Masks confusion

What are the implications for care homes and home care in the UK of the new WHO guidance on masks?  

On Friday 5 June 2020, the World Health Organization (“WHO”) published new guidance on the use of masks in the context of COVID-19. The document runs to 25 pages and contains 80 footnotes, reflecting the number of studies that have been published since its last version published on 6 April 2020 which was 5 pages with 25 footnotes. 

I am writing about this topic not because I am a mask expert (I am not), but because a failure to align national clinical policy with WHO guidance raises human rights concerns under the right to life and freedom from inhuman or degrading treatment. These considerations are relevant to the public interest of preserving life of older and disabled people, and because the actions the 4 UK governments and their public health agencies take in the next few days to make their guidance consistent with WHO guidance will be relevant to the public inquiry, which in my view is now nearly inevitable. 

How is COVID-19 transmitted? 

The current evidence about COVID-19 transmission is worth setting out in full. The WHO says that the infection:  

“is primarily transmitted between people via respiratory droplets and contact routes. Droplet transmission occurs when a person is in close contact (within 1 metre) with an infected person and exposure to potentially infective respiratory droplets occurs, for example, through coughing, sneezing or very close personal contact resulting in the inoculation of entry portals such as the mouth, nose or conjunctivae (eyes). Transmission may also occur through fomites in the immediate environment around the infected person. Therefore, transmission of the COVID-19 virus can occur directly by contact with infected people, or indirectly by contact with surfaces in the immediate environment or with objects used on or by the infected person (e.g., stethoscope or thermometer).”

The WHO adds that, “[c]urrent evidence suggests that most transmission of COVID-19 is occurring from symptomatic people to others in close contact, when not wearing appropriate PPE.”

It goes on to say that:

“[t]here is also the possibility of transmission from people who are infected and shedding virus but have not yet developed symptoms; this is called pre-symptomatic transmission. The incubation period for COVID-19, which is the time between exposure to the virus and symptom onset, is on average 5-6 days, but can be as long as 14 days.”

Can masks prevent transmission?

The guidance refers to medical masks which are “surgical or procedure masks that are flat or pleated; they are affixed to the head with straps that go around the ears or head or both”. It also deals with filtering facepiece respirators – FFRs, “or respirators, similarly offer a balance of filtration and breathability; however, whereas medical masks filter 3 micrometre droplets, respirators must filter more challenging 0.075 micrometre solid particles.” In Europe these are known as EN 149 or FFP2 and in the US they are known as N95.

As to whether masks prevent COVID-19, the WHO says this:

“Low-certainty evidence from a systematic review of observational studies related to the betacoronaviruses that cause severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and COVID-19 showed that the use of face protection (including respirators and medical masks) results in a large reduction in risk of infection among health workers; N95 or similar respirators might be associated with greater reduction in risk than medical  or 12–16-layer cotton masks), but the studies had important limitations (recall bias, limited information about the situations when respirators were used and about measurement of exposures) and most were conducted in settings in which AGPs [aerosol generating procedures] were performed.”

That’s not a simple yes or no answer, but science is rarely simple. So, should staff in care homes and people providing home care wear masks or not? And if yes, in what circumstances?

"Targeted continuous medical mask use"

The new WHO guidance applies to “long-term health and residential facilities”. It says:

“In areas where there is community transmission or large-scale outbreaks of COVID-19, universal masking has been adopted in many hospitals to reduce the potential of (asymptomatic, pre-symptomatic and symptomatic) transmission by health workers and anyone entering the facility with COVID-19 to other health workers and to patients.

There are currently no studies that have evaluated the effectiveness and potential adverse effects of universal or targeted continuous mask use by health workers in preventing transmission of SARS-CoV-2. Despite the lack of evidence the great majority of the WHO COVID-19 IPC GDG members supports the practice of health workers and caregivers in clinical areas (irrespective of whether there are COVID-19 or other patients in the clinical areas) in geographic settings where there is known or suspected community transmission of COVID-19, to continuously wear a medical mask throughout their shift, apart from when eating and drinking or changing the mask after caring for a patient requiring droplet/contact precautions for other reasons (e.g., influenza), to avoid any possibility of cross-transmission.”

In “locations/areas with known or suspected community transmission or intense outbreaks of COVID-19”, WHO provides the following guidance: “it is particularly important to adopt the continuous use of masks in potential higher transmission risk areas including in […] long-term health and residential facilities.” This applies “irrespective if patients are COVID-19 suspect/confirmed”.

The WHO describes this approach as “targeted continuous medical mask use” which it defines as “the practice of wearing a medical mask by all health workers and caregivers working in clinical areas during all routine activities throughout the entire shift. In this context, masks are only changed if they become soiled, wet or damaged, or if the health worker/caregiver removes the mask (e.g. for eating or drinking or caring for a patient who requires droplet/contact precautions for other reasons)”

What are the implications for the UK? 

Unfortunately, there are still significant numbers of care home outbreaks in the UK. Public Health England reported that in the week to 31 May (the latest data) there were outbreaks in 111 care homes in England. While this is a significant reduction from the 1,010 care homes that reported an outbreak in the week ending 12 April, the UK government confirms that we are “currently experiencing sustained transmission across the UK”.

There is an archipelago of statutory bodies in the UK that have issued guidance on PPE: Department of Health and Social Care, NHS England, Public Health England, Health Protection Scotland, Public Health Wales, HSC Pubic Health Agency (Northern Ireland). They all have duties to ensure that their advice achieves three policy objectives set out in the WHO's guidance on infection prevention and control for long-term care:

1. prevent COVID-19-virus from entering the facility,
2. prevent COVID-19 from spreading within the facility, and
3. prevent COVID-19 from spreading to outside the facility.

Scrap the concepts of “possible cases” and “direct resident care” 

Fasten your seatbelts for a PPE policy rollercoaster ride. The current UK government guidance on PPE for care home staff is set out in paragraph 8.11 of “COVID-19 personal protective equipment (PPE)” (updated 21 May): a medical mask, plastic apron and gloves “should be used” when providing “direct care of possible or confirmed cases”. There is no advice on PPE for residents who are not a “possible case”. The definition of “possible case” is set out in paragraph 2.2. of “COVID-19: investigation and initial clinical management of possible cases”. A possible case is someone who has “a new continuous cough or a high temperature” or [this third element was added on 18 May] “a loss of, or change in, normal sense of taste or smell (anosmia)”.

Public Health England (“PHE”) and NHS England co-authored “COVID-19: infection prevention and control guidance” (part of this family of documents), endorsed by the health agencies of the other three UK nations. It was last updated on 21 May, and before that on 18 May which according to the document included an update to the PPE advice in “section 8.1”. There is no section 8.1.

Its “Table 2” was published separately and bears the logo of the above organisations and that of the Academy of Medical Royal Colleges. It sets out that staff in “community and social care, care home, mental health inpatients and other overnight care facilities” working in a “[f]acility with possible or confirmed case(s)” and when providing “direct resident care (within 2 metres)” should wear a medical mask (sessional use, meaning the same mask for the entire shift) as well as plastic apron and disposable gloves for single use (which means that staff should dispose of the apron and gloves after each resident contact). The same is recommended for care in a person’s own home, except that a mask is mandatory for a person who is in the shielding group.

Table 4 governs periods of sustained transmission (which there currently is), and applies to “[d]irect patient/resident care assessing an individual that is not currently a possible or confirmed case (within 2 metres)”. It advises staff to wear a fluid-resistant surgical mask, but not a filtering face piece respirator. For completion, but irrelevant for our purposes, Table 1 is for acute hospital settings and Table 3 is for ambulance staff, paramedics and pharmacy staff.

If that's clear so far, allow me please to introduce some confusion. There is another document, entitled “COVID-19: how to work safely in care homes” which was published on 17 April and last updated on 27 April (which you will note is before the last update to “COVID-19: infection prevention and control guidance”). This document says that for direct care for any resident, or “whenever you are within 2 metres of any resident who is coughing, even if you are not providing direct care to them”, a sessional use mask is recommended. In addition, “[w]hen performing a task requiring you to be within 2 metres of resident(s) but no direct contact with resident(s) (i.e. no touching)” such as “performing meal rounds, medication rounds, prompting people to take their medicines, preparing food for residents who can feed themselves without assistance, or cleaning close to residents” a mask is recommended, but not aprons or gloves.

Just to summarise where we have got to, I have pointed to six policy documents that all talk about PPE in social care, some saying that masks are mandatory in care homes and home care full stop, others which say only for direct care, and others which say yes in a period of sustained transmission for assessment. I'm glad you're enjoying the PPE policy ride so far, but let's not be England-centric.

Scotland, Wales and Northern Ireland

The “COVID-19: how to work safely in care homes” document was written by Public Health England and there is no mention of the other three nations, unlike previous document which was written with the public health agencies in Scotland, Wales and Northern Ireland. If the latest document that appears to be consistent with WHO advice applies to England only, what is the policy position of the other three nations?

Scotland

Health Protection Scotland’s “IPC guidance in healthcare settings” webpage circles back to the PHE’s IPC guidance, which sets out Tables 2 and 4, and hyperlinks to the “COVID-19 personal protective equipment (PPE)” page, which uses the “possible and confirmed cases” concept. The Scottish Government’s “Information and guidance for care home settings” document of 20 May references and endorses Tables 2 and 4. You will recall that Table 4 applies only to “assessing an individual that is not currently a possible or confirmed case”. So, the current Scottish policy position seems to be that masks are recommended only for care home and home care residents with possible/confirmed COVID-19 (unless a carer is assessing someone), contrary to the current WHO guidance.

Wales

Public Health Wales ("PHW") has a link to the PHE document on this webpage, but this webpage (called “Advice on PPE guidance implementation”, which is two nouns too many for my taste) refers to Table 4, incorrectly suggesting that Table 4 applies to “all patient encounters” (as you will recall, it applies to assessments only). PHW says that Welsh health boards and trusts must follow the “updated IPC guidance including implementation of the recommendations of table 4”. The current Welsh policy position seems to be the same as that in Scotland, which is contrary to the WHO.

Northern Ireland 

The HSC Public Health Agency webpage on “Guidance for HSC staff on using PPE” contains links to Tables 2 and 4. It also has a letter dated 3 April from the NI Chief Medical Officer to health and social care boards and trusts which refers to the tables (without mentioning Tables 2 and Table 4 by name), advising that a carer in a “community care setting within two metres of a suspected or confirmed coronavirus COVID-19 patient should wear an apron, gloves, surgical mask and eye protection, based on the risk”. It is not clear whether the words “based on the risk” refer to eye protection or the whole lot. The current Northern Irish policy position seems to be the same as in Scotland and Wales and is again inconsistent with the WHO.

Consolidate policy across the UK

You will have gathered that the PHE’s “COVID-19: how to work safely in care homes”, is completely different from the other guidance documents which are still in force. However, it does not apply to “supported residential living” or “domiciliary care”. On 22 May the Department for Health and Social Care published “Coronavirus (COVID-19): provision of home care”, wherein the section on PPE refers to another PHE guidance on “Personal protective equipment (PPE) – resource for care workers delivering homecare (domiciliary care) during sustained COVID-19 transmission in England” published on 27 April and updated on 1 June. That document recommends the sessional use of masks in much the same way as the “how to work safely in care homes” document. 

My understanding is that although there are still some difficulties in obtaining supplies, most care homes in the UK are now providing staff with medical masks out of precaution (or perhaps confusion) and using masks for routine care. There is no evidence as to what is actually happening in care homes because CQC has suspended its regular inspections. Visits by family, friends and statutory advocates are still not possible in most care homes. So unless there is a whistle-blower staff member, we are unlikely to find out about homes that are not using PPE properly. 

Putting the common sense and humanitarian efforts by care home staff to one side, policy matters. It is what care home staff read to find out what they should do. Policy sets operational norms. Policy will be examined in an inquiry, and may well be raised in inquests and in civil claims. 

More importantly than all of that, clarifying the policy now (I mean within a few days: it's not that difficult) may save lives. 

Any new guidance should dump the “possible or confirmed” and “direct resident care” concepts until there is no longer sustained community transmission. Policies should be aligned with the global scientific evidence set out in WHO recommendations of “targeted continuous medical mask use” in all care homes and home care, irrespective of the care home’s outbreak profile or the individual’s symptoms.

Given the conflicting guidance across the plethora of documents as well as the odd document that advises on the implementation of guidance (mic drop), it is incumbent on the administrations in Westminster, Edinburgh, Cardiff and Belfast to work with their public health agencies to produce a singular document that sets out in clear and concise terms the PPE that people working in care homes and those providing home care should use. All other guidance should be marked "withdrawn" and kept online for archival purposes. 

While they're at it, the governments should make eye protection mandatory, per WHO recommendations: see this blog for more.

Pink flamingo 7-layer titanium grade polyester masks, 10 for £99 

Finally, if you have received push ads on social media by improbable-sounding companies trying to flog fabric masks with pink flamingo print (or is that just my algorithms?) then you’ll find the WHO’s recommendations on non-medical mask filtration efficiency, pressure drop and filter quality factor incredibly useful.