We are extremely disappointed that the Independent High Risk AGP Panel has concluded that there is not currently robust enough evidence to conclude that the insertion of naso-gastric tubes generates significantly more aerosols than other types of care and is associated with increased risk of transmission of COVID-19 to HCPs.

After months of campaigning on this issue we are shocked that this conclusion has been reached and that no change is to be made to current guidance. We believe that this decision means that healthcare professionals who are responsible for inserting naso-gastric tubes, as well as their patients and colleagues, will continue to be at increased risk of COVID-19 transmission. Without a change in the guidance, there is no obligation for health services to provide staff undertaking this and other key procedures with full PPE.

There is substantial evidence that the insertion of naso-gastric tubes causes coughing and sneezing which generates aerosols with significant viral load within 1 metre of the patient, creating a higher risk of transmission of COVID-19, which itself causes profuse coughing. The report states, “Given the limited range and poor quality of the evidence, with many studies underpowered or vulnerable to bias or confounding, it is not possible to distinguish the absence of risk from the absence of evidence”. It is inevitably very difficult to provide evidence that proves that exposure to aerosols in this way results in COVID-19 infection, but we would have expected the panel to take into account the evidence that is available and the weight of professional opinion behind this issue. It is noteworthy that the report presents no data to support a lack of increased transmission during NGT insertion using FFP2 or N95 masks. Given the current situation with 46,000 HCP off work due to Covid1 any measure which might reduce transmission to front line staff should be entertained. The possibility that this level of infection could be due to inadequate PPE cannot be excluded, so a more pragmatic precautionary approach is required. Whatever the science says, current guidance is not working.

BAPEN is part of the AGP Alliance which was formed mid-way through 2020, and comprises Royal Colleges, trade unions and professional bodies from across the health and care sector, and there is support for our views on NGTs as AGPs from many more. There is wide professional consensus on this issue, and we are astonished that the panel chose not to take on board the advice of all the organisations within the AGP Alliance. The panel has universally rejected the concerns of the AGP Alliance about a number of procedures, the insertion of NG tubes being one chief area of concern, but other procedures similarly dismissed, including cardiopulmonary exercise and lung function tests, spirometry and swallowing assessment. At BAPEN, we have a responsibility to look out for the health and wellbeing of our members as well as for the patients who require nutritional care. We are dismayed at this decision that we believe continues to put both professionals and patients in harm’s way. Healthcare professionals from many disciplines will continue to risk their own safety by ensuring patients receive the nutritional care they need, but it is wrong that they cannot be protected while doing so. By putting their health at risk, the health of the patients they treat will also be threatened. We will continue to campaign on this issue alongside our colleagues within the AGP Alliance.


  1. https://www.bbc.co.uk/news/blogs-the-papers-55606564
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