This is the last update from me for a while. CATA is standing down for the time being. Our involvement in the Covid Public Inquiry as core participants in Module 3 (Impact of the pandemic on healthcare systems across the UK) now rests on the eventual publication of the report by Baroness Hallett. She has told us that this will not be until spring 2026. CATA Executive felt that this was too long to wait for substantial changes to the 4 nation National IPC manuals (NIPCM) on which current guidance is based. These still predicate use of proper respiratory protective Equipment (RPE = FFP3 or powered hoods) only for so-called AGPs. Since most clinical contacts are made without an AGP, this places all those involved at risk of contracting that infection, be it Covid-19 (C-19), RSV or flu.
Covid-19 has not gone away. There have been 25,000 more deaths since the start of the Inquiry. To date there have been 247,000 in total. Whilst community prevalence and intra hospital prevalence are not high at present, when patients with potentially dangerous airborne respiratory infections are being managed often in open wards or bays, or even in single rooms, no respiratory protections are being made available to healthcare workers (HCWs) such as yourselves in many institutions. WHO, CDC and even the English NIPCM states that RPE MUST be worn when entering the room of such infected patients if they have an airborne transmitted disease. The problem is that the accompanying table in the NIPCM goes on to describe Coronaviruses such as SARS-CoV-2 as airborne/droplet and to state that FRSM are to be used for ALL routine care except for AGPs when RPE can be used.
The reason for this conundrum was revealed in Module 3 of the Inquiry. Government officials from UKHSA agreed C-19 transmission is airborne but then claimed that respirators such as FFP3 are no more effective than paper surgical masks in real life. This could not be more incorrect but the claim stems from the current guidelines extant during the pandemic and beyond. Since HCWs are mandated to use RPE only when performing so-called AGPs, it follows that they must use only FRSMs for all non AGP care- which is the majority of course. This in turn means that sessional use of RPE was and is not mandated unless in a setting where AGPs are performed frequently. It has now been firmly established that sessional use of RPE irrespective of procedure, rather than intermittent use for AGPs is highly protective. This theory can now be supported by the latest definitive paper on use of RPE.
Another problem is the claim that we don’t know yet whether C-19 is predominantly airborne or droplet. This is the most frustrating aspect of all. It is as irrelevant as it is wrong. Firstly, the so-called droplets >5 microns are in fact aerosols up to 100 microns. Thus all IPC guidance on droplet transmission is null and void. Secondly, it does not matter what proportion of a respiratory hazard is airborne in Health and Safety law and COSHH regulations. Any risk of an airborne exposure, no matter how small must lead to use of effective respiratory protection. FRSMs are useful for source control but are not and never have been RPE or even PPE according to the responsible body – the Health & Safety Executive (HSE). In fact, the airborne route is now recognised by WHO and CDC and even appears on some UK government websites. But still the IPC guidance remains predicated on droplet transmission and AGPs.
So this brings us to the current impasse which has prevented changes to the NIPCM across the 4 nations (which all have different versions!). CATA along with BMA, RCN, Bereaved Families for Justice and Long Covid groups wrote to the Inquiry chair asking that she publish an interim statement that C-19 was airborne and that RPE works and should be used when HCWs are exposed to potential or proven respiratory pathogens. She declined so we wrote again pointing out that some of her arguments were wrong. Again, the inquiry declined.
As described in CATA’s unanswered letter to Andrew Gwynne MP, Health Minister responsible for Covid-19 matters until he was sacked, the government is still being advised by the same people who wrote the IPC guidance during the pandemic and then the NIPCMs. The one-time chair of the IPC Cell and current Deputy Lead for IPC at NHSE, Lisa Ritchie appeared at the inquiry and claimed that she still believes that C-19 is droplet transmitted and that FRSMs are all that is needed – despite also claiming she was not an expert and that she would have changed the guidance if notified of “new” science. She was so notified by Public Health England (PHE) but chose to ignore it and still does. Until there are changes in NHSE and its counterparts in the devolved nations, the IPC guidance will remain unchanged.
In October 2024, CATA wrote to the 4 CNOs to ask for urgent revision of the IPC guidance embodied in the National IPC Manuals. After 4 months and questions about it in both Houses of Parliament, CATA finally received a reply 28th February. Again, the response contained all the usual platitudes on HCW safety we have become accustomed to hearing over the last 5 years. We have written back pointing out the illegality of current guidance which is in breach of Health & Safety law.
What does this mean for BAPEN members? When you are passing NGTs, providing central line care or dressing PEGs, or just talking to your patients, the risk of you contracting a respiratory pathogen from them remains high if that patient has already contracted such an infection, maybe in the asymptomatic phase. Those same patients are often clinically vulnerable and need to know that their doctors, nurse, dietitians etc are not going to give them a potentially fatal infection. Improved ventilation and use of HEPA filters or high level UV light will go some way towards protection HCWs and patients from “far -field transmission”, but close quarter care, especially over long periods of time requires RPE- either FFP3 or a powered hood as in Southampton where our previous President, Trevor Smith helped introduce them with great benefits.
I believe we are at crossroads in medical thinking. Intransigent blinkered thinking has been a hallmark of medical progress or lack of it throughout the ages. When Semmelweiss showed in 1847 that washing hands prevented post puerperal sepsis, this was rejected. When John Snow demonstrated in 1854 that cholera was water borne, he was ridiculed by the medical establishment. The droplet paradigm has lasted since the early 1900’s without any serious supporting science. By contrast, the science underpinning the airborne route is cast iron and has been available for almost a century and certainly since the beginning of the pandemic. Why are we so resistant to change? BAPEN exists to provide the best possible care based on the latest science. BAPEN and NNNG (both founder members of our Alliances) together with our CATA partners and others, can be proud of having had a profound impact on current scientific thinking and the Covid Inquiry. I suspect that practical changes which improve your safety and that of our patients will take longer. Maybe the module 3 report next year will be the catalyst? Until then, I will sign off!
Dr Barry Jones BSc MBBS MD FRCP
Chair of the Covid-19 Airborne Transmission Alliance
