The Doctors’ Association UK is calling for a moratorium on mandatory vaccination, followed by an urgent review of current staffing levels and their implications for patient safety.

“Allowing a proper impact assessment is a responsible way forward,” said its chair, Jenny Vaughan. “Any reassurance gained for the public about staff presenting less of a risk because ‘only’ vaccinated staff will be treating them is easily offset by the added pressures this mandate will cause to an already buckling NHS.”

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NHS staff who work directly with patients should have routine access to face masks that offer high protection because covid-19 infections threaten to overwhelm services, doctors’ leaders have said.

Three national organisations said that filtering facepiece respirators (FFP3s) should be made fully available because of the increased transmissibility of the omicron variant. The BMA, the Hospital Consultants and Specialists Association, and the Doctors’ Association UK, concerned at rising hospital admissions and rates of staff sickness, cite growing evidence that airborne transmission of SARS-CoV-2 is a major driver of infection.

They want better protection for all healthcare staff who work with or around patients who have covid-19, saying that the current guidance on FFP3 use and the NHS’s reliance on usual surgical masks leave staff at increased risk of infection.

Jenny Vaughan, who chairs the Doctors’ Association UK, said that staff were deeply concerned that the NHS could be overwhelmed by high numbers of patients needing beds in wards and critical care. “Our frontline workers must be protected,” she said.

Research published earlier this year showed that FFP3 masks for healthcare workers on covid-19 wards reduced hospital acquired SARS-CoV-2 infections.

The NHS is required to follow UK national guidance on infection and prevention control, which was updated by the UK Health Security Agency on 21 December. This says that an FFP3 respirator (or equivalent) must be used by staff when they care for patients with a suspected or confirmed infection that is spread wholly by the airborne route, and when performing aerosol generating procedures on a patient with a suspected or confirmed infection spread wholly or partly by the droplet or airborne route.

FFP3 masks can be used more widely when transmission risk remains unacceptably high, after local risk assessments that should include “evaluation of ventilation in the area, operational capacity, and local prevalence of infection/new SARS-CoV-2 variants of concern.”

But doctors’ leaders said the guidance did not do enough to minimise the risks to all staff who may be exposed to the virus, nor did it guarantee an adequate supply of FFP3 masks.

In an open letter to the UK Health Security Agency, published last week, the Doctors’ Association UK said the distinction between normal patient care and “aerosol generating procedures” was “artificial” and that the latest guidance would confuse NHS trusts over how to fulfil their health and safety responsibilities.

The letter said, “We now know that breathing is sufficient to generate airborne coronavirus capable of infecting others who are breathing the same air. With omicron rates doubling roughly every two days we must treat every patient we see as being a potential carrier of covid. We believe it is necessary to provide FFP3 masks for all staff working indoors where exhaled air from patients is circulating.”

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Hadiza Bawa-Garba has been allowed to practise again without restrictions, 10 years after a 6 year old boy in her care died of septic shock following a mistaken diagnosis of gastroenteritis.

A well regarded trainee paediatrician at the time Jack Adcock died in 2011, Bawa-Garba was later found guilty of gross negligence manslaughter. Many doctors saw her as a scapegoat for an overstretched and underfunded NHS.

An investigation at Leicester Royal Infirmary found numerous system failures on the 12 hour shift when she was working under extreme pressure, covering several wards without adequate supervision and with IT problems. 

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“MedSuppyDrive UK started last year. There was PPE in our labs not being used and I thought we could redirect it to the frontline. We’re volunteer run. We started off writing to labs and businesses—the donations came flooding in and we had 100 volunteers within a week. To date we’ve circulated around 380,000 items of PPE.

“More recently we started thinking about something more sustainable.

“In the US, they have guidelines for reusables and for decontamination. Why don’t we have guidance here? PPE provision to the NHS frontline has not been adequate. The government says there are not enough FFP3 masks to go around. Our solution? Look at reusables. Anyone who’s facing covid positive patients more than six hours a day should be thinking about reusables. Intensive care units are very well facilitated, but the forgotten few are staff in theatres and those in emergency departments, covid-19 positive wards, and acute medicine wards that see admissions.

“As a charity, our fundamental mission is to protect workers. We’re hoping that we can get the backing of the medical bodies and unions. We’re grateful to be working closely with the Doctors’ Association UK, which has supported us and advocated for us with stakeholders nationally. Changing culture and normalising reusables is one of the main things we want to do. There is almost a stigma associated with their use. We’re also working with manufacturers to see if we can innovate and help them make their masks—which have been geared to the construction industry—more appealing to the healthcare industry.

“We’re hoping trusts will pick this up so we can trial getting people trained up and fit tested for reusables, and then have regular auditing feedback from users on how we can improve compliance, on decontamination matters, and on how we can streamline. There’s a centralised NHS procurement team who are, I am told, looking into this nationally. Having a centralised stamp of approval is what everyone has been looking for, so that the legal concerns that everyone has will hopefully disappear. The main inertia is that no one is willing to put their stamp on it to say, ‘look, this could work’.”

Students were told that they could sit the exam at Pearson VUE testing centres or virtually from home, with online proctoring. However, many students were unable to get a slot at a testing centre and were forced to sit the exam online from home.

One student told The BMJ that she had been disqualified from her exam for taking notes on a blank notepad despite having sent an image of her desk, including the notepad, to her invigilator before the exam started.
Another student said that they had been disqualified for playing the audio of a video question out loud from their laptop speakers. Before doing so they had asked their invigilator whether this was allowed but received no response.

“They indicate that the treatment for some students undergoing the exams has been unfair, unacceptable, and in some cases inhumane,” they said. “This is the latest in a line of issues with the SJT [situational judgment test] delivery for this year, and we have serious concerns of the impact this will have on final year students.

“It’s clear that this is a totally unacceptable situation, and we will be taking this up with the UK Foundation Programme as a matter of urgency.”
They have written to the UKFPO calling for it to consider the allegations against Pearson VUE’s mishandling of the exam, review its online proctoring policy, and offer further extensions for students to resit the test where relevant. The UKFPO has said that fewer than 20 students—less than 0.25% of the 8000 applicants—were disqualified from the exam by a Pearson VUE invigilator for “prohibited actions.”

Mike Masding, co-chair of the UKFPO, said that he was working with applicants whose tests were discontinued and “where appropriate will offer the option to re-book.”

The Doctors’ Association said that, while it welcomed this “gesture of good will,” it had received complaints of students being forced to resit exams when they had covid-19 symptoms and of candidates not being allowed to use the toilets at test centres.

Freya Rhodes, medical student representative for the Doctors’ Association UK, said, “Telling students that their appeals have been rejected, and then days later offering resits, is a U turn that demonstrates poor preparation and lack of understanding from UKFPO and Pearson VUE.
“Furthermore, these resits have been offered with limited flexibility and extremely short notice, with some students being asked to take the examination while being unwell with covid-19. We must continue to support our final year students who are also facing the challenges of graduating during a pandemic.”

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Medical leaders have urged Public Health England to strengthen its guidance on personal protective equipment (PPE) to reflect the more transmissible forms of SARS-CoV-2 that healthcare staff are being exposed to.

Current guidance says that higher grade FFP3 masks should be provided to staff who are involved in aerosol generating procedures, but other staff looking after patients with covid-19 are only required to wear fluid resistant surgical masks.

In a letter to Public Health England sent on 13 January, BMA council chair Chaand Nagpaul said that, in light of the identification of the new variant of SARS-CoV-2, increased spread of the virus, and growing evidence of aerosol transmission, Public Health England should review its recommendations on PPE usage “so that a more precautionary approach is adopted to the provision of respiratory protective equipment (RPE) to ensure staff are protected from aerosol transmission.”

He wrote: “There are significant and growing concerns about the role of aerosol transmission of covid-19 in healthcare settings, and the need for wider use of RPE (for example, FFP3 respirators) outside of those procedures designated as aerosol generating. We are therefore calling on [Public Health England] to support the wider use of RPE in other high risk settings across primary and secondary care.”

Nagpaul mentioned evidence indicating lower infection rates among staff in areas where higher grade RPE is currently recommended.1 He also pointed out that the World Health Organization modified its guidance in December to advise that where respirators were available, they should be considered for wider use.2

The Doctors’ Association UK also called on Public Health England to review its guidelines on PPE for healthcare workers. The organisation said that there were 44 000 NHS staff currently absent because of covid-19, with many becoming unwell because of the new, more transmissible variant.

Katie Sanderson, spokesperson for the association, said, “Healthcare workers in the UK continue to become infected with covid-19 at work at rates that could be mitigated by access to better personal protective equipment.”

Jenny Vaughan, vice chair of the Doctors’ Association UK, said that the organisation was “calling for a full review of the PPE guidelines including wider access to FFP3 masks. So many NHS staff are getting sick because of the new, more transmissible variant. The covid-19 virus has changed, and yet the same guidelines we introduced in March have not been updated.”

Ensuring greater protection was especially vital for staff who were more at risk from covid-19, such as doctors from an ethnic minority background, the medical bodies said.

The interventions follow a similar call from Fresh Air NHS, a group of frontline healthcare workers who recently wrote an open letter to UK politicians urging them to recognise the importance of airborne transmission of SARS CoV-2 and to ensure that measures were in place to protect staff and patients.3

Yvonne Doyle, medical director at Public Health England, “NHS staff are under immense pressures and their safety has always been our highest priority. The NHS Infection Prevention Control group has reviewed the latest evidence and has advised that PPE should continue to be worn as laid out in the current [infection prevention and control] guidance, with FFP3 masks required for staff undertaking clinical aerosol generating procedures. This is supported by [the World Health Organization]. Emerging evidence and data on variant strains and transmission will be continually monitored and reviewed.”

Read the full article here: https://www.bmj.com/content/372/bmj.n146

References

1. ↵Shields  A, Faustini  SE, Perez-Toledo  M, et al. SARS-CoV-2 seroprevalence and asymptomatic viral carriage in healthcare workers: a cross-sectional study. Thorax2020;75:1089-94. doi:10.1136/thoraxjnl-2020-215414. pmid:32917840Abstract/FREE Full TextGoogle Scholar
2. ↵WHO. Advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus outbreak. 1 Dec. 2020, https://www.who.int/publications-detail-redirect/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak.
3. ↵Wise  J. Covid-19: Doctors and nurses demand better PPE for wider range of procedures. BMJ2021;372:n30.doi:10.1136/bmj.n30 pmid:33408072FREE Full Text