UK Inquiry Module 3: Impact on UK Healthcare Systems

[elbows]

The efforts in Southampton to come up with a practical hood-based personal respirator system during the pandemic was briefly referred to by Dr Barry Jones today. I am quite impressed by this work and if deployed at great scale and embraced by the pwoers that be, it could have helped to somewhat bridge the chasm between our own official guidance in regards health worker protection, and the 'full bunny suit' stuff we saw from a handful of countries that learnt the right lessons about SARS, MERS etc years before the pandemic and understood how to protect workers and massively reduce transmission within healthcare settings. I am no fan of people shrugging and sticking to shit guidelines in the pandemic just because our capacity for certain 'very highest standard' things could not be scaled up in time, and so I really like stuff that can be scaled up that is much better than nothing, much better than just leaving people with surgical masks or a botched FFP3 fitting programme.

https://research.uhs.nhs.uk/news/southampton-personal-respirator-approved-for-use-beyond-pandemic

 

[elbows]

Doesnt look like Im often going to get a chance to quote from evidence even when I really want to.

One of todays witnesses struggled badly for prolonged periods of their questioning, in my opinion. Dr Lisa Ritchie OBE (National Deputy Director of Infection Prevention and Control, NHS England).

Had to ask for numerous questions to be repeated, sometimes gave garbled answers, awful management speak, narrow and thoroughly unconvincing, unwilling to give any answers that would have inconvenient implications for guidance going forwards.

No wonder the fucking IPC Cell, which she chaired during a crucial year-long period, came out with such shit advice in the pandemic. Because, broadly speaking, all the shit we heard today is mostly a simple story of expediency in a management context. In this case a nursing management context from the infection prevention and control angle, but I wont single them out completely because their shit stance was enabled and supported by all the other forms of shit expediency higher up the chain. And as the likes of Chomsky often pointed out, these people are selected for these roles in the first place because they wont ask awkward questions and will willingly do what the establishment requires of them. In some cases actively driven by shit priorities, in other cases the right priorities but entirely misplaced faith in what actions and guidance will genuinely support those priorities rather than undermine them.

She got an OBE for her work in the pandemic, no surprise there.

I doubt anything revealed in the last week will be a surprise to those unfortunate enough to have had to work under these layers of management within the NHS.

Nor is this something restricted to the NHS, because a lot of the crap was enabled by crap international guidance from the WHO. I expect the same expediency will have been at work at the WHO, mixed in with some additional angles including those of international politics and 'diplomacy', dodgy prior orthodoxies within the relevant specialisms, and the malign impact of horrible dominant economic ideologies.

 

[elbows]

The most useful thing she said was that infection prevention and control issues are quite far down the pecking order of research.

 

[elbows]

Over the last day we have heard from the Chief Nursing Officers of the 4 UK nations. I cannot do proper justice to these sessions, but subjects included:

Impact on staff mental health, inability of relatives to visit patients (including in the maternity context), the awful decisions that had to be made in regards changing the nurse-patient ratios in critical care, focus on problems of availability of PPE in first wave rather than spending more time on the question of whether the PPE guidance was actually good enough, concerns about use of blanket DNACPRs and how reports were still coming through later about such misuse later despite diktats from the top against such use.

Ruth May (England CNO during the pandemic) was particularly scathing about the effect on nursing staff number that removing the bursary in England had, and was keen to highlight how we must have more nursing staff in place to deal with a future pandemic. She also described how unwilling she was to allow such awful nurse-critical care patient ratios in subsequent waves as were allowed in the first wave. When it came to the airborne and PPE angles of infection prevention, her evidence was no more impressive than other witnesses that I already criticised. But when given the opportunity to discuss what she would have most liked to have been different, and what should be different in a future pandemic, she did at least highlight that having broad access to proper testing from the start in order to help reduce nosocomial spread is crucial. The fact that there was an extreme gown shortage in the first wave and that gowns hadnt been part of the existing pandemic stockpile was also discussed, with Ruth May very unhappy with the temporary change of guidance to allow aprons instead of gowns at the peak of the gown shortage.

During questioning about the blanket DNACPRs, the chair did step in at one point and made reference to the idea that these hadnt just been used to deny people resuscitation, but that in some cases there are suggestions they were used to deny treatment more broadly, although she hadnt heard much direct evidence about that yet.

We are now hearing from professor Susan Hopkins, chief medical adviser of UKHSA and formerly PHE. It will take me a while to report back on this since I havent been able to watch it all live and am playing catchup. Its already clear that there will be plenty about the airborne stuff, the PPE and the IPC Cell.

 

[elbows]

Hopkins trod on a landmine this morning by saying that the evidence for FFP3 masks being more potective against covid than surgical masks is weak.

I havent watched that part of the session myself yet, but her words about that are being used to question her very tersely this afternoon.

Its becoming clear that one stance the defenders of the really shitty mask advice are clinging to is that 'masks are just one component of infection prevention'. Lack of formal evidence versus common fucking sense is also on display, and this is one of the reasons her FFP3 evidence comments have gone down very badly indeed.

 

[elbows]

Press coverage of this module after the opening day or two has been very poor or entirely missing, but no surprise to see that Hopkins FFP3 facemask stuff has now been reported:

Evidence for high-grade face masks was weak, Covid inquiry told

UKHSA's Prof Susan Hopkins said respirator masks may have worked no better than thin surgical masks.

www.bbc.co.uk

What sometimes gets lost in these stories is that a lot of the debate gets bogged down in what counts as good evidence. There has been a disgusting lack of effective high quality studies of certain kinds which could actually provide the sort of evidence the likes of Hopkins would require. One consequence of this is that certain expedient stances are given cover to hide behind, and so we have to be very careful about how statements in regards evidence are interpreted.

If we move the required level of evidence to a different place, set the bar differently, for example using data from particular real-world experiences of particular hospitals during the pandemic, then we do actually end up with the sort of indicators that led plenty of those hospitals to adopting much more widespread use of FFP3 for very good reasons. This does not satisfy a certain level of scientific rigour, but is still not anti-scientific, enables precautionary principals to stand a better chance of being adhered to, and injects a healthy dose of common sense.

Three infection control specialists who also have practical roles within the NHS system are being questioned today. This mask evidence topic came up and although it was not phrased in exactly the way I just did, the angle I just took did come up, with a suitable, sane, conclusion if you pay proper attention to everything that was said. When asked about evidence form and quality they had to answer certain questions in the same sort of way as Hopkins, but when it came to practical reality and recommendations for the future, they were recommending FFP3 for all sorts of scenarios. By considering the full picture, they had a degree of credibility that others lose through narrow rigidity of a dangerous kind. I will find time to quote just a tiny bit of that later.

 

[elbows]

Next weeks timetable revealed, Whitty is giving evidence next thursday.

 

[InArduisFouette]

I note that in the opening video, a GP from London mentions that they started to see people with a loss of smell in January 2020.

I think it is quite clear that Covid was in Continental Europe before the new year and because of this ( skiing trips, business trips and the like) it was in major UK cities very early in 2020 if not before. I had a week in London in feb 2020 just as the majort concenrs were beginning to kick of but every thing was still as normal theatres open, classes at Danceworks / Pineapple/ the Place/ Central all running as normal ( and packed) oddly enough i had an atypicla uppper respiratory illness the week

I

 

[elbows]

I think it is quite clear that Covid was in Continental Europe before the new year and because of this ( skiing trips, business trips and the like) it was in major UK cities very early in 2020 if not before. I had a week in London in feb 2020 just as the majort concenrs were beginning to kick of but every thing was still as normal theatres open, classes at Danceworks / Pineapple/ the Place/ Central all running as normal ( and packed) oddly enough i had an atypicla uppper respiratory illness the week

I

I never got round to looking at whether any later studies happened that could shed more light on the early cases. The top authorities werent hugely interested, and obviously the media lost interest at some point, so I'll have to do some digging myself at some point.

When people talk about February 2020, the focus is usually on the latter part of that month when the half term holiday did a hell of a lot to seed Covid in the UK big time, via skiing trips etc at a time when the prevalence of Covid in various other countries had clearly risen a lot compared to the months leading up to that point.

However we still got occasional news articles about earlier undetected UK cases, in part because Fergus Walsh of the BBC suspected he had a case of it in January 2020. For example Fergus Walsh: Was coronavirus here earlier than we thought?

Using overall deaths from all causes data for those months, we can say that there wasnt a really large wave of covid death earlier than the acknowledged 'first wave', because that would have shown up as a big spike like those we got later. But in theory there could still have been some death around, since we wouldnt be able to spot it by this method unless it reached a certain level that really stood out beyond the normal amount of expected deaths. And smaller increases would be harder to spot over winter months because more death is always expected to show up in overall death figures at that time of year.

 

[elbows]

I'm still finding time to listen to the evidence sessions so far, but not time to do further reading of written evidence, and no time to quote any of it here. I will still try to pluck out just a very few quotes later.

Evidence from Tracy Nicholls OBE (Chief Executive, College of Paramedics) was pretty harrowing yesterday, I wouldnt know where to start with quoting from that. Lots of 'felt like canaries in the coalmine' type stuff, trying to deal with guidelines that work unworkable in practice in pre-hospital settings, PPE issues, etc.

 

[InArduisFouette]

I never got round to looking at whether any later studies happened that could shed more light on the early cases. The top authorities werent hugely interested, and obviously the media lost interest at some point, so I'll have to do some digging myself at some point.

When people talk about February 2020, the focus is usually on the latter part of that month when the half term holiday did a hell of a lot to seed Covid in the UK big time, via skiing trips etc at a time when the prevalence of Covid in various other countries had clearly risen a lot compared to the months leading up to that point.

However we still got occasional news articles about earlier undetected UK cases, in part because Fergus Walsh of the BBC suspected he had a case of it in January 2020. For example Fergus Walsh: Was coronavirus here earlier than we thought?

Using overall deaths from all causes data for those months, we can say that there wasnt a really large wave of covid death earlier than the acknowledged 'first wave', because that would have shown up as a big spike like those we got later. But in theory there could still have been some death around, since we wouldnt be able to spot it by this method unless it reached a certain level that really stood out beyond the normal amount of expected deaths. And smaller increases would be harder to spot over winter months because more death is always expected to show up in overall death figures at that time of year.

I also think that the people likely to have exposure in this early stage were problably young er and fitter than average so less likely to have have really severe disease ...

biggest problem is that becasue the convalescent investigation needed proven infection, anyone who got it before testing etc was in place was excluded

 

[InArduisFouette]

The efforts in Southampton to come up with a practical hood-based personal respirator system during the pandemic was briefly referred to by Dr Barry Jones today. I am quite impressed by this work and if deployed at great scale and embraced by the pwoers that be, it could have helped to somewhat bridge the chasm between our own official guidance in regards health worker protection, and the 'full bunny suit' stuff we saw from a handful of countries that learnt the right lessons about SARS, MERS etc years before the pandemic and understood how to protect workers and massively reduce transmission within healthcare settings. I am no fan of people shrugging and sticking to shit guidelines in the pandemic just because our capacity for certain 'very highest standard' things could not be scaled up in time, and so I really like stuff that can be scaled up that is much better than nothing, much better than just leaving people with surgical masks or a botched FFP3 fitting programme.

https://research.uhs.nhs.uk/news/southampton-personal-respirator-approved-for-use-beyond-pandemic

View attachment 442337

PRPS is not a new technology , when all the 'white powder' stuff kicked off in the mid 2000s the NHS CBRN protection for decontamination teams was PRPS based as it was easier to teach that than SCBA but that was sealed in suits for CBRN

the Ambulance service jumped on PRPS combined with Tyvek 'paper' over suits as an easy solution during covid without the hassle of fit testing FPP3 for proven Covid cases and Aerosol generating procedures Such as resuscitation ( plus tyvek oversuits are standard ambulance equipment anyway to try and keep crew s clean at messy / infested scenes )

 

[elbows]

I also think that the people likely to have exposure in this early stage were problably young er and fitter than average so less likely to have have really severe disease ...

biggest problem is that becasue the convalescent investigation needed proven infection, anyone who got it before testing etc was in place was excluded

Also even when testing was very first available, really narrow restrictions were placed on what counted as a suspected case suitable for testing - a 'relevant travel history' was required and this was still the cases even for severely ill patients in hospital. It was absolutely no surprise to me at the time that as soon as they changed that testing criteria, they started finding cases and then deaths.

There have been some studies in a number of countries where they retrospectively went back and looked at old samples that were collected for other purposes 'before the pandemic began'. Some of these have found evidence of much earlier cases in some European countries. Some of these studies are disputed but others have weathered such criticism and so there is a bit of evidence out there about some infections in some places in the October 2019-Jan 2020 timeframe. I havent found anything that expands significantly on this beyond what was found on this front by studies that were published in 2020 and 2021. But I know at least one country also did the same sort of thing using retrospective analysis of wastewater samples, with the same sort of indications of a few earlier cases being found in Europe in the last few months of 2019.

Beyond those very early cases, there have also been studies from slightly later, but still before widespread community transmission in the UK was officially acknowledged, which suggest that there was way more Covid around throughout February 2020 than was acknowledged. Some of these have identified specific patients, for example in Nottinghamshire, in the weeks before cases were officially detected, again mostly in February 2020.

The last time the media in the UK got really excited about this sort of thing was when someone who died in Kent in January 2020 eventually had their death recorded as a covid death many months later (summer 2020). Again this was done via some retrospective analysis of clinical data in this case. So the UK did eventually end up with 1 Covid death officially recorded in Jan 2020, though I havent checked whether officialdom eventually found a way to remove this deatrh from the official figures. This person was old, had no relevant travel history, and initially showed some symptoms shortly before Christmas 2019, followed by hospitalisation by early January and death in late January.

In terms of why we didnt see a bigger overall death spike back in those earlier months, the theoretical reasons for that included the reason you mentioned (age and fitness of most cases), but also the still overall much lower number of cases in the earlier timeframe. In theory the possibility that the virus was less dangerous in its very earliest, sporadic incarnations in humans, compared to how it ended up being a bit later.

Anyway the public inquiry doesnt seem interested in this topic.

 

[elbows]

PRPS is not a new technology , when all the 'white powder' stuff kicked off in the mid 2000s the NHS CBRN protection for decontamination teams was PRPS based as it was easier to teach that than SCBA but that was sealed in suits for CBRN

the Ambulance service jumped on PRPS combined with Tyvek 'paper' over suits as an easy solution during covid without the hassle of fit testing FPP3 for proven Covid cases and Aerosol generating procedures Such as resuscitation ( plus tyvek oversuits are standard ambulance equipment anyway to try and keep crew s clean at messy / infested scenes )

Thanks for the info. I didnt mean to imply that the technology and form of equipment was brand new.

But it is of interest to me as to how widely available this stuff was during the pandemic. It hardly ever comes up when PPE is discussed in the public inquiry. And the Southampton development of it was probably considered newsworthy because they actually got on with manufacturing it at reasonable scale and providing it to their staff locally, despite the much weaker standard of PPE that the bullshit national guidelines continued to recommend.

 

[InArduisFouette]

Thanks for the info. I didnt mean to imply that the technology and form of equipment was brand new.

But it is of interest to me as to how widely available this stuff was during the pandemic. It hardly ever comes up when PPE is discussed in the public inquiry. And the Southampton development of it was probably considered newsworthy because they actually got on with manufacturing it at reasonable scale and providing it to their staff locally, despite the much weaker standard of PPE that the bullshit national guidelines continued to recommend.

i don;t know about the early stages but once it was established several of the ambulance services had PRPS , everyone dished out the 'hoods' and 2 or 3 paowerpacks on each Vehicle + some spares at Station so crews could all have them if necessary

 

[elbows]

It remains the case that so far, the higher up you go, the more slippery and useless the answers given are.

This applies to the CMOs.

A lot of the Northern Ireland CMOs answers yesterday involved 'not my area of responsibility'.

And today we have the Scottish CMO. A major focus of inquiry questioning in this module so far has been in regards airborne transmission. They have noticed many of the glaring failings in this area, and how the 'precautionary principal' with which they became familiar with in previous modules was completely inverted when it applied to this area, and how a 'lack of evidence' was used to justify many shit decisions. It appears that the Scottish CMO considered early WHO claims about no airborne transmission, and the way they then evolved their message slowly and somewhat vaguely during a subsequent interim period (before the shift to accepting airborne transmission as a major factor happened more substantially) to be unhelpful. But when the inquiry probed him about these concerns, it became clear that he didnt act on those concerns in a meaningful way, and didnt challenge the output of official groups in the UK that were clinging to the shit guidance (including the IPC cell).

 

[elbows]

A few quotes from last week when we heard from Dr Ben Warne, Dr Gee Yen Shin and Professor Dinah Gould (Experts in Infection Prevention and Control). From the 19th September transcript https://covid19.public-inquiry.uk/w...1310/2024-09-19-Module-3-Day-8-Transcript.pdf

Pages 40-44:

MS CAREY: Well, no, not necessarily. Yesterday we heard from Professor Hopkins, and I asked her this:

"Do you agree that where there is an accepted risk of aerosol transmission FFP3 should be recommended?"

She didn't agree with that. She said it was complicated, and she said that evidence was weak that FFP3s protected more than FRSMs, and it made us ponder why, if the evidence was weak, there has been, running throughout the guidance, this distinction between FRSMs in one context and respirators in another.

So that's the genesis of the controversy and I'd like your help with how we've ended up in this position, if you're able to help us.

DR WARNE: A lot of the evidence for this comes from SARS, so it's about 20 years old. There is no high-quality evidence, as we would understand it, so in future modules we talk about vaccines, talk about drugs and effective treatments that undergo high quality randomised control trials, so evidence which is considered to be of a high quality and is robust.

Those kind of studies are very uncommon in infection control measures so we rely on, essentially, look-back exercises, retrospective observational studies where some people had one type of infection control intervention and another group had another.

So, in SARS, there were a number of very small studies looking at people who had surgical masks or respirators or no PPE at all, and the evidence from SARS, based on those small studies, is that some PPE is much better than none, but very few of them actually compared respirators with surgical masks.

There were two studies, they're incredibly small, and those very small studies, which are by the authors' admission of poor quality, essentially are the only basis -- the only scientific basis at the start of this pandemic by which -- is quoted in guidance both of pandemic flu preparedness and other guidance at the start of this pandemic, the rationale for using surgical masks for routine clinical care above respirators.

MS CAREY: So is a lack of high-quality trial evidence that respirators are more effective than FRSM, is that --

DR WARNE: That's right because there is essentially no high-quality evidence.

MS CAREY: Right, but there is other evidence because we heard from Professor Beggs about the studies done in lab conditions.

DR WARNE: Absolutely.

MS CAREY: What about observational studies, if that be the right -- are there any other studies that help at least try and ascertain whether respirators are better than FRSMs?

DR WARNE: There's certainly been a lot, as the pandemic has progressed, observational studies which show that FFP3 respirators or other types of respirator are associated with lower risk of transmission, particularly to healthcare workers, which are the group we're talking about. None of -- again, they are being criticised because the methodology is not rigorous, they often rely
on retrospective observational data, there are chances of bias, and so on.

But that's the quality of the evidence that we're relying on and the laboratory style evidence, what we know a priori, you know, what we know about the first principles of these aerosols and how they're generated, has contributed to a body of evidence that's open to interpretation.

MS CAREY: If there is this lack of high-quality trial evidence, can you help why it is that we've ended up now, for a number of years, with a distinction nonetheless being drawn between FRSM in routine care and respirators for AGP procedures; why have we been following this for two decades?

DR WARNE: I think part of it is entrenchment that IPC measures are very slow to change. So once you have a standard which is establish, 15, 20 years ago, there is very little change that happens with IPC measures, particularly at any kind of pace, so "That's what we've always done, that's what we'll continue to do".

MS CAREY: I saw Professor Gould nodding there. As someone who has been involved in the educational side of things, do you have a view about what Dr Warne's just told us?

PROFESSOR GOULD: I think, by tradition, infection prevention people are very traditional and they are not very forward-thinking people, they tend to be backward-thinking people, they tend to be, "We've always done it this way and it's the safe way and so we'll carry on doing it the safe way". They don't think it for any malicious reason; people don't dare to change.

So there are some entrenched things that we do and we do them because we've always done them because we just don't dare to change. We always wear masks in operating theatres because we always have. Some kinds of surgery, it's probably very unlikely that transmission of infection would occur by that route but we still wear them just to be sure.

 

[elbows]

Page 47:

MS CAREY: Would you recommend that the current IPC guidelines are updated to recommend routine use of FFP3?

DR WARNE: For the care of patients with confirmed respiratory --

MS CAREY: Or respiratory virus?

DR WARNE: Yes, I would.

LADY HALLETT: I think Dr Shin wanted to say something.

MS CAREY: So sorry. Yes, Dr Shin.

DR SHIN: I broadly agree but I think we also take into account the pathogenicity of the virus we're talking about. For example, if it was rhinovirus, which is the common cold virus, then I wouldn't advocate FFP3 for that. But, yes, Covid and flu and potentially other viruses, like parainfluenza virus, there are four types, immunocompromised patients can be quite seriously ill with that, so I think there's a bit of a nuance here, basically.

MS CAREY: Understood.

 

[elbows]

Pages 23-25:

MS CAREY: Now, there was knowledge, as we know, of asymptomatic infections being possible early on and evidence emerging as we went through the pandemic about the role of asymptomatic transmission, but do you think that future guidance should assume there will be asymptomatic transmission unless and until the contrary is proven?

DR WARNE: Absolutely. So we know that there is asymptomatic transmission of a range of respiratory viruses, including influenza, including RSV. I think that there is much less with SARS, and MERS prior, but until proven otherwise, I think we should assume that there will be a substantial proportion of asymptomatic transmission.

LADY HALLETT: Are you saying, Dr Warne, that that should have been the case, given the state of knowledge when the pandemic hit us?

DR WARNE: So we knew that there were high rates of asymptomatic influenza and, although we discussed before in this Inquiry about the importance of preparing for an influenza rather than a coronavirus pandemic, the likelihood that you have asymptomatic influenza is equally likely. So I think that we should definitely have been preparing for it and should prepare for it in a future pandemic.

MS CAREY: We have become familiar with standard IPC measures and transmission based precaution but, can I just ask you this, I'm asked to ask you about Professor Beggs' conclusion that hand hygiene has a modest effect in preventing Covid-19 transmission and whether, I think probably you, Professor Gould, agree with that conclusion or any of you if you disagree with it. Start with you, Professor.

PROFESSOR GOULD: I would agree with it. Direct contact was not found to be the major -- not considered to be the major route of spread, so hand hygiene is always going to be important but would not, in this case, be the major route.

MS CAREY: Dissent from either of you two gentlemen?

DR WARNE: No, I agree with that.

DR SHIN: I agree but I think there were a few words there that were important. IPC is not just about Covid obviously, so we have to be conscious of all the other infectious threats. For that reason, hand hygiene is extremely important, as Professor Gould has just said, so I broadly agree, with that small caveat.

PROFESSOR GOULD: Could I just add, we would be concerned with the spread of Covid but we wouldn't want inadvertently to give the patients MRSA or any other infection. So hand hygiene is always good.

 

[elbows]

Pages 142-144, on the underappreciated nature of catching influenza in hospital, and some difficulties with establishing hospital cases of covid etc:

MS CAREY: You make the point that healthcare-associated transmission was a feature of hospitalised cases for SARS, I think, and MERS. What about flu?

DR WARNE: The evidence base for flu is much smaller. There was an increasing evidence base that hospital transmission of flu was important, and we have data from our own trust and from other hospitals in the UK, from the years prior to the pandemic, which showed that flu was probably an underappreciated hospital associated infection.

MS CAREY: Okay.

DR WARNE: The quoted numbers are very variable depending on the type of hospital.

MS CAREY: But it's not new that people go into hospital, nonetheless contract a virus?

DR WARNE: infection. No, or indeed any other hospital-associated

MS CAREY: All right. In relation to Covid, I think you said that the first study on Covid-19 was published from Wuhan in February 2020; is that correct? And it stated that 41% of all cases identified in patients and healthcare workers were hospital-acquired infections.

So early on in the pandemic, we were aware that there was the possibility of Covid transmitting in this way.

Can I ask you about your paragraph 11.3 though, and can you just set out for us why it is challenging to work out the location where SARS or Covid is acquired?

DR WARNE: The main reason relates to the incubation period which we talked about right at the start of today's hearing. So the time from somebody catching Covid and then to developing symptoms ranges from two to 14 days, the average being approximately six days at the start of the pandemic. That means that if you developed symptoms of Covid on day 6 of an admission, you had an essentially 50/50 chance of acquiring it in hospital or in the community, and in that preceding six days you may have moved several areas in the hospital, the preceding 14 days you may have had a number of different exposures in the community. It's often very difficult to tie down exactly the point at which you would have acquired Covid.

By comparison, influenza the average incubation period is about a day, one to two days, so a much shorter space of time for us to look back and say, "Where was the patient, who did they come into contact with, how do we investigate and manage this problem?"

(By the way, it was also mentioned at some point that the average incubation time for Covid seems to have dropped a lot by the time we got to the vaccination and Omicron era).

 

[elbows]

They discuss some figures/estimates for hospital scquired covid cases, and with the previous issue in mind, it was necessary to dicsuss the multiple different categories that are present in these numbers:

Pages 144-146:

MS CAREY: With your help, Dr Warne, can you help us with HOHA or hospital onset definite healthcare associated?

DR WARNE: These are patients that tested positive 15 days or more into their admission, so beyond the longest possible incubation period of the virus. So they acquired it in hospital.

MS CAREY: Probable healthcare associated?

DR WARNE: So these are patients who tested positive between days 8 and 14 of their admission, where the balance of probability is that they acquired it in hospital but not for definite.

MS CAREY: Right. Then indeterminate?

DR WARNE: So this is where people tested positive from day 3 to 7 of admission, so where initially the balance of probability was that it was acquired in the community.

MS CAREY: Right. Community onset possible healthcare associated: help us with the definition there?

DR WARNE: So these are patients who tested positive within two days of being admitted that had recent by been discharged from hospital. So, very early in the pandemic, it became clear that a number of people were being readmitted to hospital, having acquired their Covid on their prior admission, going into the community and coming back. This category was intended to capture
those patients.

MS CAREY: Understood. Then community onset community acquired?

DR WARNE: So these are people who tested positive in the first two days of their admission but had not had any prior healthcare contact.

 

[elbows]

And now some actual numbers. Pages 148-149:

MS CAREY: With the definitions in mind, the caveats in mind though, I think you in the report tried to estimate the number of hospital acquired SARS-CoV-2 infections. Can I ask you about your summary please at paragraph 11.17.

I think, essentially, having set out a number of different studies and the like, you said estimates of the proportion of Covid infections acquired in hospital ranged between 5 to 20% of all Covid-19 cases identified in acute hospitals; is that correct? It's quite a wide range there.

DR WARNE: Yes.

MS CAREY: But doing your best, did you come to the conclusion that, overall, it was highly likely that the true number of patients who contracted a hospital-acquired Covid infection in the UK was well over 100,000?

DR WARNE: Yes.

MS CAREY: Are you able to help us with sort of what was like the lowest estimate and what could be the highest estimate, based on the modelling studies that you looked at?

DR WARNE: So the lowest proportion that's quoted in these studies -- and this is a combination of big national datasets and smaller individual hospitals, and everything in between -- the lowest that it's come to is 5%, the highest is 20, but some modelling estimates are actually much higher than that because we don't take account, for example, of people who catch Covid but don't develop symptoms until they get into the community. So in some studies it's even higher than that 20% figure.

MS CAREY: When you say well over 100,000?

DR WARNE: Data from NHS England, which is included in the pack for this hearing states that in England alone, up until June 2021 there were 65,000 hospital acquired infections, either falling into the first two categories, the definite or probable, and that's only up until June 2021 and only in England. So I think that both national data and the data from this, the estimates from this, converge on that figure of being well in excess of 100,000 people.

MS CAREY: If we think about -- I don't know if you heard Professor Hopkins' evidence yesterday in relation to some Public Health England data that looked -- that found that between March 2020 and April 2021, for hospital onset definite healthcare associated figures, they were nearly 30,000, of which 9,854, almost a third of those people died.

DR WARNE: Yes.

 

[elbows]

One or two of their final thoughts and recommendations from them. Pages 164-165:

MS CAREY: Can I return to the precautionary principle, and I think to you, Dr Shin.

Clearly it's an approach to trying to mitigate the risks of the virus. You spoke about HCID being an example of the precautionary principle in practice, but by reference to your paragraphs 12.43 onwards, do you have any observations about the use of the principle or overuse of people demanding the precautionary principle? Help us please with your observations.

DR SHIN: I think in retrospect, you know, I think it's now clear that -- well, in my mind -- that Covid is transmitted through the airborne route. So with that in mind, I would agree with the earlier response that FFP3 would be what I recommend.

In terms of precautionary principle, I think it is part of our recommendation that in a future pandemic that we would suggest that before PPE steps down you need evidence that that would -- is a safe step to take, rather than step down and -- as evidence mounts that you should have RPE, then do it that way, which is what happened in this case. So I think if we were faced with a similar situation, which I hope we're not for a long time, then we would suggest that -- we can understand why there are loud voices calling for precautionary principle for PPE and I think that would be more -- all of our workforce would be more reassured if that precautionary principle was applied in a future emergency so that we only step down PPE when evidence showed that that was reasonable and safe to do so.

MS CAREY: So where there is an absence of evidence about the route of transmission, start with the highest level of protection and as you work out the routes, as the evidence emerges, then make a decision to step down if that's appropriate. Is that it?

DR SHIN: I think that's probably our consensus view.

Pages 172-174:

MS CAREY: Finally you, Dr Shin, earlier this morning you advocated for better understanding of ventilation in hospitals. We haven't touched on it, but we're aware of HEPA filters, UV lights, where it's not possible to tear down a roof and install new ventilation. Why is it that you have proposed as your headline recommendation better research and better understanding of the role of ventilation?

DR SHIN: So it was ventilation and isolation. But in terms of ventilation, this being a respiratory virus, that was obviously a very significant risk factor for the NHS.

Many hospitals are old and are not well suited to face such a -- a threat like this, so in the future it would be much better if we can -- ideally, long term, hospitals should have improved ventilation in general, as you hinted. We know that's difficult. So there are short-term solutions, for example portable HEPA-filtered air filtration units are one possible short-term measure. And in Professor Beggs' report, he talks about an ultraviolet -- a high-mounted ultraviolet filtration system, which looks to me, as a non-engineer, like it might be something feasible to retrofit to some high-risk ward areas in hospitals.

So I think risk mitigation measures should be looked at to make sure that our environments are safer, but I don't want to lose sight of increased isolation capacity as part of the recommendation as well.

MS CAREY: Yes. Apart from building more hospitals, I was just trying to think about how, practically, you could recommend that -- you say:

"We recommend that the overall NHS isolation capacity should be increased over the next 5-10 years ..."

Apart from the rebuilding programme, how else might that be achieved?

DR SHIN: So we are trying to do something like this at the moment with limited resources. What might be possible is for certain ward designs -- which are very open plan, open layout -- which might be convenient for peacetime, but in a pandemic situation that is a risk, so it could be possible to increase segmentation within the ward, which is kind of a halfway house, to full isolation, but it would probably reduce risk.

So instead of having, like, three or four bays, having, you know, a domino effect of infections, you may be able to contain it, say, in one bay, rather than allow it to spread further.

So I think we'd have to -- I think we should look at all of our hospital estate and say: what can we reasonably do in a short space of time and also long term?

 

[elbows]

I couldnt watch todays sessions yet, will have to catch up in the coming days.

There is some press coverage of today, eg:

Covid was like a daily terror attack, doctor tells inquiry

Covid inquiry hears harrowing testimony from ex-adviser in emergency preparedness at NHS England.

www.bbc.co.uk

Prof Fong described Covid as the “biggest national emergency this country has faced since World War Two”, and repeatedly broke down on the stand while describing what he had seen and his conversations with other staff members.

During the pandemic, Prof Fong, a consultant anaesthetist, conducted around 40 visits of intensive care units on behalf of NHS England to offer peer support to the doctors and nurses working there.

He wrote reports which were sent back to managers including England’s chief medical officer Prof Sir Chris Whitty.

He said the “scale of death” was “very difficult to capture in the figures”.

“It was truly, truly astounding… We had nurses talking about patients ‘raining from the sky’, where one of the nurses told me they got tired of putting people in body bags.”

“We went to another unit where things got so bad they were so short of resources, they ran out of body bags and instead were stuck with nine-foot clear plastic sacks and cable ties.”

England's chief medical officer Prof Sir Chris Whitty, who was next to speak at the inquiry, said he agreed with the evidence "very powerfully laid out" by Prof Fong.

He said that NHS hospitals in England entered the pandemic in early 2020 with a “very low” level of beds in intensive care compared to similar high-income countries.

“That's a political choice. It's a system configuration choice, but it is a choice,” he told the inquiry.

“Therefore, you have less in reserve when a major emergency happens, even if it's short of something of the scale of covid.”

Sir Chris suggested that countries like the UK had no alternative but to impose lockdown and other social restrictions to avoid a “catastrophic” amount of pressure on the healthcare system.

He accepted that “in many individual cases” doctors and nurses found the situation “incredibly difficult” but said without lockdown restrictions “the expectation is it would have got worse. Not a trivial amount worse, but really quite substantially worse”.