Frameworks for Protecting Workers and the Public from Inhalation Hazards (2022) / Chapter Skim
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Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use
Appendix B: Review of Factors Necessary to Ensure Respiratory Protection is Effective for its Intended Use
Pages 395-446
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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.
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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.
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. 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)
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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.
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. 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.
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. 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.
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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)
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(Bansal et al., 2009; Harber et al., 2009; Roberge et al., 2010b, 2013) , but whether low breathability of respiratory protective devices poses a risk to at-risk members of the public (e.g., elderly populations or those with acute or chronic respiratory diseases)
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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)
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, which can reduce their overall effective ness (Arumuru et al., 2021; Davies et al., 2013; Lai et al., 2012; Leith et al., 2021; Lindsley et al., 2021a; Oberg and Brossau, 2008; O'Kelly et al., 2021; Steinle et al., 2018) as both source control and personal protective devices.
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. While interest in antimicrobial treatments for respiratory protective devices preceded the emergence of SARS-CoV-2 (Tseng et al., 2016)
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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)
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. Different types of respiratory protective devices, including surgical masks, N95 FFRs (Toprak et al., 2021)
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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)
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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: • issues with visual and verbal communications, facial recognition, or visual acuity (Al Naam et al., 2021; Carragher et al., 2020; Freud et al., 2020; Johnson, 2016; Palmiero et al., 2016; Shelus et al., 2020)
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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)
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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)
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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)
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. 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)
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. 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.
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. 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.
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. 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)
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. 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)
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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.
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. 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.
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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.
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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)
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. 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.
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. 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)
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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.
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. 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.
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. 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)
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. 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.
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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 maskuse policies were instituted around the globe as a method for enforcing mask use by the public.
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2021b. ASTM F3407-21: Standard test method for respirator fit capability for nega tive-pressure half-facepiece particulate respirators.
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2012. Impact of multiple consecutive donnings on filtering facepiece respirator fit.
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2001. Respiratory protection as a function of respirator fitting characteristics and fit-test accuracy.
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2019. The respirator fit capability test: Enhancing the efficacy of filtering facepiece respirators.
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2011. Evaluation of microwave steam bags for the decontamination of filtering facepiece respirators.
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2018. Short communication: Health interventions in volcanic eruptions-community wearability assessment of respiratory protection against volcanic ash from Mt Sinabung, Indonesia.
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2019. Survival of microorganisms on filtering respiratory protective devices used at agricultural facilities.
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2016. Physiologic and fit factor profiles of N95 and P100 filtering facepiece respirators for use in hot, humid environments.
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2006. Comparison of perfor mance of three different types of respiratory protection devices.
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2008. Implementing fit testing for N95 filtering facepiece respirators: Practical information from a large cohort of hospital workers.
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2018. The effectiveness of respiratory protection worn by communities to protect from volcanic ash inhalation.
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2009. Assigned protection factors for the revised respiratory protection standard.
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2010a. Effect of exhaled moisture on breathing resistance of N95 filtering facepiece respirators.
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2020. Community knowledge about the use, reuse, disinfection and disposal of masks and filtering facepiece respirators: Results of a study conducted in a dermatology clinic at the University of Naples in Italy.
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2018. The effectiveness of respiratory protection worn by communities to protect from volcanic ash inhalation.
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2019. The effect on fit of multiple con secutive donning and doffing of N95 filtering facepiece respirators.
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Journal of Occupational and Environmental Hygiene 2(12)
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