Email: 20/12/20
Dear [INSERT MP]
I am writing to request your help towards highlighting the need for urgent revisions to the current PHE UK Covid-19 infection prevention & control (IP&C) personal protective equipment (PPE) policy for all “front line” health & social care staff.
Dear [INSERT MP]
I am writing to request your help towards highlighting the need for urgent revisions to the current PHE UK Covid-19 infection prevention & control (IP&C) personal protective equipment (PPE) policy for all “front line” health & social care staff.
To-date, three UK-based reports demonstrate significantly greater risk of SARS-CoV-2 infection and/or death in non-ICU UK patient-facing healthcare workers (HCWs):
The most recent (28th October) is from the BMJ (doi.org/10.1136/bmj.m3…), with data on 158,445 Scottish HCWs...
The most recent (28th October) is from the BMJ (doi.org/10.1136/bmj.m3…), with data on 158,445 Scottish HCWs...
...(1st Mar – 6th June 2020) indicating that: "patient facing HCWs compared with non-patient facing HCWs, were at higher risk [of SARS-CoV-2 infection] (HR 3.30, 2.13-5.13)...after sub-division of patient facing HCWs into…front door, ICU, non-ICU aerosol generating settings...
...and other, those in front door roles were at higher risk (HR 2.09, 1.49-2.94).”
The second report was released as a medRxiv preprint in June 2020 (doi.org/10.1101/2020.0…, n=9,809 HCWs), in which an Oxford research team demonstrated: “Risk of Covid-19 infection varied...
The second report was released as a medRxiv preprint in June 2020 (doi.org/10.1101/2020.0…, n=9,809 HCWs), in which an Oxford research team demonstrated: “Risk of Covid-19 infection varied...
...by specialty, even accounting for working in a Covid-19 facing area. Those working in acute medicine were at increased risk, (aOR 1.5, 95% CI 1.05 – 2.15, p=0.03), while ICUs were at lower risk (0.46, 0.29 – 0.72, p=0.001).”
Finally, a report into 106 HCW deaths from Covid-19
Finally, a report into 106 HCW deaths from Covid-19
...dating to 22nd April 2020, described how none of the deceased medical or nursing staff were anaesthetists, intensivists, or worked on intensive care (hsj.co.uk/exclusive-deat…).
These findings can be understood when considering that presently, front-door (non-ICU) HCWs involved with Covid-19 patient care are in a ‘perfect storm’ of greater SARS-CoV-2 infection risk, yet with sub-optimal PHE UK guideline-directed PPE:
Compared to ICU staff...
Compared to ICU staff...
...front door (non-ICU) HCWs are exposed to patients with significantly higher Covid-19-associated viral load:
- The median time from onset of Covid-19 symptoms in the community to presentation at hospital is 4 days (inter-quartile range 1-8, ISARIC A4, n=20,133 patients...
- The median time from onset of Covid-19 symptoms in the community to presentation at hospital is 4 days (inter-quartile range 1-8, ISARIC A4, n=20,133 patients...
...doi.org/10.1136/bmj.m1…).
- The median time from symptom onset to severe hypoxaemia and ICU admission is approximately 7–12 days (thelancet.com/journals/lanre…).
- The median time from symptom onset to severe hypoxaemia and ICU admission is approximately 7–12 days (thelancet.com/journals/lanre…).
- “The greatest viral load, and thus infectiousness, is observed during the first week of symptoms (especially day 0-5), declining after that.” (assets.publishing.service.gov.uk/government/upl…). 
- The typical non-ICU working environment (i.e. non-isolation wards) is subject to lower ventilation standards compared to the ICU: i.e. 6 air changes per hour (AC/hr) is permitted on general wards, half of which may be passive (i.e. requiring windows to be open and subject to...
...important external environmental fluctuations), while 10 AC/hr is mandated on the ICU, all of which must be mechanical (gov.uk/government/pub…).
Airborne / aerosol transmission of SARS-CoV-2 is now acknowledged by WHO, CDC, ECDC, SAGE (UK), and latterly, the ‘PHE (UK) Transmission Group’ (October 2020), with speaking recognised to be an important aerosol-generating activity (assets.publishing.service.gov.uk/government/upl…).
Front door (non-ICU) HCWs triaging or caring for Covid-19 positive patients are not permitted to wear respiratory PPE providing aerosol protection (i.e. FFP3 or hood), since present PHE UK guidelines only permit such protection in staff working in high risk areas...
... “when undertaking AGPs [aerosol generating procedures] on confirmed or suspected covid19 patients/individual.” (assets.publishing.service.gov.uk/government/upl…).
Moreover, providing novel insights into the present designation of intubation and/or extubation as high-risk AGPs through “real-time, high-resolution environmental monitoring”, investigators from Bristol in a manuscript accepted 2nd October 2020 (…-publications.onlinelibrary.wiley.com/doi/pdf/10.111…)...
...concluded: “The study does not support the designation of elective tracheal intubation as an aerosol generating procedure. Extubation generates more detectable aerosol than intubation but falls below the current criterion for designation as a high-risk...
...aerosol-generating procedure.” This was based on the finding: “Using the quantity & concentration of aerosolised particles generated by volitional coughs as a reference, we have shown that both intubation & extubation sequences produce less aerosol than voluntary coughing.”
While it is technically impossible to rapidly re-engineer ventilation systems within all healthcare premises to achieve ICU-equivalent levels, the provision of FFP3 (or equivalent) respirators to all UK HCWs in Covid-19 facing roles could be readily achieved...
...at the necessary scale and pace to help reduce the significantly greater risk of HCW-associated SARS-CoV-2 infection otherwise experienced as a result of inappropriate PHE UK guidelines. Therefore, I would be extremely grateful for your help towards...
...initiating PHE UK IP&C SARS-CoV-2 PPE guideline change, allowing all UK Covid-19 patient-facing HCWs to benefit from the additional protection afforded by FFP3 (or equivalent) respiratory PPE.
In keeping with General Medical Council UK ‘Duties of a good doctor’ and recognising this important threat to public health, I have already contacted PHE SW – email sent 12th November, but have received no reply.
On 19th November Prof Peter Horby responded to my email requesting help from NERVTAG, and he directed me to PHE/DHSC. DHSC is yet to respond to my enquiry via the web portal.
As a GMC registered clinician with a responsibility to protect the health of the public, my concern over this public health issue is genuine. I would be extremely grateful for your urgent help in this matter, please.
Many thanks.
Yours sincerely
David R. Tomlinson
GMC 4213048
Many thanks.
Yours sincerely
David R. Tomlinson
GMC 4213048
Outcome?
MP: Trying to help, but no joy yet. Meanwhile:
22/12/20 DHSC: You need PHE (diff email)
24/1/21 PHE: You need NHSE
NHSE: Guess what they said (next tweet)...
MP: Trying to help, but no joy yet. Meanwhile:
22/12/20 DHSC: You need PHE (diff email)
24/1/21 PHE: You need NHSE
NHSE: Guess what they said (next tweet)...
https://twitter.com/FreshAirNHS/status/1352147866249269249?s=20
103 days after I emailed:
'I understand that your query has been escalated by your MP to Mr Hancock's special advisor and in addition Greg Clark MP has also been contacted by Lucy Bailey, one of his constituents on the same matter.
'I understand that your query has been escalated by your MP to Mr Hancock's special advisor and in addition Greg Clark MP has also been contacted by Lucy Bailey, one of his constituents on the same matter.
Greg Clark MP was going to discuss this with Sir Simon Stevens.
In light of the above, it would seem that all the escalation routes have already been exhausted and you should wait for a response from your MP.'
@trishgreenhalgh @microlabdoc @mjb302 @YouAreLobbyLud @NjbBari3
In light of the above, it would seem that all the escalation routes have already been exhausted and you should wait for a response from your MP.'
@trishgreenhalgh @microlabdoc @mjb302 @YouAreLobbyLud @NjbBari3
'IN LIGHT OF THE ABOVE, IT WOULD SEEM THAT ALL THE ESCALATION ROUTES HAVE ALREADY BEEN EXHAUSTED AND YOU SHOULD WAIT FOR A RESPONSE FROM YOUR MP.'
Asad, I'm right with you at the rage end of the spectrum.
@AnthonyMangnal1, thanks for trying.
@LABailey @GregClarkMP @MattHancock
Asad, I'm right with you at the rage end of the spectrum.
@AnthonyMangnal1, thanks for trying.
@LABailey @GregClarkMP @MattHancock
@threadreaderapp unroll please. 💙
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