Hostname: page-component-78c5997874-t5tsf Total loading time: 0 Render date: 2024-11-14T07:27:29.817Z Has data issue: false hasContentIssue false

Preventing the Soldiers of Health Care From Becoming Victims on the Pandemic Battlefield: Respirators or Surgical Masks as the Armor of Choice

Published online by Cambridge University Press:  08 April 2013

Abstract

The respiratory protective equipment necessary to protect health care workers from the novel swine-origin influenza A (H1N1) virus is not known. The knowledge gap created by this unanswered question has caused substantial debate and controversy on a global scale, leading public health organizations to feel pressured into issuing decisive recommendations despite a lack of supportive data. Changes in clinical practice caused by public health guidance during such high-profile events can be expected to establish a new standard of care. Also possible is an unforeseen gradual transition to widespread N95 respirator use, driven by public health pressures instead of science, for all outbreaks of influenza or influenza-like illness. Therefore, public health organizations and other influential institutions should take care to avoid making changes to established practice standards, if possible, unless these changes are bolstered by sound scientific evidence. Until definitive comparative effectiveness clinical trials are conducted, the answer to this question will continue to remain elusive. In the meantime, relying on ethical principles that have been substantiated over time may help guide public health and clinical decisions. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S203–S210)

Type
Review
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.Crosby, AW.America’s Forgotten Pandemic: The Influenza of 1918. New York: Cambridge University Press; 2003:111.Google Scholar
2.Novel Influenza A (H1N1) Outbreak Information. http://www.cdc.gov/h1n1flu/masks.htm. Accessed August 1, 2009.Google Scholar
3.Siegel JD, Rhinehart E, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committee Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 2007. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed December 1, 2008.Google Scholar
4.Centers for Disease Control and Prevention Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities.MMWR Morb Mortal Wkly Rep. 1994;43 RR-131132.Google Scholar
5.Code of Federal Regulations. 29 CFR Parts 1910 and 1926. Respiratory Protection; Final Rule. Department of Labor, Safety and Health Administration; 1998.Google Scholar
6.Sutherland, K.Filters and Filtration Handbook, 5th ed. Oxford, UK: Elsevier; 2008.Google Scholar
7.Lemieux, C, Brankston, G, Gitterman, L, Hirji, Z, Gardam, M.Questioning aerosol transmission of influenza. Emerg Infect Dis. 2007;13:173174.Google Scholar
8.Brankston, G, Gitterman, L, Hirji, Z, Lemieux, C, Gardam, M.Transmission of influenza A in human beings. Lancet Infect Dis. 2007;7:257265.Google Scholar
9.Neuzil KM, Wright PF. Respiratory viral infections. In: Kelly WN, ed. Textbook of Internal Medicine, 3rd ed. Kelly WN, ed. New York: Lippincott-Raven; 1997, chap 311.Google Scholar
10.Sandrock, C, Stollenwerk, N.Acute febrile respiratory illness in the ICU: reducing disease transmission. Chest. 2008;133:12211231.Google Scholar
11.Tellier, R.Transmission of influenza A in human beings. Lancet Infect Dis. 2007;7:759763.Google Scholar
12.Tellier, R.Review of aerosol transmission of influenza A virus. Emerg Infect Dis. 2006;12:16571662.Google Scholar
13.McLean, RL.The effect of ultraviolet radiation upon the transmission of epidemic influenza in long-term hospital patients. Am Rev Respir Dis. 1961;83:3638.Google Scholar
14.Mubareka, S, Lowen, AC, Steel, J, Coates, AL, García-Sastre, A, Palese, P.Transmission of influenza virus via aerosols and fomites in the guinea pig model. J Infect Dis. 2009;199:858865.Google Scholar
15.Atkinson, MP, Wein, LM.Quantifying the routes of transmission for pandemic influenza. Bull Math Biol. 2008;70:820867.Google Scholar
16.29 CFR Parts 1910.134. Appendix A. Respiratory Protection; Final Rule. Department of Labor, Safety and Health Administration; 1998.Google Scholar
17.Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers. National Academies of Sciences Institute of Medicine Report.Washington, DC: National Academies Press; 2008.Google Scholar
18.Yassi, ABE.Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Occupational Health and Safety Agency in British Columbia. Am J Infect Control. 2005;33:114121.Google Scholar
19. Reusability of Facemasks During an Influenza Pandemic: Facing the Flu. National Academies of Sciences/Institute of Medicine Report. Washington, DC: National Academies Press; 2006.Google Scholar
20.Society for Healthcare Epidemiology of America (SHAE). Position Statement: Interim Guidance on Infection Control Precautions for Novel Swine-Origin Influenza A H1N1 in Healthcare Facilities. June 10, 2009. http://www.shea-online.org/Assets/files/policy/061209_H1N1_Statement.pdf. Accessed July 8, 2009.Google Scholar
21.Shapiro, TS, Meslin, MM.Ethical issues in the design and conduct of clinical trials in developing countries. National Bioethics Advisory Commission, N Engl J Med. 2002;346:627628.Google Scholar
22.American Health Care Association. Memorandum. H1N1 Swine Flu Update No. 19. July 24, 2009. http://www.ahcancal.org/facility_operations/clinical_practice/Pages/SwineFluUpdate19.aspx. Accessed July 28, 2009.Google Scholar
23. Tuberculosis morbidity—United States, 1991.MMWR Morb Mortal Wkly Rep. 1992;41:240.Google Scholar
24.Radonovich, L, Hodgson, M, Cohen, H.Do respirators protect health-care workers from airborne infectious diseases? Respir Care. 2008;53:16601664.Google Scholar
25.Pearson, ML, Jereb, JA, Frieden, TR, et alNosocomial transmission of multidrug-resistant Mycobacterium tuberculosis: a risk to patients and health care workers. Ann Intern Med. 1992;117:191196.Google Scholar
26. Initial therapy for tuberculosis in the era of multidrug resistance: recommendations of the Advisory Council for the Elimination of Tuberculosis.MMWR Morb Mortal Wkly Rep. 1993;42:18.Google Scholar
27.Code of Federal Regulations 29 Part 1910.134. http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=12716&p_table=standards. Accessed July 28, 2009.Google Scholar
28.Lee, SA, Grinshpun, SA, Reponen, T.Respiratory performance offered by N95 respirators and surgical masks: human subject evaluation with NaCl aerosol representing bacterial and viral particle size range. Ann Occup Hyg. 2008;52:177185.Google Scholar
29.Nicas, M.Markov modeling of contaminant concentrations in indoor air. AIHAJ. 2000;61:484491.Google Scholar
30. Respiratory protective devices: final rules and notice.Fed Regist. 1995;60:3033530398.Google Scholar
31.Coffey, CC, Campbell, DL, Zhuang, Z.Simulated workplace performance of N95 respirators. Am Ind Hyg Assoc J. 1999;60:618624.Google Scholar
32.Coffey, CC, Lawrence, RB, Campbell, DL, Zhuang, Z, Calvert, CA, Jensen, PA.Fitting characteristics of eighteen N95 filtering-facepiece respirators. J Occup Environ Hyg. 2004;1:262371.Google Scholar
33.Grinshpun, SR, Haruta, H, Eninger, RM, et alPerformance of an N95 filtering facepiece particulate respirator and a surgical mask during human breathing: two pathways for particle penetration. J Occup Environ Hyg. 2009;6:593603.Google Scholar
34.Medical Devices. US Food and Drug Administration Web site. http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/default.htm. Accessed July 28, 2009.Google Scholar
35.American National Standards Institute Standard. ANSI Z88.2-American National Standard for Respiratory Protection. http://engineers.ihs.com/collections/abstracts/ansi-z882.htm. Accessed July 28, 2009.Google Scholar
36.Lawrence, RB, Duling, MG, Calvert, CA, Coffey, CC.Comparison of performance of three different types of respiratory protection devices. J Occup Environ Hyg. 2006;3:465474.Google Scholar
37.Lee, BU, Yermakov, M, Grinshpun, SA.Filtering efficiency of N95- and R95-type facepiece respirators, dust-mist facepiece respirators, and surgical masks operating in unipolarly ionized indoor air. AAQR Aerosol Air Qual Res. 2005;5:2538.CrossRefGoogle Scholar
38.Oberg, T, Brosseau, LM.Surgical mask filter and fit performance. Am J Infect Control. 2008;36:276282.Google Scholar
39.Shu-Ann, L, Grinshpun, S, Reponen, T.Respiratory performance offered by N95 respirators and surgical masks: human subject evaluation with NaCl aerosol representing bacterial and viral particle size range. Ann Occup Hyg. 2008;52:177185.Google Scholar
40.Duling, MG, Lawrence, RB, Slaven, JE, Coffey, CC.Simulated workplace protection factors for half-facepiece respiratory protective devices. J Occup Environ Hyg. 2007;4:420431.Google Scholar
41.Gawn, J, Clayton, M, Makison, C, Crook, B.Evaluating the protection afforded by surgical masks against influenza bioaerosols: gross protection of surgical masks compared to filtering facepiece respirators. Health Safety Exec. 2008.Google Scholar
42.Code of Federal Regulations. 42 CFR Part 84. 1995.Google Scholar
43.American National Standards Institute. Z88.2 Practices for Respirator Protection (1992, withdrawn). Washington, DC: ANSI.Google Scholar
44.Occupational Safety and Health Administration: Assigned Protection Factors for Respirators. CFR 1910.134 (2006).Google Scholar
45.Institute of Medicine. Tuberculosis in the Workplace. Washington, DC: National Academies Press; 2001:129.Google Scholar
46.Jarvis, WR, Bolyard, EA, Bozzi, CJ, et alRespirators, recommendations, and regulations: the controversy surrounding protection of health care workers from tuberculosis. Ann Intern Med. 1995;122:142146.Google Scholar
47.Menzies, D, Fanning, A, Yuan, L, Fitzgerald, M.Tuberculosis among healthcare workers. N Engl J Med. 1995;332:9298.Google Scholar
48.Seto, WH, Yung, RWH, Ching, TY, Ng, K, Ho, M, Peris, JSM.Effectiveness of precautions against droplets and contact in prevention of nosocomialtransmission of severe acute respiratory syndrome (SARS). Lancet. 2003;361:15191520.Google Scholar
49.Lau, JTF, Tsui, H, Lau, M, Yang, X.SARS transmission, risk factors, and prevention in Hong Kong. Emerg Infect Dis. 2004;10:587592.Google Scholar
50.Teleman, MD, Boudville, IC, Heng, BH, Zhu, D, Leo, YS.Factors associated with transmission of severe acute respiratory syndrome among health-care workers in Singapore. Epidemiol Infect. 2004;132:797803.Google Scholar
51.Loeb, M, McGeer, A, Henry, B, et alSARS among critical care nurses, Toronto. Emerg Infect Dis. 2004;10:251255.Google Scholar
52.MacIntyre, CR, Cauchemez, S, Dwyer, DE, et alFace mask use and control of respiratory virus transmission in households. Emerg Infect Dis. 2009;15:233241.Google Scholar
53.Garner, JSHospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Am J Infect Control. 1996;24:2452.Google Scholar
54.Centers for Disease Control and Prevention. Flu Activity and Surveillance. Reports and Surveillance Methods in the United States. Past Weekly Surveillance Reports. http://www.cdc.gov/flu/weekly/fluactivity.htm. Accessed July 28, 2009.Google Scholar
55.Centers for Disease Control and Prevention. National Institute of Allergy and Infectious Diseases. Common Cold Fact Sheet. http://www3.niaid.nih.gov/topics/commonCold/overview.htm Accessed July 28, 2009.Google Scholar
56.Turner, RB.Epidemiology, pathogenesis, and treatment of the common cold. Ann Allergy Asthma Immunol. 1997;78:531.Google Scholar
57.Few in U.S. see doctor or get medication for flu: study. February 10, 2009. http://www.reuters.com/article/healthNews/idUSTRE51863P20090210. Accessed July 28, 2009.Google Scholar
58.Thompson, WW, Shay, DK, Weintraub, E, et alInfluenza-associated hospitalizations in the United States. JAMA. 2004;292:13331340.Google Scholar
59.Radonovich L, Magalian P, Hollingsworth MK, Baraccco G. Stockpiling supplies for the next influenza pandemic. Emerg Infect Dis. E-pub ahead of print May 2, 2009.Google Scholar
60.JrRadonovich, LJ, Cheng, J, Shenal, BV, Hodgson, M, Bender, BS.Respirator tolerance in health care workers. JAMA. 2009;301:3638.Google Scholar
61.SARS Unmasked: Celebrating Resilience, Exposing Vulnerability: Registered Nurses Association of Ontario, Canada. 2003. http://www.rnao.org/Storage/24/1891_SARS_Report_June_04.pdf. Accessed February 26, 2008.Google Scholar
62.Li, Y, Tokura, H, Guo, YP, et alEffects of wearing N95 and surgical facemasks on heart rate, thermal stress and subjective sensations. Int Arch Occup Environ Health. 2005;78:501509.Google Scholar
63.Meyer, JP, Hery, M, Herrault, J, et alField study of subjective assessment of negative pressure half-masks. Influence of the work conditions on comfort and efficiency. Appl Ergon. 1997;28:331338.Google Scholar
64.Shimozaki, S, Harber, P, Barrett, T, Loisides, P.Subjective tolerance of respirator loads and its relationship to physiological effects. Am Ind Hyg Assoc J. 1988;49:108116.Google Scholar
65.Yassi, ABE.Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. Occupational Health and Safety Agency in British Columbia. Am J Infect Control. 2005;33:114121.Google Scholar
66.Khoo, KL, Leng, PH, Ibrahim, IB, Lim, TK.The changing face of healthcare worker perceptions on powered air-purifying respirators during the SARS outbreak. Respirology. 2005;10:107110.Google Scholar
67.Doney BGM, Middendorf P, Bang KM. Respirator Surveillance at Five Veterans Affairs Medical Centers. Paper presented at the American Industrial Hygiene Conference and Exhibition, Dallas, TX; May 2003.Google Scholar
68.Jonas-Simpson, C.Courage and commitment. Can Nurse. 2003;99:912.Google ScholarPubMed
69.Lim, EC, Seet, RC, Lee, KH, et alHeadaches and the N95 face-mask amongst healthcare providers. Acta Neurol Scand. 2006;113:199202.Google Scholar
70.Bai, Y, Lin, CC, Lin, CY, et alSurvey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004;55:10551057.Google Scholar
71.Morgan, WP.Psychological problems associated with the wearing of industrial respirators: a review. Am Ind Hyg Assoc J. 1983;44:671676.Google Scholar
72.Farquharson, C, Baguley, K.Responding to the severe acute respiratory syndrome (SARS) outbreak: lessons learned in a Toronto emergency department. J Emerg Nurs. 2003;29:222228.Google Scholar
73.Johnston, AR, Myers, WR, Colton, CE, Birkner, JS, Campbell, CE.Review of respirator performance testing in the workplace: issues and concerns. Am Ind Hyg Assoc J. 1992;53:705712.Google Scholar
74.Nickell, LA, Crighton, EJ, Tracy, CS, et alPsychosocial effects of SARS on hospital staff: survey of a large tertiary care institution. CMAJ. 2004;170:793798.Google Scholar
75.Kalikow DN, Stevens KN, Elliott LL. Development of a test of speech intelligibility in noise using sentence materials with controlled word predictability. J Acoust Soc Am. 61:1337–1351, 1977 May.Google Scholar
76.Nelson, HS.USA objections to protective respirators. Lancet. 1992;340:1088.Google Scholar
77.Koller, DF, Nicholas, DB, Goldie, RS, Gearing, R, Selkirk, EK.When family-centered care is challenged by infectious disease: pediatric health care delivery during the SARS outbreaks. Qual Health Res. 2006;16:4760.CrossRefGoogle ScholarPubMed
78.The Great Pandemic. The United States in 1918–1919. http://1918.pandemicflu.gov. Accessed July 28, 2009.Google Scholar
79.Beauchamp, T, Childress, J.Principles of Biomedical Ethics, 4th ed. New York: Oxford University Press; 1994.Google Scholar