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Frameworks for Protecting Workers and the Public from Inhalation Hazards (2022)

Chapter: Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use

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Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Appendix B

Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use

While the science of respiratory protection is supported by an established body of literature on device-related factors, such as fit and filtration, comparatively less is known about other factors that impact the effectiveness of devices during real-world use. A narrative review synthesis was developed from the series of comprehensive literature reviews on the high-priority respiratory protection use scenarios described in Appendix A—four reviews related to the public and five related to workers. This synthesis presents findings from included articles on factors that influence the effective use of respiratory protective devices by the public and workers for exposures to biological agents, air pollution, and wildfire smoke. The findings from this narrative review synthesis were used to inform gaps and challenges discussed in Chapters 3 and 4, and to identify research and implementation needs addressed in Chapters 6 and 7. Of note, a narrative review synthesis is not a formal systematic review with defined inclusion/exclusion criteria and a formal risk-of-bias assessment, nor is it a meta-analysis. The committee used its judgment in selecting articles to include in this synthesis, excluding those that had limited relevance or applicability to the U.S. context, as well as those for which there were concerns regarding major methodological limitations (e.g., failure to use reproducible test methods and controls).

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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NARRATIVE SYNTHESIS OVERVIEW

Organization of the Findings by Factor of Interest

As discussed in Appendix A, the literature searches and data extraction were carried out using the committee-developed categories of device, user, and system factors to capture information about the breadth of factors that influence the effectiveness of respiratory protective devices for their intended use (see Figure 1-4 in Chapter 1). However, the extensive overlap of literature and findings across these three categories necessitated a more topical structure for the written layout of the synthesis. This narrative review synthesis presents the findings from the committee’s review of the literature for the following factors:

  • Filtration Efficiency
  • Breathing Resistance
  • Fit
  • Antimicrobial Properties, Cleaning, and Disinfection
  • Comfort and Usability
  • Knowledge, Attitudes, Beliefs, and Perceptions
  • Sociodemographic Characteristics
  • Communication, Education, and Training
  • Accessibility
  • Cultural Norms
  • Oversight and Enforcement

Variation in the structure of the factor-specific sections below reflects the key findings that the committee felt most warranted emphasis. For some factors, notable differences in findings across different hazards merited highlighting, while for others, organizing the material by population was most logical given differences in findings for the public and workers.

Respiratory Protection Terminology

In this narrative synthesis, device terminology generally reflects the term used in the cited article. In cases in which the term mask or face mask is used in the source article with no other identifying information, this will be indicated in the text for the reader’s awareness. Where cited studies refer to both masks and face coverings, this is indicated with “masks/face coverings.” Some articles discussed in this appendix use the terms mask mandate and mask-wearing behavior. The committee also uses these terms, as they are common in the public vernacular, but acknowledges that they are not specific to medical/surgical masks and may be used also in reference to face coverings and even respirators.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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FILTRATION EFFICIENCY

Filtration efficiency (FE) is a measure of how well the material of a respiratory protective device prevents particles from penetrating through the filter medium. The performance of a respiratory protective device is closely tied to FE because the penetration of particles through the filter contributes to the inhaled dose—a key determinant of risk. FE is affected by multiple factors, including, for example, filter type, flow rate (i.e., velocity of the air through the filter), and particle aerodynamic properties (including size, shape, and density) (Brown, 1989; He et al., 2013; Huang et al., 2013; Rengasamy et al., 2010). These factors and how they relate to performance are well understood for respirator use in occupational settings, but less so for nonoccupational hazards and other types of respiratory protective devices (e.g., masks and face coverings).

Particle size1 is an especially important parameter for FE. Aerosol filtration mechanisms include impaction, diffusion, gravitational settling, interception, and electrostatic attraction (Hinds, 1999). These mechanisms act nonlinearly across the aerosol-size range of interest (from ~0.01 mm to 100 mm). As a result, filters often exhibit a U-shaped relationship between FE and particle size, with maximal FE occurring at very small (i.e., 0.01–0.05 mm) and very large (i.e., 10–100 mm) sizes, and minimal FE occurring in the range of 0.05 mm to 0.3 mm, depending on the filter properties.

The National Institute for Occupational Safety and Health (NIOSH) uses standard test methods for evaluating respirator FE (see, e.g., NIOSH, 2019a). These tests are designed to evaluate FE conservatively (i.e., to approximate a worst-case condition) by specifying a highly penetrating aerosol size distribution in the submicron range (i.e., a mass median diameter between 0.2 mm and 0.3 mm) and a high flow rate (85 L/min) through the device, which minimizes particle residence time, and relevant filtration mechanisms (i.e., diffusion and electrostatic attraction) at the indicated size range. ASTM has also published standards for determining bacterial FE (ASTM, 2019) and particle FE (ASTM, 2017) for medical masks, and submicron FE for barrier face coverings (ASTM, 2021c)—the latter of which is derived from published NIOSH protocols.

The NIOSH test methods are rigorous, standardized, and reproducible, but they have limitations in their generalizability to members of the public (e.g., to children or nonoccupational settings) and in their extensibility to specific airborne hazards. For example, a mask that exhibits poor FE under standard NIOSH test conditions for N95 series filters (NIOSH, 2019a)

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1 For aerosol filtration, particle size is characterized by the aerodynamic diameter for inertial capture mechanisms (i.e., impaction and settling), by the thermodynamic diameter for diffusive and interception mechanisms, and by the electrical mobility diameter for electrostatic mechanisms. For spherical particles of standard density, these diameters are all equivalent.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

may exhibit acceptable FE for larger particle sizes relevant to other hazards, such as for airborne fungal spores (Górny et al., 1999). And whereas NIOSH test protocols operate at 85 L/min of flow through the device (to simulate human respiration under moderate exercise), most members of the public breathe at resting inhalation rates of approximately 10–30 L/min. Although a high flow rate (85 L/min) will minimize collection of submicron aerosol, it will enhance collection of supermicron aerosol (i.e., particle sizes >1 mm) within a given filter medium (Leith et al., 2021). To date, there are no standard methods for evaluating the outward leakage of respiratory protective devices (i.e., to act as a form of source control for respiratory aerosol emissions from the wearer). For these reasons, the committee considered a wide range of published literature on mask performance, beyond those that only used NIOSH or ASTM test methods.

Filtration Efficiency for Communicable Biological Agents

In response to the COVID-19 pandemic, a growing body of research has focused on the ability of different respiratory protective devices to filter biological agents for nonoccupational users as source control and, in some instances, respiratory protection for the wearer. This research encompasses traditional filter materials, such as N95 filters; commercial products, such as surgical masks; and household materials that could be used to create face coverings, such as vacuum bags or knit cotton. This body of literature complements a long history of published research on the FE of masks, respirators, and face coverings. Most of these studies are laboratory based and designed to simulate respiratory emissions (and/or inhalation) during breathing, talking, coughing, or sneezing.

Both classical filtration theory and published research suggest that the filtration mechanisms for biologically derived aerosols are largely identical to those for industrial aerosols (Gardner et al., 2013; Hinds, 1999; Rengasamy et al., 2004; Willeke et al., 1996) and that FE is primarily a function of particle size, regardless of the particle’s origin or composition (only highly nonuniform particles, such as rod-shaped bacteria, have different collection efficiency from their spherical aerodynamic counterparts, and those elongated shapes appear to be collected more efficiently). Thus, from a filtration standpoint, a biologically derived particle will behave similarly to an inert particle, such as sodium chloride (NaCl)2 (Brosseau et al., 1997; Eninger et al., 2008; Harnish et al., 2013; Rengasamy et al., 2004). Thus, particle surrogates such as NaCl and monodisperse latex spheres are commonly used in studies evaluating FE in the context of potential respiratory protective

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2 NIOSH test methods specify the use of NaCl and oil droplet aerosols; ASTM methods specify the use of NaCl aerosol and monodisperse latex spheres.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

devices for communicable biological agents. One of the challenges, however, for assessing FE of respiratory aerosols (and their associated exposure risks) is that the size range of particles emitted from breathing, talking, singing, coughing, or sneezing spans the full aerosol size distribution and beyond (from ~0.01 mm to >1,000 mm in diameter) (Duguid, 1946; Good et al., 2021; Holmgren et al., 2010; Johnson et al., 2011).

Findings from this review indicate that FE varies substantially across different types of respiratory protective devices and, as expected, as a function of particle size. Highlighted below are several key findings:

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3 Electret fibers are engineered to carry a stable electric charge at their surface. Such fibers, often made from melt-blown polymers, are the principal filtration material in most N95 filtering facepiece respirators (FFRs). Electrostatic charging is known to improve filtration efficiency of fibrous filters without adding mass or density to the material and, therefore, without adding resistance to airflow (i.e., preserving breathability) (Brown et al., 1988; Zhao et al., 2020).

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

Filtration Efficiency for Ambient Air Pollution

Comparatively few studies have assessed the importance of the FE of respiratory protective devices specifically for ambient air pollution exposures. However, as the FE of respiratory protective devices depends primarily on particle size (as opposed to particle source/type), many of the findings from the communicable disease literature are relevant and will not be repeated here. Instead, we highlight findings from studies that examine FE in relation to specific forms of ambient air pollution. Like respiratory particle emissions, sources of particulate matter air pollution produce particles that span a wide range of sizes (from <0.01 mm to 100 mm in diameter) (Seinfeld and Pandis, 2016).

  • For many types of ambient air pollution, cloth and synthetic fiber face coverings have low FE (typically less than 50 percent), surgical masks have intermediate FE (typically between 50 percent and 90 percent), and N95 FFRs offer relatively high FE (95–99 percent).

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4 Woven and knitted fabrics are two-dimensional structures made from yarns, which, in turn, are produced from fibers through the process of spinning. Woven fabrics are made by interlacing warp and filling yarns together, while knitted fabrics are made by interlooping the individual yarns. Nonwoven materials are created by using mechanical, thermal, or chemical bonding processes to entangle fibers into a three-dimensional structure (Varallyay et al., 2020).

5 Natural fibers refer to cotton, wool, silk, bamboo, and similar materials that occur in nature. Manmade fibers encompass synthetic fibers (e.g., polyester, nylon) and regenerated fibers (e.g., rayon).

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×
  • This finding was consistent across studies of urban fine particulate air pollution (particulate matter [PM]2.5) (Kodros et al., 2021), diesel exhaust (Shakya et al., 2017), urban dust from roadways and windblown sources (PM10) (Kodros et al., 2021; Patel et al., 2016), volcanic ash (Mueller et al., 2018), and wildfire smoke (Kodros et al., 2021).
  • For combustion-derived air pollution, respirators with particulate filters are effective at removing particles but not harmful vapors (e.g., formaldehyde and acrolein) (De Vos et al., 2006, 2009).
  • Bandanas are widely used as face coverings intended to protect against wildfire smoke, but like other forms of cloth masks, they offer little to no protection because of their poor FE for submicron particle sizes (Foote, 1994).

BREATHING RESISTANCE

The breathability of a respiratory protective device is characterized by a breathing resistance measurement (i.e., the pressure drop of airflow through the device at a specific rate, typically denoted by ΔP). Breathing resistance is a key performance metric because devices with poor breathability may be uncomfortable to wear (Manninen et al., 1988; Popendorf et al., 1995), more prone to leak (Campbell, 1984; Nelson and Colton, 2000; Vaughan et al., 1994), and may require more physical effort (by the wearer) to achieve a desired ventilatory rate (Caretti et al., 2001, 2006; Coyne et al., 2006; Harber et al., 1982; Johnson, 2016). NIOSH has established breathing resistance requirements for air-purifying respirators used by workers (NIOSH, 2019b), and the Food and Drug Administration (FDA) has requirements for breathing resistance of medical masks that follow ASTM standards (ASTM, 2021a). ASTM’s recently published standard for barrier face coverings also includes performance requirements for airflow resistance (ASTM, 2021c). Most of the important breathability characteristics of respiratory protective devices can be described from a review of basic fluid dynamic theory.

Darcy’s Law states that the pressure gradient required to move a fluid (such as air) through a porous medium (such as a mask or face covering) is directly related to the velocity of air within the medium (Bear, 1988; Jonas et al., 1972), when the flow within the medium is laminar (which is generally satisfied for a range of human breathing rates through most respiratory protective devices). This theory suggests that mask breathability (in terms of pressure drop, ΔP) is specific to a given flow rate (Q) and increases in direct proportion to flow rate. NIOSH specifies a test flow rate of 85 L/min for breathability; however, breathability measurements made at other flow rates are easily compared by reporting flow resistance (i.e., pressure drop

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

per unit flow, ΔP/Q), assuming the entire device is tested.6 For a given material type, an increase in thickness (e.g., by adding an additional layer) will bring about a proportional decrease in breathability (i.e., by increasing ΔP). Increasing the cross-sectional area (or decreasing the material permeability) of a device will bring about a proportional increase in breathability (i.e., a reduction in ΔP)—an important consideration for device design. In addition to these relationships, the committee’s review of the extant literature found several additional highlights worth noting:

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6 NIOSH method TEB-APR-STP-0007 specifies the entire mask area be tested for breathability at 85 L/min of flow; ASTM method F2100-19 (by virtue of standard EN 14683:2019, Annex C) specifies a measurement of pressure drop per unit area of material (4.9 cm2) at 8 L/min of flow. Conversion between these measures requires one to know the effective surface area (A) of the device.

7 NIOSH sets maximum breathing resistance levels for respirators (35 mm water column height pressure for inhalation and 25 mm water column height pressure for exhalation) (42 C.F.R. § 84).

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

FIT

Any respiratory protective device designed with a facepiece (i.e., designed to form a physical seal around the user’s nose and mouth) must achieve a proper fit to function properly. A proper fit means that the respiratory protective device seals to the face during use, which prevents inward particle leakage or, in the case of respiratory protective devices being used as source control, outward leakage of particles from around the edges of the device. Even when the FE of a tightly fitting respirator (e.g., FFR) is appropriate for the hazard of concern, if the device is not well-sealed to the face, leakage around its edges will become a route of entry for the hazardous particles (Cho et al., 2010; Grinshpun et al., 2009; He et al., 2013; Rengasamy and Eimer, 2011). Particle leakage through and around a respiratory protective device is sometimes expressed as total inward leakage, a measurement combining particles that leak around the face seal, through the filter media, and by any other means (He et al., 2014; Rengasamy and Eimer, 2012; Rengasamy et al., 2014).

The fit characteristics of some respirators may be tested during the NIOSH respirator approval process. A fit capability test is not currently required as part of the approval process for FFRs (Coffey and Miller, 2019), but ASTM recently published a standard for evaluating fit for negative-pressure half-facepiece particulate respirators (ASTM, 2021b) that enables respirator manufacturers to develop better-fitting respirators. The Occupational Safety and Health Administration (OSHA) also has published methods for respirator fit testing,8 which is required annually for any employee enrolled in a workplace respiratory protection program and ensures that the respirator selected is capable of fitting the specific worker. At the individual level, a fit factor9 is often used to define respirator fit following a quantitative fit test. At the population level, respirators are selected to provide an assigned protection factor, which is a conservative estimate of the protection that a properly functioning respirator would be expected to provide to a population of properly fitted and trained users. For example, an assigned protection factor of 100 implies that a user would inhale no more than 1/100th (or 1 percent) of the concentration of a given hazard during exposure. Both fit factors and assigned protection factors are estimates of actual protection afforded by a respirator. In real-world environments, a

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8 29 C.F.R. § 1910.134. Final rule. Fed. Reg. 63:1152–1300 Respiratory Protection. See also Appendix A to § 1910.134 Fit Testing Procedures (Mandatory).

9 A respirator fit factor is a quantitative estimate of the ratio of the concentration of a substance in ambient air to its concentration inside the respirator when worn (29 C.F.R. § 1910.134). Fit factors are used to estimate the level of personal protection provided by a respirator to an individual.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

workplace protection factor study may be conducted (or simulated in a laboratory and referred to as a simulated workplace protection factor study), which estimates performance of the respirator during regular workplace tasks. Workplace protection factors often may be lower than fit factors due to unique challenges of specific work tasks (OSHA, 2009).

A large body of published literature exists describing the fit of respirators in the workplace. This research demonstrates the following salient points:

Literature on the fit of nonrespirator devices (e.g., masks and face coverings) and nonoccupational users is less abundant but has grown rapidly since the emergence of SARS-CoV-2, from which the committee found several important findings:

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

ANTIMICROBIAL PROPERTIES AND IMPACT OF CLEANING AND DISINFECTION ON FUNCTION

Antimicrobial Properties

Microorganism survival on filter media is dependent on multiple factors, including the type of microorganism in question, the length of exposure, humidity, and the presence of biocides (Jachowitz et al., 2019). While interest in antimicrobial treatments for respiratory protective devices preceded the emergence of SARS-CoV-2 (Tseng et al., 2016), the ongoing COVID-19 pandemic has spurred new research efforts on the treatment of filtering materials with a variety of antimicrobial properties to deactivate viruses through contact (as reviewed by Balachandar et al., 2020; Pullangott et al., 2021). This nonexhaustive review of the literature shows that questions exist regarding the potential need for antimicrobial properties, given that (1) particles captured on filter media are likely to stay captured; (2) that collected particles are more likely to be found on the exterior of the device (and not necessarily in contact with the wearer) or on the interior of the device (when the wearer is the source); and (3) that particle migration through the filter media over time is likely negligible. As the antimicrobial properties or treatments have the potential to place additional risk on the wearer (via inhalation and/or ingestion), more research is needed to develop and evaluate existing and novel coatings and properties, and to assess potential risks and benefits to the wearer (Pullangott et al., 2021). FDA requires manufacturers that make antiviral claims to provide to the agency supporting evidence demonstrating the effectiveness and safety of their products.

Cleaning and Disinfection

The impact of cleaning, washing, disinfecting, and other manners of reprocessing on the fit and FE of respiratory protective devices (both those intended for single use and those intended for multiple use) over time is not well understood. While this nonexhaustive review identified several studies assessing the impact of various reprocessing methods on fit and FE, the

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10 These technologies are commonly called “mask fitters” or “braces.” They are worn over the mask and then secured with head ties or elastic ear loops.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

findings indicate that more research is needed to understand how function is impacted by the cleaning and disinfection of various types of respiratory protective devices. Several studies found that various techniques studied for the washing of different types of cloth masks either slightly improve fit and FE or do not greatly negatively affect it (Clapp et al., 2021; Sankhyan et al., 2021; Varallyay et al., 2020). Multiple studies have also found various technologies (microwave steam bags, heat, ultraviolet light, vaporous hydrogen peroxide) effective at decontaminating microorganisms from respiratory protective devices, including N95 FFRs, cloth face coverings, and surgical masks, without extensive degradation of the FE (Fisher et al., 2011; Liao et al., 2020; Wigginton et al., 2020). However, decontamination of N95 FFRs using gamma sterilization (Kumar et al., 2020) and other technologies for decontamination, such as use of ethanol, chlorine, or hydrogen peroxide gas plasma, have been shown to have a more significant negative impact on FE (Liao et al., 2020; Wigginton et al., 2020).

COMFORT AND USABILITY

Filtration efficiency, breathing resistance, and fit—which, as explained above, determine the level of protection that a respiratory protective device may be able to provide under ideal conditions of use—can be measured objectively. However, issues related to comfort and usability exist at the interface of the device and the user, and are complex in that these factors relate not only to the design and function of the device (size, weight, breathing resistance) but also to the user’s perception of how these characteristics impact them (e.g., claustrophobia, anxiety), actual physiological impacts (e.g., increased heart rate, changes in respiration), and the context in which the device is used. Respirators, specifically FFRs, have a number of issues related to comfort and usability that are well documented in occupational settings—particularly in health care—and can impact whether a device is used and used correctly. While much of the body of research on the comfort and usability of respiratory protective devices is derived from studies of respirator use in occupational settings, increasing interest in the use of devices for inhalation hazards impacting broader populations, such as exposure to particulate matter and biological agents (e.g., SARS-CoV-2), has led to research on use by more diverse populations—both the public and certain worker groups. The research identified in this review suggests that user concerns associated with comfort and usability of devices are generally similar across both public and occupational users, although certain groups (e.g., children, wildland firefighters) present unique needs that will need to be addressed in device designs.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

Comfort

Among the populations of interest for the committee’s review, issues with comfort centered on difficulty breathing, temperature, and humidity regardless of the inhalation hazard of concern, although much of the research was conducted in the context of the COVID-19 pandemic. Concerns about discomfort have been noted by researchers as potential barriers to effective use and spanned a variety of types of respiratory protective devices across a diverse population of public and occupational users (Al Naam et al., 2021; Ali et al., 2021; Cheok et al., 2021; Cramer et al., 2017; Ferng et al., 2011; Liu et al., 2020; Vereen et al., 2021). Specifically, compounding issues with heat, humidity, and breathing challenges (Allison et al., 2010; Chao, 2020; Cheok et al., 2021; Gershon et al., 2010; Liu et al., 2020; Mojtahedzadeh et al., 2021; Mpofu et al., 2002; Riden et al., 2020; Smart et al., 2020); dermatological concerns or pain (Al Naam et al., 2021; Allison et al., 2010; Cheok et al., 2021; Riden et al., 2020; Szepietowski et al., 2020); and issues with sizing (Allison et al., 2010) were among the most frequently reported causes of discomfort. These findings are generally consistent with experiences of discomfort during the use of FFRs by occupational users, with discomfort levels increasing dramatically when users perceive or experience increased levels of facial or total body heat, such as during physical exertion or in warm, humid environments (Baig et al., 2010; Foster et al., 2020; Roberge et al., 2012). Different types of respiratory protective devices, including surgical masks, N95 FFRs (Toprak et al., 2021), and KN95 respirators (Liu et al., 2020), were associated with different levels of discomfort.

Device designs that incorporate exhalation valves into air-purifying respirators can help decrease discomfort by dissipating humidity and reducing temperature within the facepiece (Roberge, 2012). However, due to concerns about exposure to respiratory secretions in the exhaled air discharged from the wearer’s exhalation valve, the Centers for Disease Control and Prevention does not recommend the use of a respirator with an exhalation valve as a source control device by the public or in certain health care settings (NPPTL, 2020). FDA does not clear surgical and medical masks with exhalation valves for the same reasons.

Physiological response to the use of respiratory protection and experience of comfort are interrelated in many respects, and the impact of this relationship can range from insignificant to incompatible with use. For example, ventilation and cardiopulmonary-exercise capacity can be reduced during the use of surgical masks but more substantially impaired during the use of FFRs; these variables are also affected by the user’s activities while wearing the device (Fikenzer et al., 2020). For some user populations, such as wildland firefighters, unique needs can directly impact whether a

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

device can be worn comfortably and safely during exposure to the inhalation hazard of concern. The most common challenge reported by wildland firefighters related to the comfort and usability of respirators was the reduction in work intensity or performance as a result of increases in the work of breathing during use (Beason et al., 1996; Sharkey, 1997). Studies comparing identical respirators equipped with different cartridges (HEPA versus HEPA + OV/AG [organic vapor/acid gas]) observed that the decline in performance while using a respirator was proportional to the breathing resistance, with a doubling in breathing resistance resulting in a doubling in the decline in work performance. Additionally, the material used to remove carbon monoxide, a major hazard of wildfire smoke exposure beyond particulate matter, adds breathing resistance and causes an even greater decline in user performance (Sharkey, 1997).

In cases where the user is not performing metabolically demanding tasks, some evidence suggests that respirator use can be associated with minor increases in such measures as heart rate and transcutaneous carbon dioxide, although these changes are tolerable in healthy individuals (Kim et al., 2013), while other studies have found no significant differences in physiological responses (Roberge et al., 2010b, 2013). Despite this reported variability in physiological responses, studies of occupational users report such physical sensations as shortness of breath (Hopkins et al., 2021; Rebmann et al., 2013), breathing discomfort (Kim et al., 2016), headache, and lightheadedness (Rebmann et al., 2013), as well as such psychological responses as anxiety, distress, and feelings of claustrophobia (Johnson, 2016; Wu et al., 2011). Some types of devices may trigger greater psychological responses relative to other types (Wu et al., 2011).

Very few studies have examined the physiological impacts of respirators on user comfort when these devices are used by the public, including among vulnerable populations (e.g., children and people with chronic obstructive pulmonary disease [COPD]) when exposed to particulate matter and communicable biological agents. Among children wearing a specially designed N95 FFR, breathing parameters (end-tidal carbon dioxide [ETCO2], fractional concentration of inspired carbon dioxide [FICO2], respiration rate, heart rate, and oxygen saturation [SpO2]) remained within normal range, and over 90 percent of children reported no issues with breathing while wearing the device, indicating good comfort and safety levels (Goh et al., 2019). However, among individuals with severe COPD and airflow limitations who wore an N95 FFR during a 6-minute walking test, certain physiological variables (e.g., forced expiratory volume [FEV] of <30 percent) were found to be associated with an increased likelihood of respirator removal due to dyspnea, breathing discomfort, decreased blood oxygen saturation, and increased partial pressure of end-tidal CO2 (PETCO2). Even among those participants who continued using the N95 FFR during

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

the walking test, their breathing frequency, blood oxygen saturation, and PETCO2 differed significantly before and after use for 10 minutes while in a resting state, indicating that N95 FFRs may not be well adapted to COPD patients (Kyung et al., 2020).

Studies conducted during the COVID-19 pandemic found that while cloth face coverings/masks were associated with discomfort, participants in the United States were not deterred from use (Shelus et al., 2020). Efforts to make devices more breathable, “cooler,” and better fitting may have an impact on comfort and overall wearability (Galea et al., 2018; Smart et al., 2020).

Usability

The usability of respiratory protective devices of all types may impact proper use and thereby the effectiveness of devices for their intended use. The literature related to the usability of respiratory protective devices for the public and the worker groups of interest to this review identified a number of factors that impact the usability of devices (generally, respirators for workers, and masks and face coverings for the public), including the following:

The majority of available research focuses on the use of respiratory protective devices, primarily face coverings and surgical and other masks, during the COVID-19 pandemic. Generally, these common usability issues may lead to a lack of user compliance (e.g., pulling a device away from the mouth to communicate, improperly placing the device on the face, or

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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storing the device in an unsafe manner) and increase the likelihood that the intended level of respiratory protection is not being attained.

Communication and Vision Impediments

The ability to communicate clearly is essential to a safe work environment, as well as to interpersonal interactions within and outside the work setting. The use of respiratory protective devices of any type by both workers and members of the public may impact the intelligibility and transmissibility of speech, although the degree to which speech intelligibility is reduced is debated, and may depend on device type, ambient noise, and the context of use (Muzzi et al., 2021; Palmiero et al., 2016; Radonovich et al., 2010). Even when speech intelligibility is not impacted, users may feel as though they are not communicating clearly, and the reading of facial expressions may be affected (Allison et al., 2010). Such impediments to communication may have far-reaching implications in schools (Allison et al., 2010; Caniato et al., 2021) and other work settings where communication is a critical part of workers’ job functions. For example, a study of German home care professionals reported that the use of devices while providing personal and nursing care in patient homes during the COVID-19 pandemic significantly impeded their ability to communicate and interact and, by extension, to build close relationships with their patients (Mojtahedzadeh et al., 2021).

Additionally, the weight, bulk, and other physical characteristics of respirators can impede users’ activities and performance. Obscured vision may occur when a respirator interferes with vision (i.e., downward gaze or visual acuity) or through fogging of the lens of a full facepiece respirator (Johnson, 2016). Fogging is often the result of an ill-fitting or improperly placed respirator and may be addressed by using a tightly fitting device and performing a user seal check to ensure that the device is correctly placed and outward leakage is reduced.

For such occupations as wildland firefighting, devices that impede communication and visual acuity are incompatible with many job tasks and have been described as a significant barrier to use (Beason et al., 1996; Sharkey, 1997).

Donning and Doffing

Correctly donning and doffing a respiratory protective device is essential for effective use. Research conducted during the COVID-19 pandemic has suggested that while the majority of study participants from the public

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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were able to correctly position a respiratory protective device, typically masks or face coverings, on the face, incorrect placement exposing the nose or mouth and other incorrect practices were prevalent (Deschanvers et al., 2021; Jabbari et al., 2020; Machida et al., 2020; Mueller et al., 2021; Rahimi et al., 2021; Tam et al., 2021). Improper practices commonly observed in public users in the donning, wearing, and doffing of respiratory protective devices included inadequate hand hygiene and failure to avoid touching the surface of the device after placement (Kellerer et al., 2021; Lee et al., 2020; Machida et al., 2020). Proper donning and doffing may pose particular challenges to some vulnerable groups, such as those with cognitive disorders. For example, in one study conducted during the COVID-19 pandemic, nearly three quarters of patients living with dementia were unable to independently don and wear a mask, but the majority were able to successfully don a device with the assistance of a caretaker (Kobayashi et al., 2020).

Reuse and Storage

As discussed above, steps taken to enable reuse of respiratory protective devices, including cleaning or disinfection and storage, may impact the effectiveness of the device for its intended use. Relatively few studies have explored how devices are cleaned and reused by the public. Findings from studies conducted during the COVID-19 pandemic suggest that, among the public using devices for communicable biological agents, practices for cleaning and reuse vary and often depend on the device type. This variation may be the result of a lack of knowledge, lack of standard processes for reuse for specific devices like face coverings (Doung et al., 2021; Matusiak et al., 2020; Scalvenzi et al., 2020), or a function of risk perception (Yu et al., 2021). For example, in one study respondents were more likely to change their surgical mask if it was used in a location that was perceived as high risk (i.e., a hospital, public transportation, and gathering places) (Yu et al., 2021).

Similarly, methods for device storage while not in use were found to vary widely in studies conducted with participants from the public during the COVID-19 pandemic, although research is limited. Respiratory protective devices, largely face coverings and surgical masks, were most commonly stored in pockets and designated bags (Chao, 2020; Scalvenzi et al., 2020), on desk tops (Chao, 2020), or on the wrist/arm (Scalvenzi et al., 2020). The lack of a defined place for safe storage could impact the risk of fomite transmission.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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KNOWLEDGE, ATTITUDES, BELIEFS, AND PERCEPTIONS

Knowledge

Research identified in this review suggests that user knowledge of the role of respiratory protection, the inhalation hazard of concern, and the proper use of respiratory protective devices is likely to be associated with greater awareness of the value of respiratory protective devices and/or improved performance of effective use practices (Al Naam et al., 2021; Ali et al., 2021; Cummings et al., 2006; Domiati et al., 2020; Ferng et al., 2011; Horwell et al., 2019; Kelly, 2020; Kuo et al., 2011; Lei et al., 2019; Riden et al., 2020; Sikakulya et al., 2021; Xiong et al., 2018; Yang and Wu, 2020). However, this finding is not universal. Several studies included in this review illustrated that knowledge was not always a predictor of practice (Cowling et al., 2010; Cummings et al., 2006; Kamau et al., 2019; Lambrou et al., 2020; Tenzin et al., 2017; Zierold et al., 2016), and knowledge levels vary considerably from study to study, with some populations showing low respiratory protection knowledge (Cummings et al., 2006; Gershon et al., 2010; Shelus et al., 2020). These findings held true across hazards and across worker and public populations.

Attitudes, Perceptions, and Beliefs

A body of available research describes how user attitudes, perceptions, and beliefs impact whether and how respiratory protective devices are used to prevent inhalation of infectious hazards, air pollution, and wildfire smoke (personal protection), as well as transmission of infectious respiratory hazards (source control). The findings of these studies cover a range of different populations (i.e., nationalities, cultural groups, demographics) and indicate that these user factors are varied and are tied to sociocultural and structural forces within the broader system. Findings from these studies have been roughly categorized into subgroups of motivators and barriers to practice: risk perception, perceived effectiveness of respiratory protective devices, perceived self-efficacy, and perceived acceptability. Of note, results of these studies show conflicting conclusions across hazards and populations. Depending on the study, risk perception and perceived effectiveness of respiratory protection were both predictors of respiratory protection use and uncoupled from user behavior.

Risk Perception

Studies examining risk perception were limited to the public’s use of respiratory protective devices in the context of communicable diseases. The

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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available literature suggests some relationship between a user’s perception of risk of the infectious inhalation hazard and use of respiratory protective devices. Generally, members of the public are more likely to use respiratory protective devices to prevent transmission if the perceived risk of the disease outbreak or pandemic is sufficiently high (Barceló and Sheen, 2020). This relationship between risk perception—including fear about illness or fatality and severity of illness—and face covering/mask use was generally present regardless of user population (Cowling et al., 2010; Ferng et al., 2011; Kwan et al., 2021; Lau et al., 2010; MacIntyre et al., 2009; Ozdemir et al., 2020; Tang and Wong, 2004). Of note, perception of risk can decline over time and impact preventive behaviors (Fielding et al., 2014; Lau et al., 2011).

Perceived Efficacy of Respiratory Protective Devices

Like perception of risk, available research indicates that there may be a relationship between the perceived effectiveness or perceived efficacy of masks/face coverings in the context of communicable disease and the use of these devices by the public (Chan et al., 2020; Lau et al., 2007; Tang and Wang, 2004; Vereen et al., 2021). Similarly, limited research suggests that the use of respiratory protective devices for wildfire smoke provides members of the public with a sense of protection, regardless of the actual level of protection provided (Mott et al., 2002). However, for communicable diseases, as was found with perceived risk, beliefs in the effectiveness of masks/face coverings can deteriorate over time (Lau et al., 2010), and not all studies described a positive connection between perceived effectiveness and adherence to the use of devices (Chan et al., 2015; Ferng et al., 2011).

Conclusions from studies examining workers’ perceptions regarding the effectiveness of respiratory protective devices varied based on worker population and hazard. Studies of agricultural workers found knowledge of air pollution hazards and perceived usefulness of respirators did not translate into use of respiratory protective devices (Cramer et al., 2017; Kearney et al., 2014). Indeed, despite studies showing that while most farmers suggest and believe that they engage in actions to protect themselves from respiratory disease, among those studied, very few wear respiratory protective devices of any type (<10 percent), and importantly, most remain ambivalent about the usefulness of these devices for dust exposure (Carruth et al., 2008). When the respirator or dust mask (terminology used in the study) was used, higher usage continued to be associated with higher levels of user knowledge about occupational exposure and the risks associated with dust (and bacterial exposure) from grain and animal handling, as well as knowledge about the importance of NIOSH approval, seal, and fit-testing processes (Cramer et al., 2017).

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Despite the lack of an appropriate “wildland respirator,” wildland firefighters have noted their belief that respiratory protection is needed in their line of work. In a 1997 analysis, Sharkey reported that of 300 state and federal respondents involved with wildland firefighting 82.2 percent felt that the smoke hazards that they encountered warranted the use of a respirator. In the few studies that assessed user perceptions of respirators during use in wildland firefighting, respirator use was generally viewed positively, but results were mixed (Beason et al., 1996; De Vos et al., 2006; Sharkey, 1997), and the literature is notably outdated.

Self-Efficacy and Use of Respiratory Protective Devices

Self-efficacy, defined for this purpose as the perceived ability to perform risk-reducing behaviors during a threat to protect oneself, is likely to play a role in how the public adheres to the use of respiratory protective devices to reduce exposure risk (Avery et al., 2021). Limited research in this area suggests that the public’s perception of their own knowledge may, in turn, enhance their confidence in their own ability to effectively employ practices to protect themselves from communicable diseases (Tam et al., 2021). However, feelings of self-efficacy do not universally translate into effective protective practices. A study of the Chinese public did not identify any significant predictors between participants’ self-efficacy and the practice of protective behaviors, despite the fact that participants who perceived COVID-19 infection as more severe exhibited a greater likelihood of wearing a face covering/mask (Rui et al., 2021).

Social Acceptability and Use of Respiratory Protective Devices

Studies examining social acceptability were limited to the public’s use of respiratory protective devices in the context of communicable diseases. Social acceptability of respiratory protective devices is a broad category that, for the purposes of this review, encompasses attitudes, beliefs, and feelings that act as motivators or barriers at an individual level as to whether and how respiratory protective devices are used. Several studies have noted issues with perceived social barriers that impact use of respiratory protective devices. While overall compliance with and knowledge of the use of respiratory protective devices may be high during a pandemic or major outbreak, embarrassment about wearing a respiratory protective device of any type could act as a barrier to use (Al Naam et al., 2021; Ferng et al., 2011; Seale et al., 2012). Another barrier related to social acceptability and the effective use of masks/face coverings, as noted by Shelus and colleagues (2020), was the tendency of individuals to reduce their use when close to family or

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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friends, even among populations that report a high level of compliance with the use of these devices in general (Shelus et al., 2020).

User Anxiety and Mental Health

Studies examining user anxiety and mental health were limited to use of respiratory protection by Chinese workers during the COVID-19 pandemic and suggest that user anxiety may influence the effective use of respiratory protective devices. A survey of 67,357 teachers in China indicated that anxiety and the use of respiratory protective devices impact one another in several defined ways. For example, teachers who did not know how to properly use masks (terminology used in the study) during the COVID-19 pandemic had higher odds of anxiety than users who did have knowledge of proper use practices, and failure to adhere to proper mask use resulted in a 39 percent increase in odds of anxiety (Li et al., 2021). A study among factory workers in China during the COVID-19 pandemic found that depressive symptoms were associated with consistent face mask use (Pan et al., 2020a).

SOCIODEMOGRAPHIC ASSOCIATIONS

Sociodemographic factors may be associated with differences in the use of respiratory protective devices among members of the public and workers exposed to inhalation hazards, although the nature of these associations vary by population and exposure type. In the United States, limited evidence suggests that gender, concern about health effects, and higher education level are associated with greater mask use in the setting of wildfire smoke and communicable disease (e.g., COVID-19) outbreaks.

Findings for the Public

Data is mixed across the literature but suggest that sociodemographic characteristics, such as gender, age, and education level, may influence the likelihood of the use of respiratory protective devices by the general public. Women are consistently more likely to believe in or adhere to the use of respiratory protective devices, as demonstrated in the United States (Cowling et al., 2010; Haischer et al., 2020; Lu et al., 2021; Sugerman et al., 2012) and in multiple international settings (Cheok et al., 2021; Lee et al., 2020; Machida et al., 2020; Takahashi et al., 2017).

Evidence of a relationship between older age and greater likelihood or odds of using respiratory protective devices has been noted in several studies (Barceló and Sheen, 2020; Lau et al., 2010; Lu et al., 2021; Rahimi et al., 2021), including studies in the United States during the COVID-19

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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pandemic (Haischer et al., 2020) and during wildfire smoke conditions (Sugerman et al., 2012). During wildfire smoke conditions in California, having a history of chronic lung disease has been associated with compliance with messaging regarding use of respiratory protective devices (N95 FFRS and other devices), likely due to concern about personal health risks (Sugerman et al., 2012).

Higher levels of education have been associated with higher likelihood of use of respiratory protective devices of all types in multiple U.S. studies, both for infectious disease outbreaks and wildfire smoke exposure (Anderson et al., 2021; Clements, 2020; Sugerman et al., 2012). In the cleanup of New Orleans after Hurricane Katrina, residents with higher education were more likely to identify respirators as appropriate devices to reduce exposure to mold, while knowledge of respiratory protection did not differ on the basis of sex, age, race, or previous experiences with flooding and mold (Cummings et al., 2006). There is limited evidence that higher income may be a predictor of the use of respiratory protective devices in the United States for protection against COVID-19 (Anderson et al., 2021) and wildfire smoke (Sugerman et al., 2012), although very low income has also been associated with greater compliance (Anderson et al., 2021).

In addition to cultural and societal forces that impact social stigma around mask use, residing in an urban or rural area may impact the likelihood or actual use of respiratory protective devices. In the United States, most studies suggest greater likelihood of preventive behaviors, including mask use, among those living in urban or suburban locations as compared to rural locations (Callaghan et al., 2021; Haischer et al., 2020; Lu et al., 2021), although not all studies have found this pattern (Anderson et al., 2021).

Findings for Worker Groups

Several studies have evaluated use of respiratory protective devices among farmworkers who are exposed to agricultural dusts, and these studies have consistently found that younger farmers are more likely than older farmers to report wearing a form of respiratory protection, typically respirators (Donham et al., 2011; Mitchell and Schenker, 2008; Mpofu et al., 2002; Syamlal et al., 2013; Virolainen et al., 1987). In addition, differences have been found by smoking status, with greater use of respiratory protection against dust while working among ex-smokers and a lower likelihood of use among current smokers. As in the general public exposed to ambient pollution, higher education attainment, concerns about respiratory problems, and a prior history of respiratory disease have been associated with a higher likelihood of wearing a respirator of any type to prevent exposure to dust in the farm setting (Schlenker et al., 1990; Virolainen et

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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al., 1987). The size and earnings of the farm are also an important determinant of use of respiratory protection, with greater likelihood of availability of respirators for farmworkers at larger or higher-earning farms (Cramer et al., 2017; Kearney et al., 2014; Syamlal et al., 2013; Virolainen et al., 1987). Although studies of the use of mask/face coverings in the workplace during the COVID-19 pandemic are still emerging, studies of market and poultry workers conducted in Asia have consistently found that education level, older age, and longer work experience were associated with preventive practices, including the use of such devices to reduce transmission of infectious disease (Lei et al., 2019).

COMMUNICATION, EDUCATION, AND TRAINING

Factors and Attributes That Influence Adherence to Recommendations on the Use of Respiratory Protective Devices

Public health messaging, education, and training can influence user knowledge (Cummings et al., 2006), attitudes, and practices (Kelly, 2020) regarding use of respiratory protective devices of all types. However, relatively little is known about factors impacting decision making about such device use and how public health messaging and educational interventions could be more effective (Shelus et al., 2020).

Much of the research conducted during the COVID-19 pandemic on the use of respirators, face coverings, and surgical masks by the public sought to describe these complex cultural, behavioral, and sociodemographic factors. Findings from these studies identify key factors and attributes associated with mask wearing that can be used to tailor messages, risk communication, and programs to specific, targeted segments of the population to enhance uptake among vulnerable groups (Barceló and Sheen, 2020; Casola et al., 2021; Chan et al., 2015; Fisher et al., 2020; Siu et al., 2016; Zhang et al., 2019).

These findings, many of which are discussed in earlier sections of this appendix, include the following:

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Of note, behaviors and risk perception can change over time (Fielding et al., 2014), which emphasizes the importance of understanding the population’s barriers and motivations, and developing strategies based on this understanding for responsive communication and messaging for the public on the use of respiratory protective devices (Teasdale et al., 2014).

Information Seeking

Research conducted in the context of the COVID-19 pandemic found that online information-seeking behaviors and search themes provide valuable information about what the community needs at a given time (Bento et al., 2020; Galido et al., 2021). These findings are likely to be broadly applicable to other inhalation hazards. Importantly, these search patterns will evolve over time and require adjustments to public health messaging and communication of guidance.

Best Practices in Public Health Communication and Messaging

Appropriately designed and targeted communications can improve the public’s adherence to recommendations regarding the use of respiratory protective devices and positively impact health outcomes. The literature review identified the following best practices, primarily from the review of the public’s use of respiratory protective devices to protect against communicable biological agents. The studies largely focused on the use of face coverings and masks, although some studies specific to wildfire smoke also examined communication and messaging around respirator use. These best practices are expanded on in sections below.

  • Target Messaging to Specific Audiences
  • Tailor Materials and Ensure Cultural Appropriateness
  • Use Positive Framing and Avoid Stigma
  • Convey Clear Simple Messages That Address User Needs and Questions
  • Leverage Trusted Partners and Diverse Information Sources
  • Update Messaging Based on Continuous Evaluation
Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Targeted and Tailored Messaging

Targeting groups with low adherence The evaluation of factors impacting the willingness of the public to comply with recommendations on the use of respiratory protective devices for respiratory infection prevention is critical because it allows for the identification of key groups that are less likely to comply and may benefit from targeted and tailored risk communication strategies or health education (Barceló and Sheen, 2020; Fisher et al., 2020; Ozdemir et al., 2020; Taylor et al., 2009). Mediators and barriers that predict adherence to the correct use of respiratory protective devices of any type require in-depth and ongoing evaluation, as these factors and attributes mediating perception and use are not static. Key population groups can include those demonstrating resistance to mask use (Barceló and Sheen, 2020; Majam et al., 2021), specific demographic groups (Daoust, 2020), and individuals demonstrating personality characteristics associated with reticence toward mask wearing (Barceló and Sheen, 2020). Ultimately this tailoring of education campaigns and guidance to particular population segments or predictors of adherence will require large population studies to identify these underlying determinants (Majam et al., 2021). The complexities of mask/face covering use during the ongoing COVID-19 pandemic demonstrate the need for research to develop more complete understandings of behavioral predictors and other motivators and barriers to use of respiratory protective devices by the public.

Tailoring materials and ensuring cultural appropriateness Public health messaging and communication activities should be tailored to address the key needs, barriers, and motivators specific to the population of interest (Riden et al., 2020; Sim et al., 2014) and should be culturally appropriate (Ferng et al., 2011; Vereen et al., 2021). Language should resonate with the intended audience (Shelus et al., 2020), and materials should be developed and disseminated in collaboration with the community of interest.

Message/Guidance Content

Using positive framing and avoiding stigma For the U.S. public, studies show public health communications to encourage mask wearing may be improved by the use of short, clear requests paired with examples of direct and positive benefits, such as protecting one’s community, saving lives, and reducing transmission (Fisher et al., 2020; Shelus et al., 2020; Vereen et al., 2021). Additionally, positively framed and toned messages are more impactful on behavior than fear-based messaging (Vereen et al., 2021). It is important to avoid the use of images or wording that may draw

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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unintentional or damaging associations between a disease and particular groups (Batova, 2021).

Using clear, simple messaging to guide effective use of respiratory protective devices To address challenges related to adherence with public health recommendations on use of respiratory protective devices, as well as improper use, which may be an issue even in communities with high levels of adherence to the use of such devices (Tam et al., 2021), public health communications need to clearly convey the risks from the inhalation hazard (i.e., why use of the device is recommended) (Kelly, 2020); benefits and risks of the type of device used, including uncertainties (McDonald et al., 2020); and guidance regarding when and how to properly use the devices and where they can be accessed (Kellerer et al., 2021; Scalvenzi et al., 2020; Vereen et al., 2021). It is also important to address misinformation about correct use (Azlan et al., 2020; Scalvenzi et al., 2020) to avoid a false sense of protection.

Differences have been noted in the emphasis on respiratory protective devices in public health messaging regarding protective measures for communicable infectious agents, such as SARS-CoV-2, and wildfire smoke. Cook (2020) found that the majority of public health materials pertaining to wildfire smoke did not focus on the use of a respirator or other type of respiratory protective device, and instead included such recommendations as remaining indoors or reducing outdoor activities. These findings indicate that attention should be paid to increasing the balance (between detail and simplicity) of messaging and to providing more information about how and when different protective measures should be employed.

Public health communications would benefit from providing clear information about who can and cannot safely use respiratory protective devices (Vereen et al., 2021). For example, messaging around the use of respiratory protective devices by children, who are also highly susceptible to the negative health effects of wildfire smoke exposure, has been noted to lack clarity. Cook’s (2020) evaluation of public health materials on wildfire smoke exposure found that, while materials noted that children should not use adult-sized masks when exposed to wildfire smoke, no alternative options were offered nor was information offered about why an adult mask would not function properly, leading to potential confusion about whether effective masks for children exist and why adult masks cannot be used by children (Cook, 2020). Furthermore, public health materials for wildfire smoke included contradictory information about the use of N95 FFRs by the public during the 2018 Camp fire and caused confusion by creating the impression that those with respiratory and cardiac conditions should not use the respirators, although they are in fact the group most in need of protection from exposure.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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In crafting messages, technical language and jargon should be avoided. Sugerman and colleagues (2012) found that public health messages about wildfire smoke that included technical terminology, such as “use respirators during clean up [of ash following wildfires],” were less easily remembered than messages with nontechnical terminology, such as “stay indoors” or “keep windows and doors closed.” It is important to confirm that messages are accessible and understandable and address misinformation (Pan et al., 2020b). Additionally, individuals from different socioeconomic levels access information about mitigation measures differently and will view the clarity of messaging differently (Aburto et al., 2010).

A lack of clarity in messaging can have long-term consequences for the use of respiratory protective devices, as illustrated by the struggle over communication of guidance on mask use early in the COVID-19 pandemic when recommendations were changing regularly and information sources presented conflicting information (Casola et al., 2021; Erikainen and Stewart, 2020; Shelus et al., 2020). Shelus and colleagues (2020) concluded that mixed messages contributed to significant confusion and concerns over the efficacy of masks and face coverings for the public.

Leverage Trusted Partners and Diverse Information Sources

Effective behavior change in the public to expand adherence and proper use of respiratory protective devices will require the coordinated efforts of a variety of stakeholders (Sim et al., 2014). Trust is an important component of public health messaging during a pandemic, but preferences for and trust in designated information sources can change over time (Fielding et al., 2014; Lau et al., 2011). Logistical and cultural challenges in adopting preventive practices are more easily overcome when local public health departments prioritize building ongoing, trusted relationships within communities. This improved relationship can in turn improve the distribution and cultural acceptability of public health messaging and adherence of the population to essential preventive measures (Ali et al., 2020). Clear communication, up-to-date scientific information, and transparency in government decision making may be effective in improving adherence to preventive measures. A communication platform created in collaboration with government and academic institutions could address these needs and act as a unified source for disseminating information to the public (Lau et al., 2009).

Role of the media Mass media (radio, television, newspapers, and websites) plays a significant role in the dissemination of information about inhalation hazards and preventive measures, including the use of respiratory protective devices, to the public. This has been the case with communicable biological agents, such as COVID-19 (Anwar et al., 2020) and H1N1 influenza

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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(Aburto et al., 2010); air pollution (Zhang and Mu, 2017); and mold (Cummings et al., 2006).

During the COVID-19 pandemic, social media has also been used as a key communication platform for information exchange, and the evaluation of interactions on social media can allow for greater understanding of how messages can spread and impact attitudes and practices for mask use over time (Ahmed et al., 2020). Social media analysis can be used to identify themes and attitudes shared by the population to inform the content and dissemination of outreach to the public.

Role of government and public health experts Information presented by experts may impact adherence to mask wearing and other preventive behaviors (Rui et al., 2021). In addition, governmental or professional association guidance for workers was indicated in two articles as important to the effective use of respiratory protective devices and other preventive practices during the COVID-19 pandemic (Homer et al., 2021; Jones et al., 2021). Health departments, followed by the Federal Emergency Management Agency and other government agencies, were viewed as most appropriate for educating the public about mold remediation practices requiring the use of respirators (Cummings et al., 2006).

Role of employers For workers, employers have a critical role in communication and education regarding the use of respiratory protective devices to protect employees against inhalation hazards. In one study, when asked what entities bear the responsibility for educating workers about prevention of mold exposure using respirators, surveyed workers performing mold remediation reported that employers (70 percent) followed by OSHA or another government agency (34 percent) were best suited for this responsibility. However, these perceptions varied by employment status (self-employed versus employed by a company), level of education, and prior work experience with mold remediation in flooded structures (Cummings et al., 2006).

Role of manufacturers Manufacturers can play a role in educating the public on correct use of respiratory protective devices, although little research exists that explores these opportunities in the context of public use. Manufacturers can address some of the user errors that lead to improper use of respiratory protective devices by providing accessible and clear instructions on packaging, and engineering certain design features to reduce errors in donning (such as the common error of wearing the device inside out) (Tam et al., 2021). Of note, Kelly (2020) found that N95 FFR manufacturer instructions, which did not include health risk messaging, did not significantly

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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change participants’ responses on knowledge, attitudes, and practices in the context of donning a respirator for protection against wildfire smoke (Kelly, 2020).

Update Messaging Based on Continuous Evaluation

Ongoing evaluation of factors and attributes impacting adherence to recommendations on use of respiratory protective devices, as well as monitoring of public perceptions of policies on preventive measures would facilitate regular assessments of risk communication and other public health outreach (Lau et al., 2011).

Specific Training Needs for Workers

Few captured studies relevant to workers without respiratory protection programs provided information on their specific training needs. Discussed below are the findings related to training for agricultural workers and wildland firefighters.

Agricultural Workers

The studies reviewed for agricultural workers exposed to air pollution emphasized the importance of providing training and guidance for farmworkers in order to effectively support behavior change aimed at reducing farmwork-related risk of exposure to dust and other air pollutants. A Canadian study by Mpofu and colleagues (2002) noted that less than half of the respondents reported having had previous training or instructions on how to use respirators, which could explain the overall low prevalence of respirator use in this outdoor worker population. However, evidence on the effectiveness of training has been mixed. Two studies demonstrated that farms or farmers in educational intervention groups saw an increase in the use of respirators as compared to the control groups (Donham et al., 2011; Virolainen et al., 1987). A third study found that farms (pig and dairy farms) that received an educational intervention (including provision of informational documents about farmer exposures, the associated risks, and advice on how to mitigate those risks) showed an overall significant decrease in dust exposure through behavioral changes compared to the control group. However, the authors did not observe a significant difference in respirator use between the intervention and control groups, and respirator use remained low in both groups (Basinas et al., 2016).

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Wildland Firefighters

For wildland firefighters, the development of a culture of safety will require a commitment to routine trainings of workers in both a classroom and a field setting (Reinhardt and Ottmar, 2000). Multiple articles included in the committee’s review referenced the importance of training and education for the effective use of respirators by wildland firefighters. Issues that need to be addressed in training include hazard assessment, the limitations of respirators for wildfire smoke, proper donning and use, maintenance and service life (Reinhardt and Ottmar, 2000), and fit (Sharkey, 1997). Reinhardt and Ottmar (2000) wrote that hazard awareness training is critical for helping users understand why exposure to the components of wildfire smoke is of concern and how a respirator can and cannot reduce that exposure. This understanding of the limits of protection and when to don a respirator is of critical importance for avoiding exposure to carbon monoxide while wearing an air-purifying respirator with a particulate cartridge (as described by De Vos et al., 2009; Haston, 2007; and Reinhardt and Ottmar, 2000). Training could be provided for users during annual training and during recertification (Reh and Deitchman, 1992) and should be led by qualified personnel (Beason et al., 1996). Reinhardt and Ottmar (2000) noted that education about the hazards of wildfire smoke should begin before workers are deployed to the field and then routinely refreshed both in a traditional classroom setting and in the field.

ACCESSIBILITY

The use of respiratory protective devices requires users to be able to access the device and, in many cases, to be able to afford to purchase the correct device. As such, accessibility issues are an essential component to ensuring effective use of devices at a population level and in occupational settings. At this time, there is very limited research relating to supply, access, and affordability of respiratory protective devices for the populations covered in the committee’s review.

Accessibility for the Public

Individual perception of cost and accessibility of respiratory protective devices may act as a barrier or motivator for use, although the number of studies identified in this review that point to cost and accessibility of devices as a barrier is extremely limited (Aburto et al., 2010; Anwar et al., 2020; Casola et al., 2021; Selby et al., 2020). Studies have suggested that public use could be encouraged by the government providing devices for free rather than requiring the public to pay out of pocket (Anwar et al., 2020;

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Casola et al., 2021; Selby et al., 2020). However, little is known about how distribution of free respiratory protective devices would affect actual use.

In the context of wildland fire smoke exposure, McDonald and colleagues (2020) noted that respirators, which more effectively filter out hazardous particles in air pollution (e.g., smoke) to protect the wearer, are more expensive than other types of nonrespirator devices, such as surgical masks. These authors also suggest that this additional cost may necessitate the mass distribution of respirators by public health agencies or by donation directly from the manufacturer for distribution to the population (McDonald et al., 2020).

Supply issues were a major challenge in the early months of the COVID-19 pandemic when public health authorities recommended the public use cloth face coverings to protect low supplies of surgical masks and respirators for frontline workers. This created a public demand for new types of products, like face coverings, which were not yet widely available. Within a very short period of time, new industries that produced these products emerged. One notable example is the wax fabric mask industry in Ghana that marketed to consumers via social media and messenger applications. The mask products created great public interest and resulted in a new government investment in the local production of masks (De-Graft Aikins and Akoi-Jackson, 2020). More research is needed to understand the interplay between sociocultural factors and market forces.

Controlled or optimized distribution of masks to those at greatest risk of adverse outcomes (such as the elderly) and, in scenarios where supply is extremely limited, could target resources toward prevention of the most severe or deadly infectious cases (Worby and Chang, 2020). Such an approach would preserve supply of respiratory protective devices in the setting of “panic buying,” such as was seen early in the COVID-19 pandemic. When many parts of the world experienced severe supply chain shortages of personal protective equipment, South Korea and Taiwan both implemented centralized inventory management programs to improve the efficiency, reliability, and cost of masks for public use (Kim, 2021; Lin et al., 2020). A review of the actions taken by South Korea with regard to early attention to respiratory protective device supply and distribution in the COVID-19 pandemic demonstrates a centralized approach in managing supply, the value of an enterprise approach, and those qualities and actions that need to be leveraged to improve access to respiratory protective devices by the public in a timely manner via a mask inventory service. The success of South Korea in maintaining adequate supply and access to respiratory devices is attributed to (1) collaboration of stakeholders across the enterprise; (2) clearly defined roles and responsibilities, and communication pathways; (3) cooperation and buy-in from the population; and (4) information technology (IT) infrastructure and coordination of data sharing across institutions

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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in real time (Kim, 2021). Taiwan carried out a coordinated mask dissemination and inventory management program through its pharmacy network, and rationed the number of masks that could be sold to an individual and on what days masks could be purchased by defined groups of individuals (Wang et al., 2020).

Accessibility for Worker Groups

Perceived or actual lack of access to respiratory protective devices is a barrier to effective use in the occupational setting (Duruk et al., 2020; Gershon et al., 2010; Homer et al., 2021; Jones et al., 2021). For example, the perception of lack of availability of respirators in the workplace was noted as a barrier to respirator use in a survey of 384 home health care workers in the United States (Gershon et al., 2010). A study comparing infection prevention and control practices within home health care agencies in the United States in December 2019 reported that, while almost all agencies (more than 99 percent) provided personal protective equipment (PPE) (including surgical masks) to staff prior to the COVID-19 pandemic, just 39.7 percent provided N95 FFRs (Shang et al., 2021). In other contexts, the provision of free masks and other PPE by authorities was identified as a tool for increasing compliance with the use of respiratory protective devices by both employees and customers of neighborhood businesses that supply essential goods to their communities, during the COVID-19 pandemic (Jones et al., 2021).

Among farmworkers, limited research suggests that use of respirators is low, although in one study this appeared to be related to lack of education, safety audits, and performance incentives rather than lack of access to respiratory protective devices onsite (Donham et al., 2011). On the other hand, in the setting of wildland fire smoke exposure, access to respirators has been found to be an important determinant of use (Amster et al., 2013).

CULTURAL NORMS

Cultural and social norms—shared belief systems within a social group that influence behavior and the management of relationships (Santana et al., 2020)—play a significant role in shaping user perceptions and practices regarding mask wearing among the public. Understanding these cultural nuances and establishing relationships with communities are critical to designing responsive public health programs (Barceló and Sheen, 2020; Santana et al., 2020; Siu et al., 2016) and disseminating culturally acceptable public health messaging (Ali et al., 2020).

Mask wearing is more acceptable in some countries with such cultural values as a strong sense of collectivism, and was common practice even

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

before the COVID-19 pandemic. A sense of interdependence may motivate use of respiratory protective devices in countries with a greater sense of collective purpose and dissuade it in cultures that value self-expression (Casola et al., 2021). Unsurprisingly, members of the public are more likely to use respiratory protective devices if they live in a region or country where use is more prevalent and widely accepted (Barceló and Sheen, 2020; Zhao and Knobel, 2021). In some areas, past outbreaks and pandemics (e.g., SARS, H1N1) have resulted in the integration of mask use into the societal fabric (Siu et al., 2016).

Importantly, factors mediating the use of respiratory protective devices within a population are not static and can shift over time. Positive social influences, including feelings of solidarity, civic responsibility, and altruism, can be short lived and taper off as an epidemic wanes and the threat is no longer perceived as serious. This process can be followed by a shift into more negative feelings (Tsang and Probst et al., 2021). Public health communications, educational outreach, and guidance would benefit from responding to fluctuations in perceptions regarding the use of respiratory protective devices in future public health events.

In occupational settings, safety culture may shape norms related to respiratory protection at the organizational level (Beason et al., 1996). Limited research shows that employer and supervisor attitudes toward safety (Riden et al., 2020) and modeling behavior by management (Jones et al., 2021) are important drivers of effective use of respiratory protective devices by workers.

OVERSIGHT AND ENFORCEMENT

Oversight and Enforcement for Workers

In the occupational setting, employers are required by OSHA—or, in some cases, other regulatory agencies—to establish respiratory protection programs (RPPs) and supply employees with respirators when such devices are necessary to protect workers from inhalation hazards. Workers whose employers have instituted elements of an RPP (e.g., provision of respirators, fit testing, training) may be more likely to consistently use and be knowledgeable about respirators when facing inhalation hazards (Cummings et al., 2006; Gershon et al., 2010). In the case of home health care workers, implementing RPPs and providing access to respiratory protective devices, among other strategies, may also be important for ensuring employee willingness to continue performing their job functions in the context of a pandemic (Gershon et al., 2010). However, lack of employer compliance with RPP requirements is a barrier to effective use of respiratory protective devices. Lack of training and fit testing has been reported even among

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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.
×

workers whose employers had provided respirators (Cummings et al., 2006; Gershon et al., 2010). As a result, access to respirators in the workplace does not necessarily translate to knowledge on or proper use of respiratory protective devices.

Some workers reported that a top-down approach featuring strong regulatory oversight and incentives for employers, including financial incentives (e.g., penalties for noncompliance), would be needed to ensure full compliance with worker safety and health measures, such as RPP requirements (Riden et al., 2020). However, a top-down approach may not be effective in all circumstances. For example, in the case of wildland firefighters, enforcement without worker buy-in may not lead to consistent use of respirators in the field, underscoring the importance of communication among regulatory agencies, unions, and employees (Reinhardt and Ottmar, 2000).

Tailoring RPPs to the needs of specific worker populations is critical for addressing the unique needs of that group (Earle-Richardson et al., 2014). For example, language barriers, lack of transportation, and lost work hours associated with fit testing and medical clearance were noted as disincentives for migrant farmworkers (Earle-Richardson et al., 2014) and would need to be considered in the development of an RPP. Pilot programs have been suggested as a mechanism for developing RPPs that effectively address the unique needs of wildland firefighters related to training, fit testing, and medical clearance (Sharkey, 1997).

Oversight and Enforcement for the Public

In the context of the use of respiratory protective devices by the public, there is no established equivalent to an OSHA-mandated RPP. Consequently, little research exists related to oversight and enforcement of the use of respiratory protective devices by the public, outside of some limited research on mask mandates.

During the COVID-19 pandemic, both mandatory and voluntary mask-use policies were instituted around the globe as a method for enforcing mask use by the public. The impact of these two policy types—mandatory versus voluntary—is just beginning to be assessed and the few articles identified by this review suggest that mandatory policies may be more effective than voluntary policies in effecting compliance (Schmelz, 2020; Sprengholz et al., 2020). One study suggests that mandatory policies may be perceived as more effective and fairer than voluntary policies (Sprengholz et al., 2020). Thus while some policies may be effective in encouraging mask use by the public (Fischer et al., 2021), more needs to be known about challenges and best practices for implementation.

Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Page 425
Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Page 427
Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Page 429
Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Page 431
Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Page 433
Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Page 434
Suggested Citation:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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:"Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use." 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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Next: Appendix C: The Regulatory Landscape Regarding Respiratory Protection »
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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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