In the almost two years since the first UK-wide COVID lockdown, the growth in scientific understanding of the transmission, prevention and treatment of the SARS-CoV-2 virus has been vast.

These advances in understanding have informed and refined strategies around preventing infection, with the use of PPE (personal protective equipment) a central part of combatting the spread of the pandemic.

Yet there has been growing frustration among many doctors that the national guidelines being followed by many NHS trusts concerning the use of respirators in COVID infection control are still not robust enough, and not fulfilling the duties imposed by health and safety law.

Until the start of this year the guidance published by the UKHSA (UK Health Security Agency) or its antecedent, continued to deem the use of fluid-resistant surgical masks appropriate when treating patients with suspected or proven COVID infection.

Last December, the BMA wrote to the chief executives of all NHS trusts highlighting their responsibility to ensure the safety and wellbeing of employees when at work, as per the Health and Safety at Work Act 1974.

That same month saw the NHS publish new criteria for completing a local risk assessment in acute inpatient areas of hospitals, although no such guidance has been produced for doctors in primary care settings.

The many months leading up to this change had seen staff at more than 30 UK trusts lobby their management to enable the use of FFP3 (filtering face piece 3) respirators when dealing with patients with confirmed or suspected cases of COVID.

The trusts have been described as ‘pace setters’ and one of them is CUH (Cambridge University Hospitals) which, just before Christmas, ensured the fit-testing and use of FFP3 or equivalent respirators for all healthcare staff across COVID red wards.

BUTLER: ‘Ask to use a respirator if you are likely to be working with infected patients’

CUH consultant geriatrician Matthew Butler was one of those who called on management at this trust to move to using respirators for COVID-19 patients, while occupational health consultant Mark Ferris subsequently helped conduct a study into the effect of their use.

Both are now eager for this example to be replicated across the UK.

Dr Ferris was one of the authors of a study at his trust on the effect of extending use of FFP3 respirators to red wards during the second wave of the pandemic, which subsequently found that doing so indicated significant protection from infection among staff on red wards. ‘We changed to FFP3 during the alpha variant peak but before we started vaccinating hospital staff.

Analysing staff case rates subsequently showed that while cases were increasing on green wards, as community prevalence increased, they were going down or staying the same on red wards,’ explains Dr Ferris. ‘Cases of COVID-19 in staff working on red wards was higher before the change [to FFP3] but similar afterwards.’

A month on from this change, Dr Butler was one of more than 1,700 clinicians whose signature was included on an open letter by the Fresh Air NHS campaign group calling for healthcare workers to have their PPE upgraded to protect against airborne transmission of COVID.

Dr Butler strongly believes that doctors should not simply wait for permission to begin using respirators, but instead have the confidence to implement change directly. ‘I would just ask to use a respirator if you are working, or likely to be working, with infected patients.

If they say no, ask for it in writing that they’ve said no. I suspected that if you did that, they wouldn’t refuse you,’ he says. ‘It’s difficult to do that as an individual, but like we’ve seen with the number of trusts that have flipped, the momentum is building.’

BLACK: Enabled members of his practice to switch to FFP3 masks

BMA Northern Ireland council chair and GP Tom Black says his practice always maintained a supply of respirators right from the earliest days of the pandemic.

‘I give due credit to our local trust here who fit tested all the GPs, and nobody said no when we asked for a small amount of FFP3,’ he says.

‘We didn’t have very many, but we used them for what we felt were high-risk COVID patients.’

With the emergence of Omicron in November last year and despite the absence of official guidance instructing GPs to do so, Dr Black took the decision to ensure that all members of his practice switched to using FFP3s when seeing all patients.

BMA occupational medicine committee co-chair Raymond Agius says that, while progress has been made on shifting the guidance around use of respirators for hospital doctors, more action is needed if GPs are to be better supported.

‘Following the increasing numbers of trusts such as CUH using FFP3 respirators to protect all their staff dealing with potentially infected COVID patients it was welcome to see a significant change consistent with this approach in UKHSA guidance on 17 January.

‘However, [the] guidance still has shortcomings especially in respect of general practice. It is essential that the guidance be extended to take GPs and their staff into account and that they be provided with fit-testing facilities as well as respirators.

'There are signs that [the Department of Health and Social Care] is moving in the right direction and hopefully soon “pace setting general practices” will be followed by others in implementing better protection for their staff.’