Respirators or masks? A 'Solomonic' decision
HICPAC says masks, new director looks to IOM
The Centers for Disease Control and Prevention is expected to issue a ruling by Oct. 1 on whether health care workers should wear surgical masks or N95 respirators when treating patients infected with H1N1 influenza A.
An Institute of Medicine (IOM) committee was slated to weigh in by Sept. 1 on the latest iteration of the respiratory protection debate, forwarding its recommendation to the CDC for a final decision that will in all likelihood leave one group or another disappointed.
The current debate is about protecting health care workers from H1N1, but occupational health experts and infection preventionists have been wrangling over this issue since tuberculosis resurged in the 1990s. Somewhere at the heart of the current debate is the question of whether flu virus can be transmitted via the airborne route (thus warranting respirators) or is only spread at short range via droplets (masks are sufficient). The other issue is that H1N1 is something of an unknown quantity, a pandemic virus that can cause severe infections in some and mild illness in others. Then there's the matter of real-world implementation, as the standing CDC N95 recommendations have been dropped by many hospitals and health departments in the name of patient care, resources, and costs.
"I don't think we are going to be able to do the N95 respirators," says Donald Kennedy, MD, a professor of infectious diseases at Saint Louis University. "If you've ever worn one — you can't wear it for very long. If you make that recommendation people aren't going to be able to comply with it. The standard surgical mask should be fine unless you are doing some procedure like a bronchoscopy. I favor good standard infection control practices, including droplet isolation and cohorting, if necessary. But applying it universally, instead of having really great [N95 respirators] for the mega medical centers and nothing for Indian reservations and innercity clinics."
The CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) recently recommended that the agency officially downgrade the current N95 recommendation for H1N1 in favor of surgical masks. The HICPAC position is that "at a minimum," health care personnel should adhere to standard and droplet precautions for seven days after the onset of a patient's symptoms. An N95 respirator or higher level of respiratory protection should be used with procedures likely to produce aerosols, including bronchoscopy, cardiac pulmonary resuscitation, open airway suctioning, and sputum induction. Decisions on the level of protection also should take into account factors at the hospital, such as the number of patients with novel H1N1 and any evidence of transmission of pandemic virus at the facility, the committee observed.
"We also considered the patient very much in this whole context," says Patrick Brennan, MD, chairman of HICPAC. "Care has to be delivered and the [N95] devices are very difficult to wear for periods of time so we had to take all of that into account." New CDC director Thomas Frieden, MD, MPH, will apparently make the final call.
"The director is going to have to blend it all and come up with a Solomonic decision," Brennan says. "The charge to the IOM is more narrowly construed. They specifically stated that they are not going to consider economic and logistical factors in the recommendation that they make. But [HICPAC] is an advisory panel on infection control practices. We used an evidence-based approach, weighed the evidence and came to a recommendation."
Occ-health vs. infection prevention
Three labor union representatives resigned from the HICPAC working group that drafted the recommendation. One of them said they felt "shut-out" of a process that was skewed against an occupational health perspective.
"We felt quite strongly that these are issues that the current membership of HICPAC doesn't have sufficient expertise in — in terms of respiratory protection and bioaerosol dispersal," says Bill Borwegen, MPH, health and safety director for the Service Employees International Union (SEIU). "H1N1 is not like seasonal influenza in many respects. There's a disconnect. The infection control folks are trying to prescribe a level of risk that the Occupational Safety and Health Act doesn't really permit. It's pretty clear there that you need to protect workers using feasible methods. It's not acceptable to say a certain number of people are going to get infected."
As the issue moved on to the IOM panel, similar counter concerns about committee membership surfaced among the infection control community. "I find [the IOM panel] a very unbalanced committee to make a recommendation of health care worker respiratory protection," says William Jarvis, MD, a former top CDC health care epidemiologist who is an independent consultant. "This is an infection control issue and the infection control community should have been better represented by individuals who were knowledgeable about the NIOSH respirator recommendation process, respirators vs. masks, and the various controversies fought over during the past multidrug-resistant TB outbreaks over a decade ago."
As a practical matter, even if hospitals try to use N95s for workers treating H1N1 patients there could be a repeat of the logistical problems reported with the first wave of H1N1. Workers were reportedly wearing N95s from patient-to-patent, not wearing them appropriately or ignoring their hospitals instructions to wear them.
"I thing there are good, solid scientific and epidemiological reasons not to require N95s, and then you get into the operational issues, the supply issues, not to mention the cost issues — but those are downstream," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University in Nashville, TN. "We should really make our decision based on the best protection of our health care workers, myself included. I think the information there is sufficient to come to a decision."
By Solomon.
The Centers for Disease Control and Prevention is expected to issue a ruling by Oct. 1 on whether health care workers should wear surgical masks or N95 respirators when treating patients infected with H1N1 influenza A.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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