The updated COVID-19 infection prevention and control (IPC) guidance was released on Thursday 2 April following a rapid review of scientific evidence and consultation with the Royal Colleges as the UK moves through the COVID-19 epidemic. The guidance has been constantly reviewed and updated from the beginning of this epidemic as we learn more about the virus and the UK infection rate increases.
The updated guidance aims to clarify use of Personal Protective Equipment (PPE) according to risk in health and social care settings and provides for “place based” use of PPE and risk assessed sessional use of some PPE, as cases / cohort areas increase. It includes an “additional considerations” table (Table 4), providing guidance on use of PPE when sustained community transmission of COVID-19 is occurring and following an individual / organisational risk assessment it is felt that more protection is required to reassure staff and clients / patients that all appropriate protection is being used.
Structuring guidance in this way enables appropriate recommendations on PPE use at different stages in the epidemic and for all settings across health and social care.
Since the publication of the updated guidance, Public Health Wales has received requests for clarification regarding the implementation of the new table 4: Additional considerations, in addition to standard infection prevention and control precautions, where there is sustained transmission of COVID-19. In particular, these enquiries have related to the definition of ‘sustained community transmission’ and the application of any triggers / thresholds to guide implementation of the updated guidance.
Infection Protection and Control specialists from Public Health Wales, have participated in the UK Infection Prevention and Control (IPC) Cell and benefitted from knowledge of those detailed discussions in relation to the guidance. For consistency and to further inform this response, Public Health Wales has also raised one particular question with PHE colleagues, and received the following written response:
Sustained community transmission is where ongoing community spread is taking place and networks are unable to be clearly detected. The view is that the UK, as a whole, according to these parameters is seeing sustained community transmission.
The WHO definition of community transmission is also consistent with this:
Community transmission is evidenced by the inability to relate confirmed cases through chains of transmission for a large number of cases, or by increasing positive tests through sentinel samples (routine systematic testing of respiratory samples from established laboratories).
A recent explanation of the updates to the IPC guidance is also clear. Specific reference to the following PHE publication: ‘Explanation of the updates to infection prevention and control guidance’, which was released on 5 April 2020 clearly states:
Three new tables have been added to clearly explain the PPE required for different common clinical scenarios – one for hospitals, one for primary care, outpatient and community care and one for ambulance and first responders
An additional, fourth table describes when to use PPE for all patient encounters (not just patients with suspected or confirmed COVID-19) at a time when there is sustained community transmission of COVID-19, as is currently occurring in the UK, and the likelihood of any patient having coronavirus infection is raised
On this basis, Health Boards, Trusts and other health and social care providers in Wales should be applying the updated IPC guidance including implementation of the recommendations of table 4 in their response to COVID-19.
It is key that across Wales we ensure that PPE is used correctly and appropriately so that health and social care workers are protected. Health Boards, Trusts, other healthcare providers, together with their partner social care organisations need to work through the guidance ensuring that the place based (settings) use of PPE is consistently applied (tables 1, 2 and 3) and that staff are trained and fit-tested for the use of FFP3 respirators if they are working in high risk areas or undertaking AGPs. Staff must also be trained in the correct donning and doffing of PPE.
Outside of the clinical / care giving areas it is important that social distancing, hand hygiene and respiratory etiquette are the key measures for reducing transmission of the virus – PPE can be contaminated in use and pose a risk to others if not removed and followed by careful hand hygiene before moving out into communal areas.
Whilst table 4 of the guidance does provide for PPE use for all patient / resident encounters within 2 metres, at a time when there is sustained community transmission of COVID-19, there is still a need to risk assess the use of the masks and eye protection according to an anticipated/likely risk of contamination with splashes, droplets of blood or body fluids. Where staff consider there is a risk to themselves or the individuals they are caring for they should wear a fluid repellent surgical mask with or without eye protection as determined by the individual staff member for the care episode/single session.
The guidance highlights the requirement for risk assessment on an individual/ organisational basis. As such, it is recommended that in implementing table 4, each Health Board, Trust, health and social care provider in Wales, assesses and documents the reasons for local implementation in line with their responsibility under the Health and Safety at Work Act and the COSHH (Control of Substances Hazardous to Health) Regulations, and working with partners, ensure consistency across local and national (Wales) health and social care service provision.