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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Frameworks for
PROTECTING
WORKERS AND
THE PUBLIC

from Inhalation Hazards

Jonathan Samet, Autumn Downey, and Olivia C. Yost, Editors

Committee on Respiratory Protection for the Public and Workers
Without Respiratory Protection Programs at Their Workplaces

Board on Health Sciences Policy

Health and Medicine Division

A Consensus Study Report of

images

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by contracts between the National Academy of Sciences and the Centers for Disease Control and Prevention (Contract #200-2011-38807/75D30120F00086) and the Environmental Protection Agency (Contract # 68HERC19D0011/68HERC21F0115). The study received additional support from the CDC Foundation and the Department of State. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-27137-0
International Standard Book Number-10: 0-309-27137-1
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for protecting workers and the public from inhalation hazards. Washington, DC: The National Academies Press. https://doi.org/10.17226/26372.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

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Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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COMMITTEE ON RESPIRATORY PROTECTION FOR THE PUBLIC AND WORKERS WITHOUT RESPIRATORY PROTECTION PROGRAMS AT THEIR WORKPLACES

JONATHAN SAMET (Chair), Dean and Professor, Colorado School of Public Health

GLORIA ADDO-AYENSU, Director, Fairfax County Department of Health

WÄNDI BRUINE DE BRUIN, Provost Professor of Public Policy, Psychology, and Behavioral Science, University of Southern California

SARAH COEFIELD, Air Quality Specialist, Missoula City-County Health Department

HOWARD COHEN, Consultant, Professor Emeritus, University of New Haven

JOSEPH DOMITROVICH, Physiologist, National Technology and Development Program, United States Forest Service

KAREN EMMONS, Professor, Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health

SHAWN GIBBS, Dean and Professor, Texas A&M University School of Public Health

AYSE P. GURSES, Professor and Director, Armstrong Institute, Center for Health Care Human Factors, Johns Hopkins University

ROBERT HARRISON, Clinical Professor of Medicine, Division of Occupational & Environmental Medicine, University of California, San Francisco

STEPHANIE HOLM, Co-Director, Western States Pediatric Environmental Health Specialty Unit, University of California, San Francisco; and Public Health Medical Officer, Children’s Environmental Health Center, Office of Environmental Health Hazard Assessment, California EPA

SUNDARESAN JAYARAMAN, Professor, School of Materials Science and Engineering, Georgia Institute of Technology

JAMES JOHNSON, Consultant, JSJ and Associates

BRUCE LIPPY, President, The Lippy Group, LLC

DAVID MICHAELS, Professor, Environmental and Occupational Health, Milken Institute School of Public Health, The George Washington University

MARY RICE, Assistant Professor of Medicine, Beth Israel Deaconess Medical Center

KEVIN RILEY, Director of Research and Evaluation, Labor Occupational Safety and Health Program, University of California, Los Angeles

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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DANIEL SHIPP, President (retired), International Safety Equipment Association

ROSEMARY SOKAS, Professor, Department of Human Science, Georgetown University School of Nursing and Health Studies; Professor, Department of Family Medicine, Georgetown University School of Medicine

JOHN VOLCKENS, Professor of Mechanical Engineering, Director, Center for Energy Development and Health, Colorado State University

Study Staff

AUTUMN DOWNEY, Study Director

OLIVIA C. YOST, Program Officer

AURELIA ATTAL-JUNCQUA, Associate Program Officer

CLAIRE GIAMMARIA, Associate Program Officer (until June 2021)

MICHAEL BERRIOS, Research Associate

LYDIA TEFERRA, Research Assistant

SCOTT WOLLEK, Senior Program Officer

ANDREW M. POPE, Senior Director, Board on Health Sciences Policy

Consultants

TODD AAGAARD, Charles Widger School of Law, Villanova University

JOHN BECKMAN, California Department of Public Health

RONA BRIERE, Briere Associates, Inc.

ERIN HAMMERS FORSTAG, Independent Science Writer

ARDEN ROWELL, University of Illinois College of Law

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ELI Y. ADASHI, Brown University, and DAVID L. EATON, University of Washington. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Preface

In November 2020, as the Committee on Respiratory Protection for the Public and Workers Without Respiratory Protection Programs at Their Workplaces held its first meeting, the COVID-19 pandemic was beginning a deadly surge, and the nation had just seen the end of one of its most severe wildfire seasons. A gap in providing respiratory protection for workers exposed to SARS-CoV-2 (the virus that causes COVID-19) was evident, and the number of workers needing an effective respiratory protective device was mounting as the exposure risks for essential workers became apparent. The public also sought effective respiratory protection and in some locales was mandated to do so, although there was uncertainty about what devices should be used, and misinformation concerning respiratory protection for the public circulated widely.

In addressing its charge, the committee understood the urgent context of its work and the need for change in the national approach to respiratory protection, both for workers and for the population at large. The committee’s approach to this study began with a broad assessment of what is known about respiratory protection for its two target populations—workers not covered by a workplace respiratory protection program and the public—and what systems are in place to provide such protection when needed. Summarizing a substantial body of material, the committee found that too many workers are left unprotected because of such failures as inadequate enforcement of existing Occupational Safety and Health Administration (OSHA) regulations, lack of relevant standards, and lack of OSHA coverage. The committee also found that the public has received little attention with respect to respiratory protection, with the exception of the major

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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pollutants regulated by the Environmental Protection Agency, particularly as regards airborne particulate matter, as well as wildfire smoke. The COVID-19 pandemic has brought attention to the critical role of aerosols (small infectious particles) in spreading the disease, but systems are generally lacking for guiding the population on what devices to use for protection against these airborne hazards.

In this report, the committee provides its approach to creating the frameworks needed to protect workers not covered by a respiratory protection program and the general population. The committee recognized that only a systems approach would remedy the failings and gaps it had identified. It also found that the needed frameworks could not be implemented without action at the highest levels of government, and that authorities need to be designated through agency, congressional, and White House actions if the nation is to provide respiratory protection equitably for the entire U.S. population.

The committee’s proposed frameworks and its associated recommendations constitute a template for action, detailing the steps that need to be taken. There are still choices to be made among the options for moving forward that are laid out in this report, and the committee details which of these options it believes are best supported whenever its findings provided a clear direction. Regardless, we are unified in urging that the proposed frameworks should be implemented without delay.

In addressing its complex charge, the committee gathered input from diverse sectors, including federal, state, local, and tribal public health; occupational safety and health; labor unions and other worker organizations; private-sector manufacturers; and federal regulatory agencies. We wish to express our gratitude to the many individuals who gave presentations and participated in discussions during our public meetings, as well as the reviewers whose constructive feedback on the draft of this report made for a much stronger final product.

The committee is particularly grateful to Arden Rowell, professor at the University of Illinois College of Law and consultant to the committee. Professor Rowell authored a remarkably comprehensive paper on the regulatory landscape for respiratory protection that guided us through the maze of regulations and laws relevant to our task. She also provided always thoughtful and timely reviews of the draft report. The committee would also like to recognize Todd Aagaard, professor at the Villanova University Charles Widger School of Law and consultant to the committee, for his review of and commentary on the regulatory landscape paper and input to the committee. We appreciate as well the assistance provided by John Beckman, BS, California Department of Public Health, with the analysis of OSHA citation data.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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The committee is deeply grateful to the staff of the National Academies of Sciences, Engineering, and Medicine, led by Autumn Downey, senior program officer. The members of the staff team included Olivia C. Yost, Aurelia Attal-Juncqua, Claire Giammaria, Michael Berrios, Lydia Teferra, Scott Wollek, and Andrew Pope. We single out Autumn for bringing a deep understanding of our task and contributing invaluable insights as she kept the committee focused and on time, and she was always available at “crunch time” as we completed and revised the report. The team was ably supported by the skillful writing efforts of Erin Hammers Forstag and editing work of Rona Briere and Allison Boman.

Finally, as chair, I thank the committee for its engagement with completing our task. Of necessity, we were a diverse group with the needed wide breadth of expertise and experience. We learned from each other and made our way through challenging discussions as we resolved tough issues. Thank you for making my job as chair easy and fun.

We will all be watching and waiting for the next steps called for in our report. Taking them will benefit public health.

Jonathan Samet, Chair
Committee on Respiratory Protection for the Public and Workers
Without Respiratory Protection Programs at Their Workplaces

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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4-1 Questions the Public May Have About Respiratory Protective Devices

4-2 Counterfeit Respirators on the Market

4-3 Lessons Learned from a Respiratory Protection Distribution Program in Israel

4-4 Essential Questions for Effective Education and Communication

4-5 Importance of Risk Communication in Addressing the Public Use of Respiratory Protection: Lessons from Taiwan

4-6 The Importance of a Cohesive Strategy to Address Sociobehavioral and Logistical Barriers to Use of Respiratory Protection: Lessons from South Korea

4-7 Selected Examples of Federal Guidance on Public Use of Respiratory Protective Devices

5-1 Characteristics Essential to Success of the Coordinating Entity

7-1 Necessary Stakeholder Capabilities and Oversight Authority Options for Function F0

7-2 Necessary Stakeholder Capabilities and Oversight Authority Options for Function F1

7-3 Necessary Stakeholder Capabilities and Oversight Authority Options for Function F2

7-4 Necessary Stakeholder Capabilities and Oversight Authority Options for Function F3

7-5 Necessary Stakeholder Capabilities and Oversight Authority Options for Function F4

7-6 Necessary Stakeholder Capabilities and Oversight Authority Options for Function F5

7-7 Consolidated Roles for the Coordinating Entity Across Functions

FIGURES

S-1 Core functions in the committee’s framework for oversight and guidance for respiratory protection

1-1 Examples of respirators, medical masks, face coverings, and barrier face coverings

1-2 Comparison of particulate matter size fractions

1-3 Hierarchy of controls

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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1-4 A general risk-reduction paradigm for protection against inhaled agents

1-5 A system model depicting factors that influence the effectiveness of respiratory protective devices

2-1 PPE conformity assessment framework

2-2 NIOSH process for respirator approval

3-1 Potential failure points for workplace use of respiratory protection

3-2 OSHA requirements related to voluntary use of respirators

3-3 Summary of PM and carbon monoxide concentrations measured on wildland firefighters

3-4 Relative risk of lung cancer and cardiovascular disease associated with length of seasonal wildland firefighting work

3-5 Respiratory protection practices for health care workers exposed to airborne hazards

3-6 Evolution of health and safety risks across the phases of a disaster

5-1 Processes needed to deliver respiratory protection from design and manufacturing to use

5-2 Examples of evidence-based performance requirements for respiratory protective devices in the context of an influenza pandemic

5-3 Core functions in the framework for oversight and guidance for respiratory protection

5-4 Function F0: subfunctions related to ongoing development and approval of respiratory protective devices

5-5 Function F1: subfunctions related to assessing a hazard and determining the need for respiratory protection

5-6 Function F2: subfunctions related to determining the necessary respiratory protective devices

5-7 Function F3: subfunctions related to ensuring availability and access pathways for the respiratory protective devices

5-8 Function F4: subfunctions related to engaging, informing, and ensuring access for the target community via multiple stakeholders and pathways

7-1 A hub-and-spoke model for coordination related to respiratory protection for the public

7-2 Drivers and outcomes of a framework for the public

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Acronyms and Abbreviations

AIV avian influenza virus
ANSI American National Standards Institute
APF assigned protection factor
APR air-purifying respirator
AQI air quality index
ASPR Office of the Assistant Secretary for Preparedness and Response
ASSP American Society of Safety Professionals
ASTHO American Society of State and Territorial Health Officials
ATD aerosol transmissible disease
ATSDR Agency for Toxic Substances and Disease Registry
BLS Bureau of Labor Statistics
CBRN chemical, biological, radiological, and nuclear
CDC Centers for Disease Control and Prevention
CEL Certified Equipment List
CEN European Committee for Standardization
CLAS culturally and linguistically appropriate services
COPD chronic obstructive pulmonary disease
CPSC Consumer Product Safety Commission
CPWR Center for Construction Research and Training
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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DALY disability-adjusted life year
DoD Department of Defense
DPA Defense Production Act
EID emerging infectious disease
EPA Environmental Protection Agency
ETS emergency temporary standard
FDA Food and Drug Administration
FE filtration efficiency
FEMA Federal Emergency Management Agency
FFR filtering facepiece respirator
FHSA Federal Hazardous Substances Act
FIFRA Federal Insecticide, Fungicide, and Rodenticide Act
GAO Government Accountability Office
HAZWOPER Hazardous Waste Operations and Emergency Response
HCW health care worker
HHS Department of Health and Human Services
ICRP International Commission on Radiological Protection
IDLH immediately dangerous to life and health
IEC International Electrotechnical Commission
ISA Integrated Science Assessment
ISEA International Safety Equipment Association
ISO International Organization for Standardization
JIT just-in-time
MCM medical countermeasure
MSHA Mine Safety and Health Administration
NAAQS National Ambient Air Quality Standards
NACCHO National Association of County and City Health Officials
NCEH National Center for Environmental Health
NEP National Emphasis Program
NFPA National Fire Protection Association
NIEHS National Institute of Environmental Health Sciences
NIOSH National Institute for Occupational Safety and Health
NIST National Institute of Standards and Technology
NPPTL National Personal Protective Technology Laboratory
NRC Nuclear Regulatory Commission
Page xxiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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NTTAA National Technology Transfer and Advancement Act
NWCG National Wildfire Coordinating Group
OSHA Occupational Safety and Health Administration
PAHPA Pandemic and All-Hazards Preparedness Act
PAPR powered air-purifying respirator
PCA principal component analysis
PEL permissible exposure limit
PERC Pesticide Educational Resources Collaborative
PHEMCE Public Health Emergency Medical Countermeasures Enterprise
PM particulate matter
PNOR particulates not otherwise regulated
PPE personal protective equipment
RPED respiratory protective escape device
RPD respiratory protective device
RPP respiratory protection program
SCBA self-contained breathing apparatus
SES socioeconomic status
SLTT state, local, tribal, and territorial
SNS Strategic National Stockpile
SOII Survey of Occupational Injuries and Illness
SV spontaneous volunteer
SWPF simulated workplace protection factor
TCID Texas Center for Infectious Disease
UFCW United Food and Commercial Workers Union
USDA United States Department of Agriculture
VA Department of Veterans Affairs
VOAD National Voluntary Organizations Active in Disasters
VOC volatile organic compound
WHO World Health Organization
WPS worker protection standard
WSPEHSU Western States Pediatric Environmental Health Specialty Unit
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Glossary

A variety of terms are used to describe personal devices worn to reduce adverse health effects from inhalation hazards. Definitions and descriptions of these devices vary, and no one consistent definition is used by federal agencies and other authoritative stakeholders for such terms as respirator, face covering, and mask (see Annex 1-1 in Chapter 1 for a table of terminology used by federal agencies and others). This glossary is intended to provide general committee-generated definitions of key concepts and devices discussed in this report. Where definitions were taken from other sources, the source is noted in a footnote.

Assigned protection factor: The workplace level of respiratory protection that a respirator or class of respirators is expected to provide to employees when the employer implements a continuing, effective respiratory protection program as specified by section 29 CFR 1910.134.1

Barrier face covering: A product that conforms to ASTM F3502-21 and that is worn on the face, specifically covering at least the wearer’s nose and mouth, with the primary purpose of providing source control and a degree of particulate filtration to reduce the amount of inhaled particulate matter.2

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1 OSHA (Occupational Safety and Health Administration). 2009. Assigned protection factors for the revised respiratory protection standard. OSHA 3352-02.

2 ASTM International. 2021. ASTM F3502–21 standard specification for barrier face coverings. https://www.astm.org/Standards/F3502.htm (accessed October 5, 2021).

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Conformity assessment (CA): Demonstration that specified requirements relating to a product, process, system, person, or body are fulfilled.3

Dust mask: Also known as nuisance masks, these are non-approved devices that are worn to reduce exposure to airborne contaminants when working in dusty environments. They do not protect against toxic dusts and are not approved as respirators. Unlike medical or surgical masks, there are no standards that govern their construction or the quality of their filtration.

Face covering: A type of device that covers the nose and mouth but does not conform to any specific standard and does not provide a known degree of protection. The device may be constructed of single or multiple layers of cloth, filtering material, or a combination of base material and filter elements and may appear visually similar to barrier face coverings or surgical/medical masks.

Hazard: Anything (substance, situation, or behavior) that has the ability to cause an adverse outcome, including fatal or nonfatal injury or illness.

Inhalation hazard: Any type of gas, vapor, or particle, including airborne transmissible microorganisms (bacteria, viruses, molds), that can be breathed in and potentially cause harm.

Mask: With the notable exception of dust masks (defined above), these are devices worn by individuals that cover the nose and mouth and are designed and intended to reduce the spread of infectious agents found in large droplets such as from saliva, sneezes, and coughs.

Respirator: A device that is designed to protect the wearer from the adverse effects of inhalation hazards by removing contaminants from the surrounding air or by supplying clean air from a safe source.

Respiratory protection: Broadly describes any approach designed to reduce exposure to hazards that can be inhaled (i.e., inhalation hazards). Devices worn to provide respiratory protection can either protect the wearer or, for some hazards (e.g., airborne transmissible microorganisms), protect others from an infectious source. Some devices may provide some level of protection to both the wearer and to others.

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3 ISO (International Organization for Standardization). 2020. ISO/IEC 17000:2020 conformity assessment—vocabulary and general principles. https://www.iso.org/standard/73029.html (accessed October 5, 2021).

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2022. Frameworks for Protecting Workers and the Public from Inhalation Hazards. Washington, DC: The National Academies Press. doi: 10.17226/26372.
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Respiratory protective device: Any personal device that provides protection against inhalation hazards when used effectively, acknowledging that each device may offer either personal protection or source control or both at varying levels. The blend of personal protection and source control is context specific (i.e., depends on both the device and the hazard in question).

Risk: The likelihood that a hazardous exposure will result in an adverse outcome.

Source control: An approach to eliminating or reducing the introduction of harmful substances into the environment. In the context of an infectious aerosol, devices worn by individuals that cover the nose and mouth may be used for source control to reduce the emission of harmful infectious agents from the wearer, thereby decreasing the potential danger to others in the immediate environment.

Surgical/medical mask: Unfitted devices generally regulated by the Food and Drug Administration for use in health care settings. They provide a physical barrier to fluids and particulate materials, and may provide some protection against contamination of the surrounding environment by their wearer by reducing the amount of infectious agents released during exhalation, coughing, or sneezing.

Susceptibility: An individual’s risk for harm when exposed to a particular hazard.

Vulnerability: An individual’s likelihood of being exposed to a hazard because of who they are; where they work, study, or play; or where they live.

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Individuals in the United States and Americans abroad are exposed to inhalation hazards from a variety of sources, and these hazards can have both short- and long-term adverse effects on health. For example, exposure to wildfire smoke, which contains particulate matter and toxic chemicals, can lead to respiratory problems, increased risk for heart attacks, and other adverse health outcomes. Individuals also may be exposed to airborne infectious agents through aerosol or droplet transmission, and as demonstrated by the COVID-19 pandemic, the individual and public health consequences of these exposures can be severe. Storms, floods, and hurricanes can increase exposure to moisture-driven hazards, such as mold, and to accidental releases from production facilities or transport vehicles that may result in chemical exposures.

The current regulatory system is focused primarily on ensuring access to respiratory protection in occupational settings characterized by well-defined hazards and employer-employee relationships. With this narrow regulatory focus, the respiratory protection needs of the public and many workers are not being met. As climate change increases the incidence and severity of wildfires, hurricanes, floods, infectious disease outbreaks, and other phenomena that impact air quality and human health, it is imperative that the United States ensure that the respiratory protection needs of the public and all workers are met. Recognizing the urgent need to address the gaps in the nation's ability to meet the respiratory protection needs of the public and workers without workplace respiratory protection programs, this report makes recommendations for a framework of responsibilities and authorities that would provide a unified and authoritative source of information and effective oversight for the development, approval, and use of respiratory protection.

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