Committee, Council & SIG Updates
Nasogastric Tube Special Interest Group (NGSIG)
Dr Barry Jones, Member and Wendy-Ling Relph, Chair NGSIG
Email: ngsig@bapen.org.uk
Website: www.bapen.org.uk/about-bapen/committees-and-groups/bapen-special-interest-groups/ng-sig
The Prime Minister stated early in the pandemic that the government would be guided by ‘the science’. As I write this article, I heard the Chief Scientific Officer state that he wants ‘the science’ to be at the centre of all government policymaking (Today Programme, BBC Radio 4, 12 October 2021). All well and good you might think! However, this was followed by the publication of the Parliamentary report ‘Coronavirus: Lessons Learned to date’ with the damning verdict on the lack of challenge by government of its scientific advisers leading to the ‘worst public health failure ever’.
In my first piece on the subject of Nasogastric Tube (NGT) insertion and its non-Aerosol Generating Procedure (AGP) status in In Touch June 2020, I asked: ‘what if the science is wrong?’ BAPEN and its NGSIG concluded that NGT/Nasojejunal Tube insertion must be an AGP because of the coughing caused by the procedure as well as by COVID-19 itself (www.bapen.org.uk/pdfs/covid-19/ngt-and-agp-and-ppe-15-04-20.pdf). We were supported in this view by no less than 21 professional bodies, including all Royal Medical and Surgical Colleges in GB and Ireland, and four international PEN societies.
We have striven to bring this to the attention of Public Health England (PHE), and other government bodies, from our first letter on the subject (www.bapen.org.uk/pdfs/covid-19/bapen-letter-to-public-health-england.pdf) – to our most recent – as part of the extraordinary AGP Alliance (AGPA) of healthcare professional bodies, experts and unions. Our original title of AGPA has changed to Covid Airborne Protection Alliance (CAPA), to better reflect our objectives. These objectives have not changed, but the route required to achieve them has altered. Thus we still wish NGT insertion to be on a par with currently recognised AGP, but that the AGP list should be abolished altogether in favour of a policy of Respiratory Protective Equipment (RPE) for ALL close range care and procedures as suggested in The Lancet doi.org/10.1016/S2213-2600(21)00216-2
Please note the use of the acronym RPE, not PPE. Just to be clear, PHE/IPC regard surgical masks as PPE against droplet transmission but fluid-repellent surgical masks (FRSM) have never been designed, or designated as RPE or even PPE under health and safety law. FRSM are ‘medical devices’ to protect the wearer from droplet deposition but not from aerosols. The downgrading of SARS-CoV-2 from the Highly Consequential Infectious Disease (HCID) list on March 13, 2020, was followed on March 16, 2021, by withdrawal of guidance to use FFP3 airborne RPE to be replaced by FRSM for droplet transmission. Despite our best efforts and the coming of two serious Covid variants, PHE has refused to alter its guidance, variously falling back on WHO guidance and its own review systems.
Once again, we should consider the findings of these reviews.
The Independent High Risk AGP Panel set up by the Chief Medical Officer, in response to BAPEN’s approach to the Chief Nursing Officer, reported in January 2021 that it saw no reason to change guidance on AGP or NGT insertion despite finding only the same two papers critiqued by BAPEN in its first letters to PHE and the Secretary of State for Health and Social Care, May 2020 (www.bapen.org.uk/pdfs/covid-19/bapen-letter-to-rt-hon-matt-hancock.pdf). You may recall they dealt with the risk of acquiring SARS in 2003 but were regarded as of ‘low quality’ by the WHO reviewer (Tran et al, 2021, doi: 10.1371/journal.pone.0035797) and ‘not suitable for medical decision making’ by Health Protection Scotland in 2017. Despite this PHE adopted the AGP list and has stuck rigidly to it ever since. It will come as no surprise that subsequent reviews by the high-risk panel repeated their conclusions in June 2021 despite finding no new data. Of note is their failure to find any papers on dysphagia assessment – which also causes coughing – and should be an AGP. They found not a single paper but still concluded that this was not an AGP. So much for a scientific approach!
On June 3, 2021, BAPEN and AGPA (now CAPA) met with the DHSC/PHE/IPC Cell as part of an even more extraordinary and unprecedented collaboration comprising the AGPA, RCN, BMA, RC Midwives, QNI and RC Pharm amounting to 26 professional bodies and unions representing at least one million healthcare workers (HCW). We repeatedly asked for an answer to the question: ‘do you agree that risk of aerosol transmission is greatest at close range?’ But the chair shut down the questioners including myself. No further answer was forthcoming in written responses over a month later.
The latest development was the publishing of new draft guidance on Infection Prevention and Control from PHE for consultation over a short window of two weeks. BAPEN and CAPA responded independently as did many of the member organisations of CAPA. We have little confidence that our comments will be listened although the publication of the Parliamentary report on ‘Coronavirus: Lessons Learned to Date’ may help (https://committees.parliament.uk/publications/7496/documents/78687/default/). The failure to recognise the significance of airborne transmission was raised in his evidence by Dominic Cummings and evidence submitted by CAPA was initially acknowledged but has not been included in the references to published evidence. This report fails to mention anything about the need for airborne mitigation, or the wrong type of PPE being advised throughout the pandemic from March 2020. Instead, it concentrates on inadequate PPE supply and inequity of access to PPE by BAME groups.
Over this summer, BAPEN and CAPA have been working with the RCN and British Occupational Hygiene Society (BOHS) to develop a risk management tool for use by employers and employees to determine the risk of aerosol transmission and the need for RPE - either FFP3 or respirator hoods. A useful tool was made available by our Health & Safety expert, David Osborn on his website (www.tridenthse.co.uk/covid-hcw.html) which you may find useful while waiting for the BOHS tool. The emphasis for employers must now be on satisfying COSHH and legal health and safety obligations, the emergency COVID-19 legislation having lapsed since July 17, 2021. This means that PHE guidance no longer has the potential to overrule health and safety law which should protect HCW from exposure to SARS-CoV-2 and other airborne viruses.
What is the evidence for Covid being airborne? Have a look at these papers which summarise the case doi.org/10.1136/bmj.n913 and doi.org/10.1016/S0140-6736(21)00869-2
Further evidence comes from the Bristol ‘Aerator’ study Aerosol emission from the respiratory tract: an analysis of relative risks from oxygen delivery systems | medRxiv (www.medrxiv.org/content/10.1101/2021.01.29.21250552v1?_ga=2.105725635.1756207761.1634043541-613714160.1634043541) which shows that even simple breathing generates aerosols capable of carrying the virus. Coughing releases many times more aerosol than so-called AGP and yet procedures such as NGT insertion are not designated as AGP. In Addenbrookes, Cambridge, replacing FRSM with FFP3 masks in ‘red’ areas reduced to almost zero the 47-fold excess of HCW infections compared to low-risk areas. More recently, our own President has co-authored a paper on the use of re-usable powered respirators for all front line HCW in his hospital in Southampton. They not only received good feedback from the wearers but showed a markedly reduced HCW COVID-19 positivity rate compared to many other hospitals doi:10.3389/fmedt.2021.72658
So, science means different things to different people! Some disregard all evidence for aerosol transmission despite accepting that some procedures liberate aerosols. Others have taken a more sensible precautionary approach which not only protects their staff but patients, who have suffered from high nosocomial rates of COVID-19 infection. There are still more than 7,000 patients in UK hospitals, so it is not too late to make a difference, but sadly it is too late for the many who might have avoided infection had they been given the correct protective equipment. BAPEN is joining with CAPA to become a core participant in the public enquiry next year and discussions with lawyers are ongoing.
Deaths of British HCW and patients are among the highest in the world. This might not have been the case had PHE guidance advised better PPE for all staff providing close range care and procedures, not just for AGP. Our government has been badly advised with bad science.
Prepared by Dr Barry Jones, NGSIG member, Chair of CAPA and BAPEN IAC
Members of CAPA:
BAPEN, BSG, BASP, NNNG, BAPEN Medical, RCSLT, BDA, CSP, College of Paramedics, QNI, Doctors Assoc UK, Medical Supply Drive UK, Fresh Air NHS, David Osborn H&S expert, HCSA, Unite, GMB
doi.org/10.3389/fmedt.2021.729658
The Nutrition Society
Dr Bernadette Moore, University of Leeds, The Nutrition Society Clinical/Medical Advisory Council member
Email: office@nutritionsociety.org
Website: www.nutritionsociety.org
Twitter: @Nutritionsoc
Instagram: the_nutrition_society
LinkedIn: /nutrition-society
What another crazy year we’ve had. Time seems to have flown by as we spent the first few months in a national lockdown before the staggered easing of restrictions allowed us to begin meeting each other face-to-face and attending the events we have all been missing.
The lifting of COVID-19 restrictions meant the Nutrition Society was able to host its Nutrition Futures conference, as its very first hybrid event in early September. Aimed at nutrition students, many came away with an understanding of the career pathways they could take should they wish to work within the medical field. Over 160 delegates from 14 countries attended, approximately 50% online and 50% in-person, and a short overview can be found here: www.nutritionsociety.org/past-conference/nutrition-futures-2021-conference-overview.
Hybrid events certainly seem to be a way forward, with the continued pressures I know my BAPEN NHS colleagues continue to face and added challenges as we move into colder months. I am sad not to be seeing colleagues this November as BAPEN’s annual conference is postponed, but have my fingers crossed we will yet meet again in Brighton. The BAPEN Programmes Committee has done a brilliant job to coordinate in a short time frame the many exciting webinars that will take place this year instead, from Monday 29 November to Thursday 2 December at 16.00-17.30hrs each day. I am very much looking forward to hearing of BAPEN’s activities and achievements over the last 12 months at the opening ceremony on 29 November. Find out more: www.bapen.org.uk/resources-and-education/meetings/annual-conference.
As the year comes to a close, the Nutrition Society also continues to remain busy, and I think the topic of our winter meeting: ‘Obesity and the brain’ is fascinating, timely and likely to be of interest to many BAPEN members. It will be a hybrid event, which I think is great for members who might not be able to travel to London on 7-8 December. The conference will bring together neuroscientists and clinicians to discuss the mechanisms of the impact of obesity on brain structure and function. The question of whether bariatric surgery can lead to improvements in cognitive function will be addressed, and barriers to behavior change in weight management will be examined. Registration will remain open until 30 November, and further details can be found here: www.nutritionsociety.org/events/winter-conference-2021obesity-and-brain.
Following the Nutrition Society Training Academy short summer break, The Nutrition Society Journal Club (www.nutritionsociety.org/events/nutrition-society-journal-club-nsjc) and live webinars (www.nutritionsociety.org/training-academy/webinars-and-workshops) are now back. On-demand webinars have been categorised, making it easier for healthcare professionals to find the most relevant content: (www.nutritionsociety.org/training-academy/on-demand-webinars). This really is a fantastic CPD resource, aiming to support nutrition scientists and practitioners at different stages of their career development, with all NSTA activity being endorsed for CPD.
Finally, a reminder to the gastroenterologists among you will also be interested to hear of the current waiver on all fees to publish in the Society’s latest open access journal Gut Microbiome. Details can be found here: www.cambridge.org/core/journals/gut-microbiome.
With all my very best wishes,
Bernadette