National Academies of Science

The Use and Effectiveness of Powered Air-Purifying Respirators in Health Care: Workshop Summary
Released: January 6, 2015
Protecting 18 million United States health care workers from infectious agents—known and unknown—involves a range of occupational safety and health measures that include identifying and using appropriate protective equipment (CDC, 2014a). The 2009 H1N1 influenza pandemic and the 2014 Ebola virus outbreak in West Africa have called attention to the importance of personal protective equipment (PPE) in different health care settings and have raised questions about how best to ensure appropriate and effective use of different kinds of PPE (such as respirators), not only to promote occupational safety but also to reduce disease transmission, in general.

Since 2005, the National Personal Protective Technology Laboratory (NPPTL) at the National Institute for Occupational Safety and Health (NIOSH) has sponsored the Institute of Medicine (IOM) Standing Committee on Personal Protective Equipment for Workplace Safety and Health. In mid-2014, NPPTL asked the IOM to convene a workshop, “The Use and Effectiveness of Powered Air-Purifying Respirators in Health Care,” to help prioritize and accelerate NIOSH activities to update certification requirements for powered air-purifying respirators (PAPRs) for use in health care.

Occupational Health Nurses and Respiratory Protection: Improving Education and Training – Letter Report
Released: August 2, 2011
At the request of NPPTL, the Institute of Medicine (IOM) Committee on the Respiratory Protection Curriculum for Occupational Health Nursing Programs examined existing respiratory protection curricula in occupational health nursing programs and made recommendations to improve the education and training of occupational health nurses (OHNs). The IOM identified essential content that should be included in education and training programs for OHNs and the best approaches to teaching that content.

The IOM found that current respiratory protection education for OHNs receives varying amounts of dedicated time and resources and is taught using a variety of approaches. The IOM makes several recommendations to occupational health nursing education and training programs and NPPTL, such as expansion of respiratory protection information provided across all levels of nursing education and training; consistent integration of essential content into graduate curricula and continuing education programs for OHNs; continued and expanded use of innovative teaching methods, such as online courses, use of simulation and case studies, and field observation and practice; and exploration of the development of core competencies in respiratory protection.

Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel Update 2010
Released: January 27, 2011
In light of the unanswered research questions following the 2009 H1N1 influenza pandemic, NPPTL asked the IOM to assess the progress of PPE research and to identify future directions for PPE for healthcare personnel. While the IOM finds that there are gaps and deficiencies in the research about PPE use in healthcare, there is sufficient knowledge to recommend a four-pronged strategy for effective PPE use:

1. Deliberate planning and preparation at the leadership and organizational levels
2. Comprehensive training for all personnel, including supervisors and managers
3. Widespread and convenient availability of appropriate PPE devices
4. Accountability at all levels of the organization

The IOM also offers several recommendations for continuing the momentum of PPE research that are detailed in the report and the report brief. The more scientists and researchers know about how to maximize the effectiveness of PPE and its use, the more prepared we will be for the next influenza pandemic.

Certifying Personal Protective Technologies: Improving Worker Safety
Released: November 11, 2010
Millions of workers in worksites across the United States rely on personal protective technologies (PPT) to guard against injury, illness, or death. To ensure that PPT will perform as intended, government agencies, man­ufacturers, purchasers, and many other stakeholders participate in an array of activities that are referred to collectively as conformity assessment. Currently, the nature and rigor of the conformity assessment processes vary widely. The National Institute for Occupational Safety and Health (NIOSH) asked the IOM to examine the various approaches to performance testing and verification that are cur­rently used to certify the effectiveness of PPT; to review the standards and regulations that cover PPT; and to assess the benefits of certification to worker safety.

The IOM concludes that current approaches to evaluating occupational PPT, often by job sector, are frag­mented and vary in the extent to which third party independent assessments are conducted. Therefore, the IOM recom­mends the establishment of a com­prehensive framework for PPT conformity assess­ment. This framework would categorize products based on the health or safety hazards that workers would encounter due to product failure and each cat­egory of risk—high, medium, or low—would require a different level of conformity assessment. In addition, the IOM recommends that NIOSH establish an electronic surveillance system for PPT product effectiveness in the workplace to collect information on failures of PPT and adverse outcomes that occur while workers are wearing personal protective equipment or devices.

Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A: A Letter Report
Released: September 3, 2009
During any flu season, health care workers are at the front lines of fighting the disease and protecting public health. In preparation for this year’s fall and winter flu season with novel H1N1 influenza A (nH1N1), the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration asked the Institute of Medicine to provide recommendations on necessary respiratory protection for healthcare workers in their workplace against nH1N1.

The resulting report, Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A, focuses on the scientific and empirical evidence on the efficacy of various types of personal respiratory protection technologies (e.g., medical masks and respirators) as one measure to protect healthcare workers against nH1N1. The report states that an emphasis is needed on launching a range of strategies to minimize the risk of infection among healthcare workers exposed to patients with suspected or confirmed nH1N1.

Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers
Released: September 18, 2007
During an influenza pandemic, healthcare workers will be on the front lines delivering care to patients and preventing further spread of the disease. Protecting the more than 13 million healthcare workers in the United States from illness or from infecting their families or the patients in their care is critical to limiting morbidity and mortality and preventing progression of a pandemic. As the nation prepares for pandemic influenza, multiple avenues for protecting the health of the public are being carefully considered, ranging from rapid development of appropriate vaccines to quarantine plans should the need arise for their implementation. One vital aspect of pandemic influenza planning is the use of personal protective equipment (PPE) – the respirators, gowns, gloves, face shields, eye protection, and other equipment that will be used by healthcare workers and others in their day-to-day patient care responsibilities.

In 2006, NPPTL asked the Institute of Medicine (IOM) to conduct a study on the personal protective equipment needed by healthcare workers in the event of an influenza pandemic. The IOM committee determined that there is an urgent need to address the lack of preparedness regarding effective PPE for use in an influenza pandemic. Three critical areas were identified that require expeditious research and policy action:

1. Understand influenza transmission
2. Commit to worker safety and appropriate use of PPE
3. Innovate and strengthen PPE design, testing, and certification

Assessment of the NIOSH Head-and-Face Anthropometric Survey of U.S. Respirator Users
Released: June 29, 2007
Millions of Americans use respirators in their places of work to protect themselves from exposures to such respiratory hazards as toxic vapors and gases, harmful particulate matter, and airborne pathogens. Some respirators filter the ambient air, while others employ a separate air supply; but in either case the respirator will protect its user only if it fits properly. It must mold to the user’s face in such a way that no air from the outside can leak in, even when the user is moving or speaking.

It is the responsibility of NIOSH to certify that respirators from manufacturers meet certain minimum performance levels. NIOSH performs this task with the help of fit test panels, each of them a group of about 25 people who have been chosen because, collectively, their facial dimensions are assumed to be representative of the respirator-wearing workforce as a whole. In 2001 NIOSH contracted with Anthrotech, Inc., to collect new anthropometric data that would be representative of today’s respirator-wearing workforce and to use those data to design new fit test panels. After Anthrotech finished that task, NIOSH contracted with the Institute of Medicine (IOM) to establish an ad hoc committee to review the NIOSH-sponsored Anthrotech study. This report contains the findings, conclusions, and recommendations of that IOM committee.

Measuring Respirator Use in the Workplace
Released: January 24, 2007
The mission of NIOSH NPPTL is to prevent work-related illness and injury by ensuring the development, certification, deployment, and use of personal protective equipment and fully integrated, intelligent ensembles. This is accomplished through the advancement and application of personal protective technology standards. Like everything else about this new agency of government (founded in 2001), this is an evolving mission statement for a changing and evolving agency. While NPPTL inherited a portfolio of research into personal protective equipment technology and an extensive real-world standards-setting and certification program that impacts directly on the use of respirators in the workplace, NPPTL has been striving to seek new ground in a performance-driven environment in which there are new areas of emphasis, technologies, and responsibilities.

As part of a multifaceted look at the inherited and evolving portfolio of the NPPTL, the laboratory asked the National Academies to undertake a special look at the informational underpinnings of the respirator use program in mid-2005 and to report back expeditiously with recommendations.

Reusability of Facemasks During an Influenza Pandemic: Facing the Flu
Released: April 26, 2006
In the event of an influenza pandemic, public health officials will need to resort to multiple measures to reduce the impact. If effective vaccines and anti-viral medications do not exist or are not available in adequate quantities during a pandemic situation, respirators and medical masks could help prevent or slow influenza transmission.

Based on the assumption that efforts to produce and stockpile sufficient supplies of disposable masks and/or respirators may fall short in the event of a pandemic, the U.S. Department of Health and Human Services requested that an IOM committee examine issues relative to the potential reuse of medical masks and N95 respirators in the event of an influenza pandemic. Over the course of three months, the committee held two meetings, requested information from manufacturers, and read a wide body of technical literature. The committee, in its expert opinion, was able to develop a method of use that may allow for extended use of an N95 respirator. This recommendation is outlined in greater detail in the committee’s report.