Frameworks for Protecting Workers and the Public from Inhalation Hazards (2022) / Chapter Skim
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4 Respiratory Protection for the Public
4 Respiratory Protection for the Public
Pages 207-268
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From page 207... ...
This chapter examines experiences with the use of respirators, medical masks, and face coverings outside of occupational settings to mitigate inhalation hazards; the challenges that impede application of the occupational model to the public; and the need for an organizational and regulatory framework for addressing current gaps in processes for oversight of and guidance on respiratory protection for use by the public. This chapter serves as a complement to Chapter 3, which examines respiratory protection for workers whose employment settings fall within the purview of a federal regulatory agency (e.g., the Occupational Safety and Health Administration [OSHA]
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From page 208... ...
. Beyond such emergency-related scenarios, the public may require respiratory protective devices in more routine aspects of daily life, such as while engaged in home maintenance or hobby-related activities that result in exposure to inhalation hazards.
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Device Use • Where should I look for information on the need for respiratory protection? • Should I use a respiratory protective device (i.e., is there a device recom mended for people like me for this hazard)
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. This section briefly describes the landscape of devices that have been used by the public with the intent of reducing exposure to inhalation hazards during past public health emergencies as well as devices that have emerged in the market during the COVID-19 pandemic.
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From page 211... ...
However, the public does not have authenticated information with which to make an informed decision among such offerings, including whether any of them could be considered a respiratory protective device offering some level of respiratory protection. Rather, the decision to buy a particular product is often driven by price and consumer ratings, which tend to reflect bias on the part of the individuals submitting the reviews (Amazon, 2021)
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Needs of Users in the Public for Respiratory Protective Devices User needs for respiratory protective devices and how they influence the selection of a device are briefly described below. Factors related to performance, comfort, usability, and availability are discussed in more detail in Appendix B
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As this is not the case, manufacturers of all respiratory protective devices would benefit from consulting with experts in health communications and health literacy in order to restructure information provided to users -- such as clear indicators of the limitations of device use and instructions for donning and doffing -- in a clear and accessible way. Consideration should also be given as to how educational materials can be provided to multiple users.
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. Consistent minimum guidelines are needed across manufacturers regarding what information should be included on all labels, packaging, and instructions for respiratory protective devices.
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Respiratory protective devices and other forms of personal protective equipment (PPE) can become contaminated from the workplace environment where they are used.
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Additionally, concerns related to the exhalation valves on respiratory protective devices during the COVID-19 pandemic have led to the development and approval of elastomeric facepiece respirators without these valves (AIHA, 2020)
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AVAILABILITY AND ACCESS ISSUES FOR RESPIRATORY PROTECTIVE DEVICES FOR THE PUBLIC The selection and use of appropriate respiratory protective devices by members of the public depend on the availability of the devices on the market and the ability to access them. Availability and access for the public are limited by multiple factors, however, including a complex, demandbased supply chain, reliance on foreign manufacturing, and inequitable distribution and affordability of devices in times of public health emergencies (Aburto et al., 2010)
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When NIOSH's National Personal Protective Technology Laboratory (NPPTL) becomes aware of counterfeit respirators or those misrepresenting NIOSH ap proval on the market, it posts warnings on its website to alert users, purchasers, and manufacturers (CDC, 2021a)
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offering unknown effectiveness for both source control and respiratory protection (Fonseca, 2020; Godoy, 2020)
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Those wishing to make an in-person purchase for respiratory protective devices are limited by their transportation options. Individuals who do not live within walking distance to a point-of-sale location need accessible, efficient, affordable, and safe transportation alternatives (Malekafzali, 2009)
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. And for those who can afford respiratory protective devices, the effectiveness of those devices will be undermined if they are chosen or used improperly (Seltenrich, 2017)
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While an RPP in an occupational setting is designed to respond to changing requirements for devices based on the identification and monitoring of established OSHA occupational exposure limits, public health agencies are challenged in establishing guidelines for the selection and use of respiratory protective devices because for many inhalation hazards facing the public, both exposure levels and safe levels are unknown. Determining the acceptability of risk is difficult.
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, and there is emerging evidence on the effectiveness of respiratory protective devices in protecting the public from these hazards (Holm et al., 2021; Kodros et al., 2021; Laumbach, 2019; Rajagopalan et al., 2020; Shi et al., 2017) , the actual reduction in risk from the use of different devices across different levels of exposure remains unclear.
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are especially susceptible to respiratory infections. These groups are likely to benefit greatly from respiratory protection, yet some chronic health conditions (e.g., advanced heart failure, lung disease)
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Assessing whether a user will receive the expected level of protection from a respirator therefore necessitates fit testing, a required component of workplace RPPs. Although there is currently no universal or standard sizing for respirators, most are sold in three sizes (small, medium, and large)
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Thus, the need to ensure proper fit of respiratory protective devices for the public represents both a technology and a communication challenge. Qualitative or quantitative fit testing is both time- and resource-intensive.
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Health Risks from Use of Respiratory Protective Devices and Medical Clearance for the Public Limited research on the health risks associated with respiratory protective devices has been focused specifically on use by the public, whose health profile differs from that of workers. Much of the research that has been conducted in this area, some of which is described below, is related specifically to the use of respirators.
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. Overall, the potential risks for members of the public with serious chronic health conditions -- a group that likely would benefit the most from respiratory protection against inhalation hazards -- remain unknown.
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Additional research is needed to understand what contraindications to respirator use might exist for public users and the costs and benefits of respirators for groups at risk of adverse effects from both use of respiratory protection and inhalation hazards. Given the challenges of applying such an occupational model in the context of public use, a new and distinctly different framework is needed to support decision making and practice around the public's use of respiratory protection in the absence of a formal RPP.
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Conclusion 4-4: The occupational model of a respiratory protection program under OSHA, including the fundamental program com ponents of hazard assessment to guide respirator selection, medical clearance, regular fit testing, and user training, is neither suitable nor feasible for the public. BEHAVIORAL AND EDUCATIONAL CONSIDERATIONS FOR ENSURING EFFECTIVE USE OF RESPIRATORY PROTECTIVE DEVICES BY THE PUBLIC Because respiratory protective devices, if used incorrectly, may not be effective, and in rare cases may even be harmful to the user, educating the public in their proper use is crucial.
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. The Israeli military collaborated with the education ministry to establish emergency drills in schools and teach students how to don their respiratory protective devices properly.
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The sections below review evidence from RCTs focused on the effectiveness of providing respiratory protective devices to members of the public to promote protection against specific hazards, the role of "mask mandates" in promoting public use of such devices, and audience needs critical to improving compliance to achieve more effective use. Evaluations of Interventions to Improve Use of Respiratory Protective Devices by the Public A recent review reports on the few RCTs that have been conducted in community settings to examine the benefits of providing people with medical/surgical masks or N95 FFRs and educational materials in the form of
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. The most promising findings come from an RCT involving Australian adults who received surgical masks with information about infection control, respirators (with information about infection control but no fit testing)
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The lack of compliance with instructions among study participants also demonstrates the importance of understanding the sociobehavioral factors that influence the proper use of such devices. Improving Effective Use of Respiratory Protective Devices During Public Health Emergencies During the COVID-19 pandemic, public compliance with recommendations related to use of respiratory protective devices increased over time, possibly as a result of public health messaging and mask mandates.
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. Understanding and Addressing Barriers to Effective Use of Respiratory Protective Devices An important focus for identification of educational needs related to respiratory protection for the public, then, is that such public education be informed by the evidence-based recommendations of medical and public health experts as to which devices are most effective for protection against which hazards, as well as social science evidence regarding gaps and misconceptions in people's knowledge and other potential barriers to
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population to ensure that members of the public understand the risks posed by different inhalation hazards. Otherwise, it is unlikely that respiratory protective devices, even those well suited to the user and the hazard, will be used.
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. This particular result, along with the attitudes expressed by the live poultry market workers despite their high level of exposure to AIVs, shows the importance of proper risk communication, both before and in the midst of outbreaks, to encourage public acceptance of government control measures and prompt the use of personal protective equip ment when needed.
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From page 238... ...
. Barriers to effective respiratory protection for these inhalation hazards are also related to the social dimensions of device use and include user perceptions of social acceptability (Barceló and Sheen, 2020; Ferng et al., 2011; Nakayachi et al., 2020; Santana et al., 2020)
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. The Korean government also adopted a range of tactics for dealing with shortages of respiratory protective devices and other personal protective equip ment (PPE)
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Summary and Synthesis Ultimately, respiratory protective devices are effective only if they are used properly. Public awareness, perceived risk, belief in the efficacy of the devices, and social norms all affect consumers' decisions about using respiratory protection, and public health messaging can play a significant role in the public's awareness and decision making about use.
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For inhalation hazards, a combination of intervention approaches may be needed (Conway, 2021) , based on a broad understanding of people's specific needs and other strategies (beyond use of personal respiratory protective devices)
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. These ATS guidelines also state that while medical evaluations are necessary for the safe use of respiratory protective devices, the process for carrying out these evaluations has not been determined, and clinical judgment should be applied (Harber et al., 1996)
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Role of the Public Health Community Much like health care providers, the public health community is expected to serve as a primary resource for the public on the proper use of respiratory protective devices. Like the medical community, however, the public health community receives limited education in respiratory protection to support them in this role.
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Summary and Synthesis Health care providers and public health agencies are frequently viewed as sources of advice for the public's use of respiratory protective devices; however, these stakeholders often lack the expertise and resources to address the public's information needs. Health care providers, who receive little or no training in providing guidance on respiratory protection to their patients, are asked to rely on their clinical judgment in determining clinical fitness for device use and addressing patients' questions.
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. In early 2021, several European countries had already begun requiring individuals to wear more protective devices (N95 FFRs, KN95s, FFP2s, or surgical masks)
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During the Camp fire in 2018, for example, the City of Sacramento had a program in place for distributing N95 FFRs to the public, while supplies lasted, for protection from wildfire smoke. The respirators were dispersed to the city from the California Office of Emergency Services and the California Department of Public Health, with requests being routed through the County of Sacramento (Sacramento City Express, 2018)
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From page 247... ...
Gaps in Federal Guidance Multiple federal agencies develop and disseminate guidance for the public on the use of respiratory protection. For example, EPA, which regulates environmental pollutants and provides air monitoring data, has produced guidance for public health officials on protecting the public from wildfire smoke, including the use of respiratory protective devices.
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From page 248... ...
For example, some of the information included is designed for use by SLTT public health agencies in developing consistent and comprehensive guidance on use of respiratory protection, while other examples are factsheets intended for use directly by the public. Across the guidance reviewed, the greatest variability in content relates to the level of detail on how, when, and why respiratory protection should be used for a given hazard and to the means used to enhance the accessibility of BOX 4-7 Selected Examples of Federal Guidance on Public Use of Respiratory Protective Devices Centers for Disease Control and Prevention (CDC)
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From page 249... ...
Guidance on the use of respirators for protection from COVID-19 directs the reader to purchase from a "reputable seller." Clear information for the potential users of respiratory protection about where they can find the appropriate devices, who reputable sellers are, and how they can know they are buying the right products would reduce confusion and increase the likelihood of an appropriate device being acquired. Additionally, gaps in guidance exist around conveying all critical aspects of effective use of respiratory protective devices -- specifically, how to ensure that the device fits, how to put it on and take it off correctly, when the device should be worn, when it has reached the end of its lifespan, and how it should be cared for.
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Relatedly, the guidance lacks information on respiratory protection targeted specifically to vulnerable groups, such as children and others (e.g., pregnant women, the elderly) , who are at particular risk from exposure to inhalation hazards but may be unable to find respiratory protective devices tailored to their needs.
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First, related to selection of respiratory protective devices, there was wide agreement across the guidance surveyed that in the context of COVID-19, N95 FFRs and other such respirators should not be used by the public and should be reserved for health care workers. The public was instead encouraged to make use of face coverings, and the guidance often included how to select or make homemade face coverings.
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Summary and Synthesis The public requires clear guidance on when to use respiratory protective devices for protection against specific inhalation hazards, such as wildfire smoke, ambient air pollution, volcanic ash, and infectious agents. However, there is no unified, authoritative system for identifying inhalation hazards -- either existing or emerging -- that may warrant use of respiratory protection by the public.
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This need could be met by a unified and authoritative source that is empowered to ensure the availability of respiratory protective devices for diverse populations (including children) , provide answers for the research priorities noted throughout this chapter, and address the knowledge gaps regarding respiratory protection for the public laid out in Box 4-1 -- a source that is dedicated to the health and safety of the public, especially in the event of a public health emergency.
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From page 254... ...
2021. Respiratory protection in a time of crisis: NIOSH testing of interna tional respiratory protective devices for emergency use.
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2021. Presentation at the January 25, 2021, meeting of the National Acad emies of Sciences, Engineering, and Medicine Committee on Respiratory Protection for the Public and Workers Without Respiratory Protection Programs at Their Workplaces, virtual.
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2001. Respiratory protection as a function of respirator fitting characteristics and fit-test accuracy.
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2021. Presentation at the January 25, 2021, meeting of the National Acad emies of Sciences, Engineering, and Medicine Committee on Respiratory Protection for the Public and Workers Without Respiratory Protection Programs at Their Workplaces, virtual.
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2021. Presentation at the January 25, 2021, meeting of the National Acad emies of Sciences, Engineering, and Medicine Committee on Respiratory Protection for the Public and Workers Without Respiratory Protection Programs at Their Workplaces, virtual.
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2018. Short communication: Health interventions in volcanic eruptions -- community wearability as sessment of respiratory protection against volcanic ash from Mt Sinabung, Indonesia.
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1996. Respiratory protection guidelines.
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2004. Respiratory protection against mycobacterium tu berculosis: Quantitative fit test outcomes for five type N95 filtering-facepiece respirators.
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2021. Presentation at the January 26, 2021, meeting of the National Acad emies of Sciences, Engineering, and Medicine Committee on Respiratory Protection for the Public and Workers Without Respiratory Protection Programs at Their Workplaces, virtual.
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2015. Hospital respiratory protection practices in 6 U.S.
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2016. Critical review of health impacts of wildfire smoke exposure.
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2018. Non-occupational uses of respiratory protection -- what public health organizations and users need to know.
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2020. Protect yourself from wildfire smoke.
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2010. Evaluation of a large-scale quantitative respirator-fit testing program for healthcare workers: Survey results.
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