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NIOSH and healthcare worker respirators redux

Proving that a once-read blog post can still provide new information in the online world, I revisited the NIOSH blog post, “N95 Respirators and Surgical Masks,” [1] which I previously wrote about, here [2].

The NIOSH post, authored by Lisa Brosseau, Sc.D., and Roland Berry Ann is still the best authoritative site explaining the ins and outs of respirator vs. surgical mask selection for H1N1 protection, in my opinion. So, on revisiting it, I was delighted to find a healthy amount of comments to which Brosseau and Berry Ann offered answers.

Here are some excerpts addressing questions that OSHA Healthcare Advisor readers have also posed.

For healthcare workers who just can’t get past the old influenza contact transmission paradigm:

Presentations made at the IOM [Institute of Medicine] meeting in August indicate that influenza transmission is also associated with close range exposure to small particles generated during speaking, coughing, and sneezing… The traditional infection control paradigm does not consider this type of exposure. Surgical masks do not provide wearer protection for exposures to small particles (due to poor filtration and fit performance). Respirators are designed to offer such protection.

OK, if respirators are needed, then why isn’t novel H1N1 2009 officially designated an airborne disease? Again NIOSH references the IOM:

Although there is strong evidence to support airborne transmission across short distances as a potential mode of transmission, there is not evidence to suggest that this agent is able to transmit over long distances (such as through air handling systems) or to cause prolonged airspace contamination. Thus, it differs from agents such as TB. In view of this, CDC guidelines recommend respiratory protection for close contact, defined as a distance of fewer than 6 feet from a patient or entry into a shared airspace equivalent to a typical patient room.

Shouldn’t all this N95 respirator use just apply to hospital settings and not outpatient facilities?

This guidance applies to healthcare personnel working in the following settings: acute care hospitals, nursing homes, skilled nursing facilities, physician’s offices, urgent care centers, outpatient clinics, and home healthcare agencies. CDC continues to recommend the use of respiratory protection that is at least as protective as a fit-tested disposable N95 respirator for healthcare personnel who are in close contact with patients with suspected or confirmed 2009 H1N1 influenza.

Hasn’t NIOSH or OSHA developed interim respirator guidance on non-fit test methods, for example when the Katrina or WTC cleanup occurred?

NIOSH recommends and OSHA requires fit testing for respirators and conducting a User Seal Check each time a respirator is put on. These are the only recognized methods to assure the respirator is properly sized and worn correctly

On extended use or re-use of disposable N95 respirators:

If extended use practices are implemented as a means to extend respirator supplies, measures should be taken to reduce contact transmission, including:

  • Discarding disposable N95 respirators following use during aerosol generating procedures
  • Discarding disposable N95 respirators if contaminated with blood, respiratory secretions, or other bodily fluids from patients
  • Considering use of a face shield over the disposable N95 respirator to prevent surface contamination
  • Performing hand hygiene before and after touching the respirator

If re-use is chosen as a strategy to increase availability of respiratory protection, the following should be considered to minimize risk of transmission:

  • Discard disposable N95 respirators following aerosol-generating procedures
  • Discard disposable N95 respirators contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients
  • Disposable respirators must only be used and re-used by a single wearer
  • Do not re-use a disposable respirator that is obviously contaminated, damaged or hard to breathe through
  • Consider use of a face shield over a disposable N95 respirator to prevent surface contamination
  • Store the respirator in a clean, breathable container such as a paper bag between uses
  • Avoid touching the inside of the respirator

The wearer should perform hand hygiene with soap and water or an alcohol-based hand sanitizer before and after touching a used respirator.

On the rumor that there is there is an “emergency” exception to the fit testing requirement for N95 respirators.

No, there is no emergency exception to the fit testing requirement. OSHA recently issued a compliance directive for health care workers. In the OSHA News Release from November 20, 2009, it prescribes: “Where respirators are required to be used, the OSHA Respiratory Protection standard must be followed, including worker training and fit testing. The directive also applies to institutional settings where some workers may have similar exposures, such as schools and correctional facilities.” The full text of the News Release and the Directive is available at http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=16749 [3]

Have you found this NIOSH resource as valuable as I have in explaining the current N95 respirator for H1N1 protection issue? Or, do you have other sources. If so, post them in the comment section below.