If an influenza epidemic sweeps across the United States, one of the most critical tools to keep hospital workers safe may be among the most mundane—the disposable N95 respirator mask. Designed to filter out airborne viruses that quickly could infect front-line clinicians, these effective and inexpensive masks are already in short supply as health care organizations stockpile supplies in anticipation of a potential outbreak.
But even adequate supplies won’t necessarily protect doctors, nurses and hospital staff, warns Janice Comer Bradley, technical director for the International Safety Equipment Association (ISEA), Arlington, Va.
In the following interview, Bradley discusses how without proper fit, training and adherence to the right usage protocols, N95s may be only slightly more effective in protecting health care workers than no mask at all.
Q In the event of severe shortfalls of N95 masks, would the common disposable surgical mask provide protection for clinicians against the flu virus?
A The goal of a surgical mask is to keep anything from the nose or mouth of a health care professional entering the field in front of a patient. It’s never been designed to provide protection for the person wearing it. The goal and design of an N95 respirator mask is solely to protect the wearer.
The design is based on the ability of the mask to achieve a seal against a user’s face. The fact of the matter is that hospitals need to implement some guidelines about who is supposed to get what based on the role they play if a pandemic really does come to fruition.
As a health care worker, the only way you would show up for work would be if you were guaranteed there were adequate supplies of protective equipment to use. Otherwise, staff members probably are going to wind up staying home.
Q Have most hospitals done an adequate job of putting together those kinds of guidelines if an avian flu epidemic occurs?
A I think hospitals already have a good idea about who is going to get respirators. Health care workers have had to deal with unknown entities from both emerging hazards and unknown hazards for years. The threat may be a pandemic today, but it was SARS before that and anthrax before that. There’s always some unplanned event that requires the use of PPE (personal protective equipment), and that includes respirators.
Q How is a respirator mask properly donned and removed? Is it a complicated procedure and are people being trained correctly?
A The whole donning and removing activity revolves around a fit test to ensure that those who need to wear a respirator have some experience wearing it. I don’t know anyone who would buy a pair of shoes without trying them on. Why would you not at least give that much attention to something that is supposed to protect you from an infection that can potentially kill you?
Q In terms of fit, do the masks come in small, medium and large sizes?
A Yes.
Q So when we are talking about fitting masks, we’re not talking about a custom fit.
A No, it’s more general than that. But there should be an expectation on the part of employees that not only should they be fit tested, but they also should be properly trained to use the masks correctly. That can’t be overstated. Manufacturers’ instructions tell you where to place the filtering device on the face and exactly how to place the straps. You also should have some wear time. Practice putting it on and taking it off. And learn that you’ve got to be careful not to touch things. You certainly don’t want to touch the respirator and then do something else without washing your hands. You don’t want to take it off and rub your eye. That all takes a little bit of thought. It’s not overly complicated, but the first time you do anything, you don’t do it the best way you’ll ever do it. The time to learn how to wear a respirator so that it is effective is not when a pandemic occurs. You certainly don’t want a pandemic hitting at the same time you are learning how to fit, use and take a respirator on and off. Then there’s the question of how often do you need to retrain people? It takes time away from their primary job to be trained in these types of things, but that’s what is really going to determine how effective these devices are.
Q Who in a hospital is charged with the responsibility of making sure people are properly fitted and trained?
A Many hospitals have safety and health professionals on staff—an industrial hygienist or a safety engineer. It doesn’t have to be an in-house employee; it can be done by a contract service, by safety and health professional consultants or the manufacturer.
Q The Department of Health and Human Services has been looking into the idea of reusable N95 masks. Is such a thing even possible as far as your association is concerned?
A I participated in a panel last year formed by the National Academy of Sciences’ Institute of Medicine, Washington, D.C. The Department of Health and Human Services, Washington, D.C., commissioned them to find out if there was such a thing. We’ve been saying all along that if there was such thing as a reusable, disposable mask that fit everybody, it would already be on the market and probably selling extremely well.
There isn’t one right now. I think they are going a step further to find out if there is anything that can be done to extend the life of a disposable respirator. There are things that you certainly cannot do, including disinfection procedures that may be used in a hospital. You can’t autoclave them nor can you put them in alcohol.
Q Because it destroys the material?
A Yes, it is filter media, and most of them have an electrostatic charge. It’s not just a trapping mechanism—the filter itself is treated to attract particles. So anything you do to interfere with that is a problem. Right now, there are no guidelines for reuse. That doesn’t mean it doesn’t occur, but it wouldn’t be a good idea at all. Think about it—masks are labeled disposable for a reason. Everything that went into making that mask, from the staples or the mechanism that holds the headstrap to the filter material, are materials that were not meant to last. The other consideration is that respirators become wet from the exhalation of the wearer. What happens to something when you keep wetting it, drying it, wetting it, drying it? It becomes misshapen, and that affects its ability to form a seal around the face. People ask, “Why can’t you just put it on a clothespin and hang it up?” Well, first of all, it is a device to trap viruses. They live on the mask. Barring any means of disinfecting it, do you really want to put that thing back on your face?
Q What is the life span of one of these masks? Is it per patient or per shift?
A Most of the disposables are made of materials meant to last for a shift and then be thrown away. Now there are other masks that typically are not preferred by health care institutions, but given supply shortages, might have to be introduced into that workplace. Health care workers like disposable N95 respirators because they are more like surgical masks, and you can get rid of them.
Q What are the other masks like?
A The mechanism that seals onto the face is made out of a material like silicone or rubber. And the mask is reusable. You can put it in a bucket of disinfectant and hang it up and wear it the next day.
It doesn’t grow bacteria. There are particulate cartridges that go on them, and the masks are meant to last a lot longer than disposable masks.
Q Where are these masks commonly used?
A Where people work around asbestos or gases. Health care workers are a little reluctant to wear one while they are treating a patient because it’s larger and it has the cartridges on it, but it does offer respiratory protection.
Q So people who wear them look more like construction workers than health care workers, which may affect interaction with a patient?
A Yes.
Q What are you seeing in terms of demand for the disposable respirator masks?
A It’s very high. I think hospitals are stockpiling them. Health care workers are going to be given priority among other first responders, as they should. If people really do get influenza, and they want any chance of recovering, they are not going to do it without a health care worker’s help.
But there are mask shortages. Any institutions that may be waiting to see if an influenza pandemic is going to be the real deal before they stockpile masks won’t have any masks to order [when a pandemic materializes]. There’s that much of a delay right now.
Q What sort of backlogs are you seeing?
A Several months of orders are already spoken for. But the flip side is that manufacturers have made capital investments to ramp up production capacity.
Q Has this capacity come on line yet?
A Part of it has, part of it hasn’t.
Q Do you suggest that hospitals pad their orders—maybe add an extra 10 percent or whatever—whenever they place new orders for masks?
A As part of disaster planning, hospitals need to get a really good idea of the population they serve. Is it a large population of people that would be susceptible to influenza? If so, you need to prepare accordingly. And it’s not just for respirators, but for soap, hand sanitizer, protective eye wear, protective clothing and gloves. Respirators are only one part of it.
Q Do you recommend stockpiling a supply of the various types of industrial masks you mentioned earlier, just to make sure hospitals have enough protection on hand?
A If this [pandemic] really happens, people will need to wear whatever is available, and if that means something that you otherwise wouldn’t have worn, you are going to use it anyway. So people need to take a look at what their resources are right now, and other types of respirators are definitely an option.
But there are other classes and types of disposable respirators, too, that look very similar to an N95. In fact, if you put on a P100, for example, I don’t think you’d be able to tell it wasn’t an N95 without the label. Health care workers who work in radiology and might have radiation exposure would use a P100.
It provides physical trapping of the radio nuclei. But it’s effective against viruses, too. Quite frankly, if there’s a shortage of N95s, there’s going to be a shortage of every other kind of mask. But lead times may be a little different, so it would behoove hospitals to check out what else is effective and whether those masks are available sooner.
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