NIOSH action plan: Create better respirators for HCWs
Extensive plan focuses on design, effectiveness
If an influenza pandemic strikes, public health officials may not know enough about influenza transmission and respiratory protection to adequately protect health care workers.
Acknowledging that weakness, the National Institute for Occupational Safety and Health (NIOSH) has proposed an extensive "action plan" to spur research and improve design of respiratory protection.
"Due to this lack of knowledge on influenza transmission, it is not possible at the present time to definitively inform health care workers about what [personal protective equipment] is critical and what level of protection this equipment will provide in a pandemic," NIOSH stated.
In fact, the respirators currently available to health care workers may not be practical for prolonged use during a pandemic. In a study at the North Florida/South Georgia Veterans Health System in Gainesville, FL, health care workers wore different types of respirators for an entire eight-hour work shift.
"What we have found is that most of the respirators we use regularly in our health care system are typically not tolerable for long periods," says Lewis J Radonovich, MD, director of Biosecurity Programs in the Office of Program Development at the VHA in Gainesville.
"If we were to face an influenza pandemic, how would our health care workers react if they had to wear a respirator for long periods of time, [as did] the health care workers in Toronto during the SARS crisis in 2003?" he asks.
The proposed NIOSH action plan would call for:
- surveillance of influenza transmission that would seek to connect the hospital-based spread of flu to infection control practices and the use of respirators;
- a study of the effectiveness of surgical masks and N95 filtering face-piece respirators in protecting health care workers from aerosolized particles from coughing patients;
- studies of the wearability of respirators for long periods of time, including the impact on oxygen and carbon dioxide levels of health care workers;
- the establishment of performance requirements for N95s and powered air-purifying respirators (PAPRs) that are specific to health care;
- studies on fit-testing, decontamination, and reusability of respirators.
"This is going to be the foundation of what moves us forward," says Maryann d'Alessandro, PhD, associate director for science at NIOSH's National Personal Protective Technology Laboratory in Pittsburgh, who noted that the research may lead to a better design for respirators used in health care.
Pandemic raises respirator issues
Concerns about pandemic influenza have brought respiratory protection to the forefront. The current respirators including N95s and PAPRs were designed for industrial use, not protecting against aerosolized agents.
The NIOSH report was drafted in response to a 2007 Institute of Medicine report, Preparing for an Influenza Pandemic: Personal protective Equipment for Healthcare Workers. The IOM panel called for better design for respirators and a "culture of safety" in hospitals.
Employee health professionals welcome the greater research focus on respiratory protection. The Association of Occupational Health Professionals in Healthcare in Warrendale, PA, plans to work with NIOSH on issues such as creating the most effective and efficient fit-testing protocol.
"We want to protect our employees, but we want it to be based on science," says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, association community liaison for AOHP and employee health coordinator of Western Pennsylvania Hospital (West Penn) in Pittsburgh.
Advocates for health care workers also laud the NIOSH plan as an opportunity to develop respirators that are specifically designed for health care. "We have 10 million-plus health care workers in this nation," notes Bill Borwegen, MPH, health and safety director of the Service Employees International Union (SEIU). "Can we design a respirator that doesn't need to be fit-tested? Can we design a PAPR that's focused on [the needs of] the health care worker? Can there be a whole line of respirators that's designed just for the health care workplace?
"This research will move us toward more of an evidence-based model so we have greater confidence in the protections that health care workers are given," he says.
The key question now is whether NIOSH will have the funding to follow through with the research. NIOSH should tap into funds that are designated for pandemic influenza preparedness, Borwegen says.
Meanwhile, NIOSH is expected to release new proposed criteria for N95 respirators which would require manufacturers to meet standards for "total inward leakage." Respirators would have to have a minimal level of fit even without fit-testing.
Later this year, NIOSH is scheduling a meeting to assess the current state of technology of respirators.
NIOSH also is continuing to study the attributes of surgical masks, including the potential for covering N95s with surgical masks to protect them from exterior contamination. A NIOSH study showed that wearing an N95 under a PAPR hood provides "significant additional protection," which may be particularly important for health care workers performing aerosol-generating procedures, according to the NIOSH action plan.
Health care workers sometimes confuse the protective features of a surgical mask, which is designed to protect patients from the respiratory droplets of health care workers, and respirators, which are designed to protect health care workers from aerosolized infectious particles.
"One of the challenges for the health care field is to clearly understand the differences between respirators and medical masks as well as their appropriate uses," NIOSH concluded in the action plan.
(Editor's note: A copy of the NIOSH action plan is available at www.cdc.gov/niosh/review/public/129/pdfs/lttr022208.pdf.)
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