On Expiration And Preparation
A Junior Doctor’s Perspective on COVID-19 Preparation and PPE
I think we can all agree that living and breathing coronavirus news every day is boring - especially since the 23rd March when lockdown basically started.
What is perhaps less boring, and more frightening, is the fact that health professionals are having to rely on PPE from a pandemic stock acquired in the aftermath of 2009’s swine flu that is, as of the latest Channel 4 report, 45% expired.
Of particular concern is the fact that 80% of the most powerful FFP3 respirators - disposable masks for use in the highest risk areas, filtering 99.5% of particles around the size of SARS-COV-2 - were out of date when the pandemic started.
I’ve seen this myself in my hospital. Take off the many stickers plastered on top of the original date of expiry and you can see that right at the bottom, almost faded away, is the unmistakeable number of 2014.
28/11/14
The official line from the companies and various testing authorities - and of course the government - is that the masks that have been re-distributed with these new stickers have in fact been re-tested and are fit for purpose. What they haven’t done, in an ongoing obsession with concealment that senior scientific advisors are now calling Stalinist, is clarify how they are re-tested.
I’ll give you an example why this is an issue. Masks - simply put - are made of the filtration materials themselves, a malleable portion around your nose to mould the mask to your face and the straps you use to maintain the seal. Each portion would need to be assessed for fitness for purpose, or else whatever protection you would get would be lost. I have heard numerous colleagues complain about the elastic straps of FFP3s fraying and degrading even before being properly used. In the highest risk environments, that means unacceptable levels of exposure.
So that’s one problem. The other is the fact that re-testing stock takes months. This means that with such a significant volume out of date, the functional stockpile was much less than it needed to be.
To quote the Channel 4 investigation:
'A ‘Consumable Procurement Specification List’ from 2009 stipulated what should be stored as part of a £500 million stockpile. It recommended 28.1 million respirators, 190 million surgical masks, and 116.5 million combined needles and syringes.
However, by 30 January 2020 the stockpile held 10% fewer respirators – at 26.3 million. There were also 19% fewer surgical masks at 154.5 million, and 28% fewer combined needles and syringes at 84.2 million.’
If boxes contain expired PPE, they cannot be distributed till they are re-tested. This was the case for nearly 20 million respirators (both FFP2 or 95% filtration and FFP3) and 84 million surgical masks. This became a problem with a nationwide ripple effect. In fact, with hospitals desperate for PPE, the army started to deliver these untested products, marked as already expired, from the 24th March. We use them because we have no other option.
Note also the lack of fluid resistant disposable gowns or coveralls in the above quoted list, which places like Intensive Care need just as much as FFP3 respirators. NERVTAG (The New and Emerging Respiratory Virus Threatens Action Group), headed by some of the most eminent public health specialists and virologists, recommended gowns be bought as early as June, but none were.
The importance of gowns cannot be overstated. The European Centre for Disease Control recommends them for dealing with suspected COVID-19 patients. The trouble is that the materials they are made from - a sandwich of spunbond and meltblown polypropylene known as SMS - are difficult to produce. You need only look at the announcement on Scottish company Don and Low’s website to see how:
a) most clothing production occurs overseas
b) most factories are shut down with many of the 120,000 textile workers in the UK on furlough
c) there isn’t enough of some gown products to make them swiftly enough for the country’s needs.
Though this is unsubstantiated due to the political implications, I suspect that Public Health England (PHE) – an arms-length body designed to advise the government on protecting the public and NHS workers based on the latest scientific evidence – suggested downgrading this PPE for suspected cases – saving them for areas such as ITU with aerosol-generating procedures - because they knew there were so few gowns in stock and because so few could be made.
An infographic describing current PPE guidelines for healthcare staff working with COVID-19 patients
The official line from PHE is that the recommended bare-below-the-elbow top, surgical mask and plastic apron – the kind of things you see dinner ladies wearing that leave the arms and top of the chest uncovered - are the evidenced safest approach. A recent paper from the Royal College of Physicians refutes this claim, analysing PHE’s quoted evidence and concluding that for the safety of staff, ECDC guidance should be followed to the letter. This shows us the danger of relying on sources that confirm an existing bias, uncovering in the process the motivations that underpin such bias.
At the end of the day, even as the COVID-19 peak seems to ease off, some hospitals still need to rely on day to day sources of gowns and donations from kind members of the public to replenish their supplies, re-using what gowns they have if they are not too badly soiled. This is especially galling when the much-vaunted acquisition of 400,000 gowns from Turkey has been impounded due to not being fit for purpose. My Trust bought over 30,000 gowns in mid-April for acquisition in May. I can only hope that they weren’t supposed to be from this supply and that the numbers of very ill COVID-19 patients continue to fall so pressures on stock can finally reduce.
Despite Freedom of Information Requests, we are still denied the answers.
We already know that the government ran Exercise Cygnus, a simulated flu pandemic, in 2016 – the results of which were leaked recently to the Guardian, and which had previously been analysed in the Telegraph. It is perhaps telling given our existing crisis that the word PPE was mentioned just 3 times in that document, and merely the mechanics of distribution (including in the context of hiring retired NHS staff to help make sure such PPE got where it needed to, which is a rather bizarre link to make for hopefully obvious reasons).
Admittedly I haven’t read the preceding documents from 2010, 2011 and 2014 - the 70-page “Influenza Pandemic Preparedness Strategy”, 78-page “Health and Social Care Influenza Pandemic Preparedness and Response” and 88-page “Pandemic Influenza Response Plan” – but to the best of my knowledge, these documents weren’t re-written or the situation re-evaluated despite their saying the existing pandemic infrastructure was inadequate. This was compounded by the Department of Health rejecting NERVTAG recommendations for increasing stocks of eye protection due to projected four-to-six-fold cost increases in 2017. The overall conclusion that one can make from all this is that ultimately, despite the media-friendliness of the term, the idea of ‘lessons learnt’ is a complete and utter myth and in fact, the UK’s much touted preparedness is a smokescreen for underlying emptiness.
The Doctor’s Association UK - a grassroots lobbying organisation for doctors that started in 2018 and which I joined due to their very positive lobbying work during this crisis – has been campaigning for a public inquiry for months. When it comes – and it will – questions will be asked regarding the lack of PPE and the deaths of healthcare workers. The documents I have mentioned, and many others, will come to public attention, and I can only hope that from their being brought to public attention, responsibility for the crisis we now find ourselves in can be appropriately apportioned.
I would like to end this article on the subject of South Korea. A highly developed and densely populated nation of 52 million, its test-trace-isolate stratagem has won plaudits internationally, with a death toll not in the thousands but the hundreds, months after the virus first erupted out of Wuhan. One of my friends was stuck in a negative pressure room there for over a month because you need two negative swabs to be discharged, such was the seriousness with which they treated COVID-19.
But that’s not why I’m mentioning it.
I mention South Korea because they are – in actuality – an example of a proactive nation that learned from its mistakes. When it was hit by COVID-19’s relative, Middle Eastern Respiratory Syndrome (or MERS), in 2015, relatively few people by COVID standards died, just 38. However, when it was in hospitals, MERS terrified staff. In the absence of testing kits during the early days of the epidemic -with the government refusing to disclose to the public which hospitals had outbreaks – criticism was so strong that the entire pandemic legislature was re-written. In March, when ‘herd immunity’ was being touted as the method of choice by the UK, South Korea had been churning out testing kits for over a month.
As of today, the 8th May 2020, 256 people have died in that country of COVID-19.
One can only hope - with everything that has happened this year with expired stocks of PPE, procurement issues, strategical incoherence and ultimately the deaths of hundreds of healthcare workers and thousands of laypeople - that the UK can be as prepared the next time.