How ready are you for mandatory respiratory protection?

By Cathryn Murphy
Monday, 28 August, 2017

How ready are you for mandatory respiratory protection?

The ways infectious diseases are spread are complex and some infection control experts are questioning the current paradigm that dictates the selection of personal protective equipment (PPE).1

Experts are now looking closely at the mode(s) of disease transmission and are reviewing which combinations or specific pieces of PPE are suitable and critical to prevent occupational transmission. Powered air-purifying respirators (PAPRs) provide the highest level of respiratory protection. The vexing question of when and for which specific diseases healthcare workers (HCWs) should routinely use PAPRs requires urgent consideration and clarification.2

Reports published after the 2014 West African Ebola outbreak suggest that many HCWs, including those from countries where infection prevention and control systems are robust, were unable to appropriately select, access or use respiratory PPE.3,4 Even the world’s two most powerful and respected public health agencies gave contradictory respiratory PPE advice for Ebola prevention.

The World Health Organization (WHO) continues to recommend use of medical masks for all tasks other than aerosol-generating procedures.5 For these procedures, WHO recommends N95 or equivalent respirators. WHO’s recommendation was consistent with the US-based Centers for Disease Control and Prevention’s (CDC) initial advice. However, following transmission of Ebola among nurses based in the US, the CDC upgraded its recommendation to routine use of N95 or equivalent respirators.6 For aerosol-generating procedures the CDC recommends either a PAPR or a disposable, NIOSH-certified N95 respirator.7

The 2003 global epidemic of severe acute respiratory syndrome (SARS) highlighted healthcare worker incompetence and confusion regarding selection, application, safe use and disposal of PPE.8 The 2014 Ebola and 2016 MERS outbreaks confirmed this.1,9

Some speculate that HCW transmissions are often the result of accidental self-contamination.3 Furthermore, the methods of donning, doffing and decontamination of respiratory PPE are unclear and potentially impractical. One advantage of PAPRs with a full-face covering and head shroud is that they reduce accidental self-contamination during care.

Raina MacIntyre, professor of infectious disease epidemiology, UNSW, highlights HCW misuse of PPE, suggesting that despite PPE the HCWs who contracted Ebola did so through respiratory transmission.10 Mike Edmonds, clinical professor of internal medicine – infectious diseases, University of Iowa, adds to this theory, highlighting the need for extensive PPE practice enabling HCWs to gain PPE proficiency.3 MacIntyre also reminds us of the discomfort, restriction and fatigue often accompanying extensive PPE use.10 Her reminder suggests that HCWs must also practise PPE perseverance. This is especially important when caring for a patient with Ebola, where some episodes of direct care can involve several consecutive hours of direct contact.

The current Australian recommendations for Ebola11 acknowledge discomfort with prolonged PPE use and suggest PAPRs replace P2 masks, goggles or face shields, and a head cover. They recognise the comfort of a constant supply of fresh, cool air to the HCW’s face.

Concerned by the ambiguity, vagary and contradiction of existing global advice for respiratory protection when caring for a SARS or Ebola patient, in 2016 I conducted a global survey of HCWs to better understand their behaviours and motivations around respiratory protection choice.

Respondents were invited to complete a 15-item web-based survey. Almost 400 infection control experts in Australia and the US were invited to take the survey. An invitation was also posted on Infection Control Plus’s Facebook page. All invitation recipients were encouraged to share the link to peers. Data was collected for six weeks. PAFtec Australia, an Australian-based manufacturer of respiratory protection, commissioned the survey. PAFtec had limited input into the survey design and no access to individual responses.

The 35 respondents were mostly based in Australia (48.6%), the USA (28.6%) and New Zealand (17.1%), with one each from Canada and the Netherlands. Almost all (91.4%) were responsible for or part of the team responsible for their organisation’s infection control program. 5.7% were frontline care providers.

The most commonly reported piece of respiratory protection used for patients under airborne precautions was the disposable P2/N95 or equivalent mask. These were used in the hospitals of 91% of respondents. The next most common was the re-usable PAPR, which was used in over a quarter (26.5%) of respondents’ hospitals.

Respondents gave a variety of reasons for not routinely using PAPRS when caring for patients under airborne precaution isolation. The three most frequent were PAPRs not being available, being too expensive and requiring disinfection after each use. Almost a quarter of respondents found PAPRs too difficult to don and doff and just under 10% believed PAPRs to be more dangerous than disposable masks.

When questioned about their preference to wear a PAPR when providing routine care to or when in direct contact with a patient isolated under airborne precautions and known or suspected to be infected with Ebola, MERS, tuberculosis, varicella or measles, almost all (93%) preferred a PAPR for an Ebola patient. The majority (79%) preferred a PAPR for a MERS patient. Fewer than 20% preferred a PAPR for tuberculosis (17.9%), varicella (14.3%) or measles (14.3%).

Almost all (97.1%) respondents indicated that a lightweight PAPR designed for comfortable would influence their decision to routinely use a PAPR for airborne precautions care.

When providing direct care to a patient isolated under airborne precautions, nearly all respondents (94.1%) had worn an N95/P2 or equivalent single-use mask, whereas only 26.5% had ever worn a PAPR.

The major limitation to generalisation of the findings was the sample size.

The variability in responses regarding disease-specific PAPR use is unsurprising given the ambiguity and difference in national and international guidelines and the lack of science comparing in vivo PAPR and N95/P2 mask efficiency.

The similarity between responses for PAPR use in both routine care and that involving aerosol generation is surprising given the higher transmission risks from aerosol generation. Respondents’ lack of real-world PAPR use may have biased this set of responses.

Despite small numbers, this survey highlights room for improvement in preparedness for the next, inevitable, outbreak of serious infectious respiratory disease. Proper preparation includes PPE proficiency, precision and practice. Safeguarding frontline staff depends on HCWs’ familiarity with and access to the safest level of respiratory protection and in a size and fit that provides protection over consecutive hours of wear. Our results suggest that for an Ebola patient, almost all HCWs believe a PAPR offers the safest protection. We look forward to a time when global recommendations align and reflect the HCW’s wishes for the best and safest protection. Only then will organisations be ready for the next major outbreak of serious infectious respiratory disease.

Conflict of Interest

Associate Professor Cathryn Murphy is a casual consultant to medical industry and device manufacturers including PAFtec Australia. The findings and conclusions in this presentation are solely those of the author and do not represent the views, position or the policy of any organisation except as may be specifically noted.

  1. MacIntyre CR, Chughtai AA. Facemasks for the prevention of infection in healthcare and community settings. BMJ. 2015; 350: h694.
  2. Hines S, Oliver M, Gucer P, Mueller N, McDiarmid M. Factors Relevant to Elastomeric Respirator Selection and Use in Healthcare Identified by Qualitative Data Methods. The 18th International Conference of International Society for Respiratory Protection. 2016, Yokohama.
  3. Edmond MB, Diekema DJ, Perencevich EN. Ebola Virus Disease and the Need for New Personal Protective Equipment. JAMA. 2014; 312(23): 2495-2496.
  4. Hyunwook K. Importance of Selecting Training the Use of Respirators Review of Infected Cases of Health Care Workers (HCWs) against MERS CoV in 2015 Korea. The 18th International Conference of International Society for Respiratory Protection. 2016, Yokohama.
  5. World Health Organization. Personal protective equipment in the context of filovirus disease outbreak response: Rapid advice guideline. 2014; Accessed 25 March 2017.
  6. Centers for Disease Control and Protection. Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE. 2015; Accessed 25 March 2017.
  7. Centers For Disease Control and Protection. Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE. 2015; Accessed 30 September 2016.
  8. Murphy C. The 2003 SARS outbreak: global challenges and innovative infection control measures. Online J Issues Nurs. 2006; 11(1): 6.
  9. Weber DJ, Rutala WA, Fischer WA, Kanamori H, Sickbert-Bennett EE. Emerging infectious diseases: Focus on infection control issues for novel coronaviruses (Severe Acute Respiratory Syndrome-CoV and Middle East Respiratory Syndrome-CoV), hemorrhagic fever viruses (Lassa and Ebola), and highly pathogenic avian influenza viruses, A(H5N1) and A(H7N9). American Journal of Infection Control. 2016; 44(5, Supplement): e91-e100.
  10. MacIntyre CR, Chughtai AA, Seale H, Richards GA, Davidson PM. Uncertainty, risk analysis and change for Ebola personal protective equipment guidelines. International Journal of Nursing Studies. 2015; 52(5): 899-903.
  11. Commonwealth of Australia. Infection prevention and control principles and recommendations for Ebola virus disease Including information about personal protective equipment for clinical care of patients with suspected or confirmed Ebola virus disease in the Australian healthcare setting. 2015; Accessed 25 March 2017.
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