies have pointed to rapid “line speeds” as an additional contributing factor);
  • Early quarantine of possible contacts is essential to limit spread;
  • Shared accommodation and transport did not play a significant role in this outbreak; the common factor was working together on the factory floor under these conditions;
  • Improved ventilation and airflow, installation of filtering devices, and use of face masks are required to reduce the infection risk in these environments, and in other workplaces which have enclosed indoor spaces.
  • Large secondary outbreaks can occur from an initial outbreak in a factory.  Press reports indicated an increased number of cases in the surrounding community as well (but this may have been due to increased testing).
  • There is a need for surveillance testing in high risk environments like food processing plants, given the large number of super-spreading events which have occurred in them.
  • In addition to measures like hygiene, social distancing and temperature monitoring, multi-lingual information campaigns, compulsory face masks and rapid access to testing are important.
  • Inspection by regulatory authorities is important to ensure compliance.

While there have also been numerous outbreaks in the hospitality sector, especially linked to pubs, the workplace appears to have now become the frontline in the battle against Covid-19, both here and across the EU. [4]  [5] 

5. Growing evidence and consensus around aerosol spread

Aerosol scientists, mainly in the US but also in Australia and elsewhere, and here in the UK (e.g. Professor Catherine Noakes at the University of Leeds, who sits on SAGE), have been convinced for some time that aerosol spread is a major route of transmission.  In July, 239 scientists wrote to the World Health Organisation (WHO) asking it to recognise airborne spread and amend its guidance.  WHO did shift its previous rejection of the idea and said aerosol spread “cannot be ruled out”.  Since then there has been further evidence, including the successful culturing of live virus from the air up to 4.8m from infected patients in hospital rooms.  (A surprising and concerning finding was that the rooms had fairly good ventilation rates as well as UV light air sterilisation, but live virus was still able to be cultured from the air.)  [6]

Meanwhile official documents from SAGE have referred to aerosol transmission on a number of occasions, [7] [8] and some professional associations’ guidelines now include advice on the risks of aerosol spread; for example, the Primary Care Respiratory Society says that routine assessments of patients by means of spirometry should be avoided due to the risk of droplet and aerosol spread.  [9]

Aerosol spread is officially recognised in Germany and Japan and recently the French employment minister, Elisabeth Borne, stated that compulsory mask wearing from 31 August in France, “reflects a growing scientific consensus that the virus is transmitted not only in big drops projected when a person coughs or sneezes, but also in smaller ones suspended in the air breathed out by infected people that accumulates in enclosed spaces”. [10].  Nicola Sturgeon spoke of the risk of aerosol spread in schools in Scotland on 24 August, stating her government was considering face coverings for secondary school students in communal areas.  [11]

In the US a number of institutions are actively looking at ventilation requirements in indoor spaces, using CO2 monitors as a proxy measure for adequacy of ventilation, and the addition of portable air filters to make indoor spaces safer, including in schools and universities.  A clear and practical article on this from the University of Colorado is at reference [12]. 

6. Workers and local communities are being scapegoated for factory outbreaks caused by airborne spread

We have seen in Leicester and other areas of the Midlands, accusations that outbreaks in factories have been due to workers and/or local communities failing to observe social distancing measures.  There has been racist scapegoating of Asian communities, blaming them for local spikes in infection caused by factory outbreaks (in the Leicester garment factories for example), which very likely have involved airborne transmission.  We have seen a social media post about the Greencore workers saying, “I don’t feel bad for most of the staff. The Eastern Europeans never followed regulations like distancing and not mixing in large groups in lockdown in March onwards. They don’t care.”  The role of airborne spread needs to be understood, and communicated to all concerned during these outbreaks.  Ignorance of how Covid-19 spreads is leading to victim-blaming of people who become infected, when attention should be directed to employers, public health officials and government for solutions.

It is notable that in many of these large outbreaks, workers are poorly paid and are on insecure short-term contracts.  Many receive only Statutory Sick Pay; as a result they have had to rely on food banks, and some have lost their homes as they could not afford to pay rent.  All workers forced to take time off due to having Covid-19 or having been a close contact of an infected person should receive full pay while isolating.  Not doing so is inhumane, and is obviously also self-defeating, as some workers will go to work like those who were made to do so at Greencore while awaiting test results, and thereby compromise efforts to curtail the outbreaks.  The government’s recent derisory offer of £13 per day for workers having to isolate is clearly wholly inadequate. It has been described as “a slap in the face” by a Council leader, and also only applies to areas with already high infection rates.  This is clearly wrong, we want to prevent infection rates going up, not reacting when they have already become high.  A proactive, preventive approach is needed.

7. Epidemiological studies

We believe it would be also be very helpful if detailed epidemiological studies, like the one done in the Tonnes meat packing plant, could be conducted in future outbreaks here in the UK, to better understand and learn from them.  Hopefully some are being done but we have yet to see any of these.

8. A trade union programme

  • Employers must recognise airborne spread as a covid-19 risk and take action to assess and minimise risk.
  • Improved ventilation and airflow, installation of filtering devices, and use of face masks are required to reduce the infection risk in these environments, alongside other safety measures against Covid-19.
  • Trade union supervision and control of workplace safety.
  • Weekly surveillance testing on site of all workers, including management, in addition to easily accessible testing for anyone with symptoms or in contact with Covid-19.
  • All workers forced to take time off due to having Covid-19 or having been in contact with it should receive full pay while isolating.  No-one should have to work while awaiting test results for symptomatic or contact testing.

9. Doctors in Unite

We are a national doctors’ trade union within Unite the Union; our members include working and retired GPs and hospital doctors and dentists from a range of specialties, as well as public health doctors and non-medical public health specialists, from across the four nations of the UK.  We are party to the BMA negotiating machinery by virtue of an agreement with the BMA dating from 1950 and are the only medical trade union recognised in local government. We have been involved throughout the pandemic, both in our day jobs, and also raising issues around PPE, “Covid-safe” workplaces and campaigning on the critically important requirement for locally based ‘Find, Test, Trace, Isolate and Support’ services run by the DPH in each borough.

We will also continue to lobby for a change to official guidance around transmission of Covid-19, although with the abrupt axing of PHE this may be difficult.   

10. References

[1] https://www.bmj.com/content/370/bmj.m3206

[2] https://www.bbc.co.uk/news/uk-england-northamptonshire-53860426

[3] https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3654517

[4] https://www.ecdc.europa.eu/en/publications-data/covid-19-clusters-and-outbreaks-occupational-settings-eueea-and-uk 

[5] https://www.thelocal.fr/20200803/office-not-parties-biggest-source-of-coronavirus-contagion-in-france 

[6] https://www.medrxiv.org/content/10.1101/2020.08.03.20167395v1

[7]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/887618/EMG_Environmental_transmission-_02052020__1_.pdf

[8]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/894961/6.6731_CO_Review_of_two_metre_Social_Distancing_Guidance_FINAL_v3_WEB_240620.pdf

[9] https://www.pcrs-uk.org/sites/pcrs-uk.org/files/Diagnosis%20of%20asthma%20and%20COPD%20during%20Covid.pdf

[10] https://www.theguardian.com/world/2020/aug/18/global-report-france-tightens-mask-rules-as-covid-cases-rise-europe

[11] https://www.theguardian.com/uk-news/2020/aug/24/seventeen-teachers-at-dundee-school-contract-covid-19

[12] https://theconversation.com/how-to-use-ventilation-and-air-filtration-to-prevent-the-spread-of-coronavirus-indoors-143732

[13] https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article#tnF1

[14] https://www.northantslive.news/news/northamptonshire-news/greencore-staff-lift-lid-fears-4443310?fbclid=IwAR3ZzlExqOP-JzOXanlJgmeQTr7zqmhomNfEtjdRm3bSCigTKRxfyioYxig

Exam results post-COVID: DiU Statement

Doctors in Unite (formerly the Medical Practitioners Union) are extremely concerned that thousands of young people, disproportionately from disadvantaged back grounds, have been awarded A level grades, in many cases two grades lower, than those predicted by their teachers. 

It is grossly unfair that young people from areas already hardest hit by the ravages of COVID 19 should have the fact that the virus has prevented them from taking their exams add a further barrier to their ability to achieve and to their life chances. 

We are appalled that many of the young people who expected to go on to higher education have been let down by an algorithm which takes little account of individual potential, placing more emphasis on the historic performance of the school, handing further advantage to those from more affluent areas.

In particular, as doctors, we are worried that young people who live in working class areas will fail to get the places in medical school which should have been theirs. Diversity within the medical profession is vitally important so that as doctors we can effectively represent the patients that we serve. The algorithm threatens the level of diversity amongst our colleagues of the future and many of today’s doctors would not be practicing if they had been subjected to such a system..

We call on Gavin Williamson to work with the teacher’s unions, immediately scrap the algorithm and to award young people A level grades based on the predictions of their teachers. To fail to do this will rob thousands of young people of the futures they deserve and quite rightly expect.

Doctors in Unite, 17/08/2020

We need a Zero coid-19 strategy now: say over 200 health and social care workers

Over 200 health and social care workers, from across the entire spectrum of specialties and grades of staff have signed an open letter addressed to Boris Johnson, calling on him to set out a coherent strategy that will effectively tackle the Covid-19 pandemic in England.  They include professors, consultants, GPs, nurses, therapists, administration staff, theatre porters, paediatricians, psychiatrists and mental health nurses, obstetricians and midwives, haematologists, laboratory staff, radiologists, respiratory physicians; healthcare assistants, psychotherapists, administrators, chief executives, occupational therapists, pharmacists, immunological researchers, clinical directors, senior lecturers, social workers, palliative care specialists, speech and language therapists.

The letter states that slogans like “stay alert”, “control the virus” and “whac-a-mole” do not constitute a strategy.  Given the terrible cost of the pandemic, both in terms of lives lost and lasting damage to the economy, we call on you urgently to set out an explicit strategy in relation to Covid-19”.  The letter says there is a clear choice, between mitigation, i.e. accepting ongoing infections and deaths indefinitely until a vaccine or cure is found, or suppression, i.e. aiming to eliminate the virus.  The letter says that the latter course clearly represents the best strategy in terms of both public health and protecting the economy.

The letter goes on, “This means having a much more ambitious target of suppressing the number of new cases to zero as soon as possible, and keeping it there.  This requires continuing public health measures, such as maintaining social distancing, universal use of face masks in enclosed spaces, sensible travel restrictions, and setting up countrywide community based, efficient and rapid ‘find, test, trace, isolate and support’ infrastructure across the country, including at our borders.  If done effectively and comprehensively this would successfully suppress the virus in a matter of weeks, and then keep it there.”

Dr Jackie Applebee, Chair of Doctors in Unite, the group who organised the letter, said “We cannot continue to drift on this rudderless course any longer.  Flare ups like Leicester and in the meat and poultry packing plants show the dangers of this approach and if there are enough of these there will be a second wave, forcing us all back into lockdown.”  Independent SAGE have called for a “Zero Covid” strategy; it is perfectly possible to suppress the virus in England as they have done in Scotland, with the right approach. For that to happen though we need an effective test, trace, isolate and support service, based in the community and run by Directors of Public Health, not the ineffective privatised and separate service we have now.

We ask the government, yet again, what is your strategy?

You can read the original letter here:

https://doctorsinunite.com/2020/06/21/open-letter-to-the-prime-minister-about-the-uks-covid-19-strategy-from-nhs-and-social-care-workers/?fbclid=IwAR0cIjKXS54H4cEFZHnfOW3WWG_SGe72ZS13T9bgjCjeeq-yHzbYi6nigpM

NHS 72nd Birthday

5th July 2020

The 72nd birthday of the NHS takes place in the shadow of the COVID 19 pandemic.

The progress of the virus underlines the absolute importance of having an NHS as Bevan intended when it was founded in 1948, a comprehensive health service, publicly funded from general taxation, publicly provided and free at the point of delivery for all. The aim was to end inequalities in access to healthcare and July 5th 1948 famously saw queues of people round the block in a powerful demonstration of the size of the previous unmet need.

Since 1948, and accelerated since 1990, the founding ethos of the NHS has been under threat. One of the most cost-effective health care systems in the developed world, the NHS is nevertheless subject to repeated cuts and calls for efficiency savings, along with privatisation, fragmentation and competition, which was enshrined into NHS procurement by Andrew Lansley’s dastardly 2012 Health and Social Care Act. Public Health departments have been hollowed out and side-lined, at huge cost to their vital functions.

COVID 19 has laid bare the disastrous effects of the undermining of the NHS. People of BAME origin and the poor are far more likely to die of the virus. Years of NHS underfunding and outsourcing to the private sector has left it without the spare capacity to cope with the challenges of the pandemic. There has been insufficient appropriate PPE for health and social care workers, testing for the virus has been chaotic and outsourced to the private sector with no coordination with GP services, community contact tracing that has served well countries such as New Zealand, South Korea, Iceland and even Liberia, where they are used to dealing with Ebola so know what needs to be done, has been side-lined in the UK with reliance on a national system which has been deemed by Independent SAGE as not fit for purpose.

The result of this is that the UK has the ignominious honour of having the highest death toll from COVID in Europe, and, as I write, the third highest in the world, behind Brazil and the US.

BAME staff have died disproportionately yet they are the backbone of the NHS, often employed in the lowest paid of jobs on precarious contracts. To add insult to injury the hostile environment makes some of them ineligible for free NHS care. The Tories have done a U turn and said that the health surcharge will not apply to health workers, they have yet to implement this so the pressure needs to be maintained, but it does show what can be achieved through sustained campaigning.

A publicly run health service with adequate funding and planning based on need not profit, would have mitigated many of the challenges that COVID 19 has presented.

So, on this the 72nd birthday of our NHS we must keep fighting to have it restored into public ownership. The Black Lives Matter movement chimes with the disproportionate death toll amongst our BAME brothers and sisters, everyone should have equality of opportunity in life and equal access to health care. This can only be achieved in a society based on need not profit.

We have a job to do. If we fight, we can win.