In advance of autumn and winter, the HSE is being urged to enhance Covid-19 control measures, which some unions and medical specialists have regarded as inadequate throughout the pandemic. Catherine Reilly reports.
As of mid-August, the HSE had not published detailed profile reports on Covid-19 infections in healthcare workers since December 2021. But the risks for staff have not so abruptly disappeared.
The consequences of Covid-19 infections and reinfections, and the potential emergence of further variants less susceptible to vaccines, pose significant ongoing threats to the health workforce and to the delivery of care.
While the recommendation by the national immunisation advisory committee (NIAC) for a second booster vaccine for healthcare workers has been welcomed by unions and medical bodies, there remains ongoing concern about the robustness of control measures in healthcare.
Occupational medicine experts
During the pandemic, these concerns have been expressed at the very highest levels of medical expertise on occupational health and safety in Ireland, the Medical Independent (MI) understands.
In late 2021 an expert working group of occupational medicine specialists, which was convened by the RCPI Faculty of Occupational Medicine, concluded that certain control measures outlined in HSE guidance at the time were inadequate in maximising staff safety and inconsistent with the employer’s duty of care to their staff. Specifically, the specialists strongly advised that there should be much greater use of respirator masks. These views were provided in the context of a predicted imminent surge in Covid-19 cases and were communicated to the HSE, this newspaper understands.
Since the beginning of the pandemic, a number of occupational medicine specialists have internally expressed concern that HSE guidance was not consistent with health and safety law and not taking a pragmatic approach to best available evidence.
Under law, where it is not technically possible to prevent exposure to a biological agent, employers must apply measures to ensure that “as far as technically practicable” exposure is reduced to “as low a level as necessary” in order to adequately protect employees’ health and safety.
HSE infection prevention and control (IPC) guidance is published by the Antimicrobial Resistance and Infection Control (AMRIC) division, with input predominantly from microbiology, IPC, and public health.
The Irish Nurses and Midwives Organisation (INMO) has repeatedly advocated for additional control measures in healthcare settings. In recent weeks, these communications have been continuing with HSE Chief Clinical Officer Dr Colm Henry.
“We are dealing with a droplet and airborne pathogen circulating in an environment which is not designed to deal with anywhere like the number of people that are presenting,” Dr Edward Mathews (PhD), INMO Deputy General Secretary, told this newspaper.
According to Dr Mathews, the HSE is “extremely resistant to the recognition of the nature of the airborne transmission of the virus”.
Ventilation remains a key area of concern. “We have very many enclosed spaces with poor ventilation and no appropriate mechanical ventilation and… we are seeing overcrowding not only in our emergency departments but also in many inpatient areas in our acute system. We have many of those [areas] that have no effective ventilation system, and we are asking for supplementary ventilation to be put in place. We are asking for monitoring of ventilation to be put in place and we are asking for the release of a report that the HSE has commissioned into ventilation and matters related to their estates.”
Dr Mathews said it appeared that prior to taking any action, the HSE seeks certainty that a measure is either completely or predominantly effective.
“But that is totally contrary to the precautionary principle. The precautionary principle was well established at the time of the Sars [one] outbreak where employers and state authorities waited for scientific certainty before taking action, as a result of which both patients and staff became infected, became seriously ill and some paid the ultimate price.
“What the HSE are doing here is a classic example of what the [Sars Commission] report said following the Sars outbreak in Canada, for example, which was that you should not wait for scientific certainty and act where there is evidence in support [of the fact] that this is an important strategy.”
The union has informed the HSE of studies that “confirm the benefits” of air filtration units and provided an example of research conducted in Addenbrookes Hospital, UK, on surge wards. The advice and instruction from the HSE at national level to healthcare facilities in respect of airflow is “open to too much interpretation and unlikely to result in risk reduction”, according to the INMO.
The Organisation has also been seeking “immediate reintroduction” of Covid screening for all unscheduled care presentations and has asked the HSE to promote the benefits of mask wearing in the community. In regard to healthcare staff, Dr Mathews said a respirator mask was “more effective” than a surgical mask in preventing infection and “should be available for any member of staff” as required.
PPE
HSE guidance on personal protective equipment (PPE), updated in June, removed a requirement for use of FFP2 respirator masks for “all care” (this stipulation was added in late December 2021). The HSE guidance currently states that respirator masks should be used for care of patients with suspected or confirmed Covid-19. It also advises that respirator masks should be worn in settings where the IPC team indicates there is a high risk that patients with “unsuspected Covid-19” are likely to be present.
We are dealing with a droplet and airborne pathogen circulating in an environment which is not designed to deal with anywhere like the number of people that are presenting
The Faculty of Occupational Medicine expert working group noted the “compelling” nature of evidence supporting an airborne risk of transmission. It referred to the established superiority of FFP masks for protection against airborne hazards as part of a hierarchy of control measures.
The expert working group examined HSE IPC guidance dated 5 July 2021. In line with the current guidance, this HSE document recommended use of FFP2 masks when in contact with possible or confirmed Covid-19 cases and contacts, rather than for all care.
The opinion of the expert working group was that the guidance should clearly state that FFP2 masks are recommended for all staff working in clinical areas “where Covid-19 cases may present or arise at all times, irrespective of an individual patient’s status”. Furthermore, this recommendation should be extended to “all staff” in admitting hospitals at times of high community incidence. In areas where close contact with known Covid patients was required, the higher grade FFP3, powered air purifying respirators or elastomeric cartridge respirators, were preferred.
The specialists also stated that an additional and “very important benefit” of healthcare workers wearing respirator masks was in reducing the risk of transmission to patients, who may be vulnerable and not necessarily vaccinated. As with all occupational health matters, they advised that decisions regarding the most appropriate PPE should be properly integrated into the hierarchy of controls with due emphasis on engineering and administrative controls.
There was a subsequent change in HSE guidance in favour of recommending wider use of FFP2 masks, but this has since been revised.
Occupational disease
In May, the EU’s advisory committee on safety and health at work reached an agreement on the need to recognise Covid-19 as an occupational disease in health and social care. The committee supported an update of the EU list of occupational diseases and this was agreed by the European Commission.
According to a Commission statement: “The aim is that member states adapt their national laws according to the updated recommendation. If recognised as an occupational disease in a member state, workers in relevant sectors, who have contracted Covid-19 at the workplace, may acquire specific rights according to national rules, like the right to compensation.”
Mr Kevin Figgis, Divisional Organiser, Siptu Health, noted the EU committee’s opinion as well as a recent case at an employment tribunal in Scotland, which determined that long Covid was a ground for disability under equality legislation.
“The unions are very clearly of a view that healthcare workers being infected in the workplace is an injury in their workplace and we are very clearly of a view that there are responsibilities for that on the employer, there are responsibilities on the independent bodies that are established in order to provide oversight… and there is also a role for Government,” he stated.
Dr Mathews of the INMO expressed a similar view: “The Irish State should recognise the situation in relation to Covid-19, according to the European recommendation, and apply the same rigor to managing the safety of healthcare workers in healthcare facilities as it does to caring for the health and safety of other workers in our society.”
Worker representative organisations are legally entitled to data from the HSE on the ongoing healthcare worker infections, he added. “We can say that 29 per cent of all absences in June for nursing and midwives were as a result of Covid-19,” according to Dr Mathews, who also referred to a “very large number of clusters of infection arising from healthcare settings”.
He said the Health and Safety Authority (HSA) needs to apply greater focus to the “considerable risk” for healthcare workers and monitor and direct improvements “in the same way as they would in other areas”.
“It cannot be regarded that it is an occupational hazard of the health services to be injured by pathogens in the course of work. And very serious attention is required by the Health and Safety Authority to the work environment and the work systems, not just exits and egress and matters like that, but work systems and work environment in relation to how they are contributing to or taking away from the risk faced by healthcare staff.”
Meanwhile, the health worker unions are seeking an adequate replacement to the Covid-19 special leave with pay scheme for the public service (beyond the self-isolation period), which was wound-up on 30 June. The HSE, in consultation with the Department of Public Expenditure and Reform (DPER), has issued a circular on a replacement temporary scheme for healthcare workers with restrictive terms.
“The terms that were sought to be introduced unilaterally were essentially to ensure that no-one else, no matter how they were infected or how long they were ill as a result of Covid-19 in the health service, would be able to benefit going forward from an occupational injury scheme,” said Dr Mathews.
“We have established occupational injury schemes which deal with things like MRSA infection, and infection with a blood-borne pathogen, and we are seeking the implementation of a similar scheme in relation to Covid-19, which is a workplace risk and people should not have to use up their very valuable allocation of sick leave because of something that they acquired in the workplace. We have not made progress with the employer on that as yet, but that is working its way through the industrial relations machinery of the State,” added Dr Mathews, speaking to MI on 9 August.
Mr Figgis of Siptu noted that unions had sought engagement with the HSE and Department of Health from early April about the scheme. However, this engagement was not forthcoming. “When the special leave with pay was ceasing there were people contacting us telling us they literally would not be able to pay their bills. I have spoken to people who told me they are suffering from such chronic fatigue that they spend 15 to 18 hours a day in bed.
“I have spoken to people who have told me of chronic effects of memory loss, they were working in certain jobs in the health service that they would never be allowed to go back to if those symptoms were prevailing….”
An IMO spokesperson told MI: “The IMO, in common with other health sector unions, are of the view that an occupational injuries scheme for healthcare workers with long Covid is the appropriate method to support such workers. Those healthcare workers who sacrificed their own health to protect the health of the nation should be recognised and supported by the HSE.”
In regard to control measures in healthcare, the IMO’s spokesperson said: “Public health advice and infection control measures must continue to be adhered to in healthcare settings. In relation to particular measures or additional measures, these are clinical decisions that should be taken having regard to the public health advice at any given time and the trajectory of this disease.”
HSA
The HSA made no definitive comment on current HSE guidance and control measures. “We have engaged with the HSE and employers in the sector around risk assessment requirements and the controls to protect workers; we will continue to engage with them,” said a spokesperson.
Since November 2020 under the biological agents regulations, employers are required to report cases of occupationally-acquired Covid-19 to the HSA (although comparisons with HSE data suggest there has been significant under-reporting to the HSA).
From 1 January to 30 June 2022, the HSA received 1,069 reports covering 1,748 cases of Covid-19 infection from the health and social care sector (public and private). The Authority was also aware of 23 reports of healthcare workers who had reportedly died with Covid-19.
“All fatalities that are reported as being occupationally related are investigated by the Authority. Arising from the investigation a determination on whether the fatality has arisen from an occupational-related matter is made based on the facts and evidence gathered when an investigation has been initiated. Of the 23 investigations initiated by the Authority, 12 investigations have been completed,” according to the HSA spokesperson.
From 1 January to 30 June 2022, the Authority conducted 235 inspections in the health and social care sector, resulting in 189 written advices, seven improvement notices, and one prohibition notice being issued. “The Authority does not discuss or comment on any matters that relate to individual workplaces or investigations,” its spokesperson said.
HSE response
A HSE spokesperson noted it currently recommends FFP2 masks for healthcare interactions with patients suspected or confirmed to have Covid-19 infection; interactions in areas where IPC teams advise there may be ongoing transmission of Covid-19, or unsuspected cases of Covid-19; and for care that involves the use of “aerosol-generating procedures”.
In addition, FFP2 masks “remain available” for any staff based on personal preference or where their “particular circumstances require use of these masks”.
HSE Covid-19 guidance was “reviewed and updated regularly” to take account of national, European Centre for Disease Prevention and Control and World Health Organisation guidance and changes in the disease profile, stated the spokesperson.
Asked about the HSE’s response to the expert opinion from the Faculty of Occupational Medicine, the spokesperson said the query would necessitate a request under Freedom of Information law.
Since the start of 2022, according to the spokesperson, the Health Protection Surveillance Centre had “streamlined” its reporting for Covid-19 with several reports being “restructured, amalgamated, reduced in frequency or stopped”.
“We no longer produce the interim report of the profile of Covid-19 cases in healthcare workers in Ireland. The number of healthcare worker cases [in] the previous week is reported in the weekly report on the epidemiology of Covid-19 in Ireland.
“The most reliable way to determine place of likely acquisition is through cases associated with outbreaks, though this number is not reliable as it does not consider high community circulation. The number of staff cases associated with Covid-19 outbreaks in healthcare settings is available in the Epidemiology of Covid-19 Outbreaks/Clusters in Ireland – Weekly Report.”
As of 8 August, there have been 47,502 confirmed Covid-19 cases among healthcare workers notified to the national infectious disease surveillance system this year.
“Healthcare worker status is determined both by self-classification and workplace. The definition includes anyone who self-identifies as a healthcare worker irrespective of where they work. Changes in testing policy will impact the proportion of healthcare worker cases. PCR testing is still recommended for symptomatic healthcare workers, meaning that they may be overrepresented in data on confirmed cases.”
In regard to screening of presentations to unscheduled care, the spokesperson said: “The recommendation that asymptomatic patients admitted to hospital do not generally require testing for Covid-19 aligns [with] the clinical approach which we apply for other respiratory viral infections. This is generally focused on testing symptomatic patients only. The guidance does, however, allow individual hospital settings to continue admission Covid-19 testing of all patients or some subset of patients based on local risk assessment of that service and local levels of community transmission.”
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