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Why is BAPEN involved in Covid-19 matters?

In March 2020, former BAPEN President, Dr Trevor Smith asked for evidence to explain why Nasogastric tube (NGT) insertion was not on the AGP (aerosol generating procedure) list as it seemed that NGT insertion must cause aerosol generation as a result of coughing. It was rapidly determined that NGT should be on the AGP list. BAPEN wrote to the Public Health England (PHE) but received a response indicating there would be no changes to guidance.

Also in March 2020, infection prevention and control (IPC) guidance on Covid-19 changed with respiratory protective equipment (respirators) permitted only for AGPs or in areas where many were taking place such as critical care. For all “routine care”, only surgical masks were allowed. These masks have never been designated as personal protective equipment (PPE) or respiratory protective equipment (RPE) and are not designed for, or effective at, preventing inhalation or expiration of aerosols.

BAPEN went on to garner 21 professional bodies that regarded NGT as an AGP, including four international Practice-based Evidence in Nutrition (PEN) societies. BAPEN then asked the Chief Nursing Officer, Ruth May and the Chief Medical Officer, Chris Whitty to intervene.

As a result, the Independent High-Risk AGP Panel was set up in May 2020. This did not report until January 2021 and made no new changes to IPC guidance. Nor did it comment on the very poor level of evidence used to support the AGP list, which BAPEN had drawn to the attention of PHE and the CMO/CNO. We then wrote to the Secretary of State for Health and Social Security, Matt Hancock, to which we received no response.

The AGP Alliance is born

During the summer of 2020, BAPEN linked up with others with similar views on AGPs and the AGP Alliance was formed with BAPEN’s Dr Barry Jones as chair. Together we wrote to the Prime Minister, Secretary of State, and many others, all with no response. We had the support of David Shukman  (then Science Editor of the BBC) and several online pieces appeared in support of our case, all to no avail. Unfortunately, the AGP Alliance’s outreach was not helped by the World Health Organisation (WHO) stating that Covid-19 was not transmitted through the air. This position was not changed for the better until late 2021.

Early in 2021, the AGP Alliance wrote again to the Prime Minister with the Royal College of Nursing (RCN), British Medical Association (BMA), Royal College of Midwives, and many others, but this letter was also ignored until we wrote again to the Chief Medical Officer. He set up a meeting between AGP Alliance and the Department of Health and Social Care (DHSC) which  was then expanded to include all signatories to the earlier letter to the Prime Minister to which we finally received a response – again with no change to guidance.

The proposed meeting eventually took place in June 2021 with over 20 professional organisations, representing over one million healthcare workers, led by the AGP Alliance Chair and supported by the BAPEN President. At the meeting, unfortunately answers were not provided to key questions on close-range risk and the need for RPE rather than surgical masks. Promises of future cooperation with the Alliance, BMA or RCN also failed to occur.

AGP Alliance becomes CAPA

The increasingly credible evidence for the airborne route of transmission led AGP Alliance to change its name to the Covid Airborne Protection Alliance (CAPA) so that we were no longer concentrating on the AGP list and its exclusions, but on the risk to all from the airborne route irrespective of procedure. We were encouraged by the UK Cabinet Office’s public health campaign “Hands, Face, Space, Fresh Air” which implied recognition of the airborne route. However, IPC guidance was not shifted away from the droplet route of transmission to reflect this so healthcare workers were to continue caring for patients with ineffective surgical masks.

In the absence of clear definitions within the IPC guidance on risk assessment  regarding the most dangerous route of transmission, a risk assessment tool was published in December 2021 by CAPA, alongside our partners, the RCN and the British Occupational Hygiene Society (BOHS).

Through 2022, we corresponded with UKHSA having had another letter forwarded on by the CMO. Eventually, the UKHSA stated that the “droplet-aerosol dichotomy is no longer helpful” but despite this, IPC guidance remained inconsistent and confusing and remains so to this day. This now demonstrated a clear difference between the English and Scottish IPC manuals.

It should be noted that the efforts of CAPA has always included a four nation approach, including direct meetings with the Scottish First Minister. NGT insertion is still not on the AGP list which perversely still exists and determines IPC guidance. Nor are dysphagia assessment, CPR, or chest Physiotherapy. For example, healthcare workers in an ambulance with a Covid-19 patient still only warrants a surgical mask despite the vehicle being essentially a closed inadequately ventilated box, with reports of waits outside Emergency Departments of up to 17 hours.

CAPA becomes CATA

With the announcement of the UK-wide Covid Public Inquiry, CAPA linked up with a legal firm specialising in Inquiry work. Not all CAPA members wished to continue with us so we became the Covid-19 Airborne Transmission Alliance (CATA) with additional member organisations and individuals, some suffering with Long Covid. CAPA continues to campaign for improvements in current IPC guidance whilst CATA is now deeply involved with the Public Inquiry.

CATA was a key witness in Module 1 of the Covid-19 Public Inquiry. Module 3 sees CATA as one of 30 core participants and also as a witness. Our submissions are already influencing other participants and the direction of the Inquiry. BAPEN continues to be represented by Barry Jones as Chair of CATA, supported by an Executive Team of Kamini Gadhok MBE (ex-CEO of the Royal College of Speech and Language Therapists); Kevin Bampton (CEO of BOHS), and David Osborn (a Health & Safety expert). We are represented by Saunders Law, Philip Dayle, Barrister, and Stephen Simblet KC.

Much of the correspondence relating to AGPA and CAPA can be found on this site, together with links to published evidence to the Public Inquiry. Membership of AGPA, CAPA and CATA can be found below.

Members of AGP Alliance and CAPA

BAPEN/NNNG/RCSLT/BDA/BSG/College of Paramedics (CoP)/British Association of Stroke Physicians (BASP) & British & Irish Association of Stroke Physicians (BIASP)/Chartered Society of Physiotherapists (CSP)/Queen’s Nursing Institute (QNI)/FreshAirNHS/Doctors’ Association UK (DAUK)/Hospital Consultants and Specialists Association (HCSA)/Association of Respiratory Technicians and Physiologists (ARTP)/Medical Supply Drive UK/David Osborn/British Occupational Hygiene Society (BOHS)/Unite the Union/GMB Union.

Members of CATA

BAPEN/ NNNG/RCSLT/BOHS/BDA/BSG/CoP/ARTP/BIASP/DAUK/QNI/Patient Safety Learning/Gillian Higgins (Surgeon)/Nathalie MacDermott (ID doctor)/Geraint Jones (Pharmacist)/David Tomlinson (Cardiologist)/Marianne Tinkler (Respiratory Physician)/T Lawton (Intensivist), David Osborn (Health & Safety Expert).

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