8  Personal Protective Equipment (PPE)

8.1  Respiratory
N-95 respirators (see Fig 3 & Fig 3a & Fig. 4 15 ) are required for airborne protection from COVID-19. Per OSHA regulations, HCW must be properly fit-tested with either a qualitative or quantitative device to ensure the mask makes a proper seal with the wearer's skin and offers adequate protection. Users must be clean shaven for mask use as well as for the fit test. Numerous brands are available from multiple manufacturers16 (see photos from NIOSH webiste below). Users with beards cannot be fit tested with an N95, since an adequate seal is not possible17 . HCW with beards can use a powered air-purifying respirator (PAPR) with a hood, since these function without the need for a tight skin seal and therefore also do not require fit testing (see photos).
Fig. 4 face shield and N95 for airborne protection.
N95 designation is from NIOSH, meaning it is actually a dust-mist respirator which filters out 95% of small particles, but is not resistant to oil (N= Not; 95= 95% filtration efficiency). An R95 has the same filtering capacity but is recommended for oily solvents (R= recommended). Higher designations such as P100 mean they filter out 99.99% of particles (P= particles; 100=essentially 100% efficiency). Higher levels of protection (i.e., R95, P100) are acceptable if a situation calls for N95 and an N95 is not available, but lower levels of protection (i.e., simple procedure or surgical mask) are not (Fig. 9).
Some of the styles of N95 masks available:
Photos courtesy of 3M, Kimberly-Clark, and Moldex 18 .
Since OSHA declares N95 masks for HCW as respirators, their use is governed by the OSHA Respiratory Protection Standard 1910.13419 . Employers must have a program in place with the following components:• Written worksite specific procedures;
• Program evaluation;
• Selection of an appropriate respirator approved by NIOSH
• Training
• Fit testing
• Inspection, cleaning, maintenance, and storage (for loose-fitting hoods- N/A to disposable single-use N95 masks)
• Medical evaluations
Paragraph 1910.134(e)(2)(i) of the standard explains that the medical evaluations are to be performed by a physician or other licensed health care professional (PLHCP) identified by the employer to perform medical evaluations using a medical questionnaire or an initial medical examination that obtains the same information as the medical questionnaire. The employer shall ensure that a follow-up medical examination is provided for an employee who gives a positive response to any question among questions 1 through 8 in Section 2, Part A of Appendix C 20 or whose initial medical examination demonstrates the need for a follow-up medical examination. Questions 10-15 and all of part B regarding full-face respirators do not apply to HCW using N95 or loose fitting PAPR hoods. Since the N95 respirator is a negative pressure respirator, if the PLHCP finds a medical condition that may place the employee's health at increased risk if the respirator is used, the employer shall provide a PAPR (such as the hood described above and pictured in Fig. 5, Figs. 5 and 6 21 ).
Fig. 5 .
Figs. 5 and 6 PAPR loose fitting hood with HEPA filters (no fit test required; suitable for bearded HCWs).
Fit testing for the N95 respirators is required, but can be performed qualitatively using isoamyl acetate (banana oi), saccharin solution, or Bitrex© Fig. 4a (see Fig. 4a), or quantitative using an approved device, such as Port-a-Count® (see Fig. 7, Fig. 8 ) 22 . The fit test must be performed with exact make, model, and size of respirator the HCW with be using in the workplace. Qualitative testing does not compromise the mask integrity and therefore after the test the employee can take the N95 with them for future single use (important consideration in time sof shortages). Quantitative fit tests require insertion of a probe through the mask, compromising mask integrity, and therefore the N95 must be discarded after a quantitative fit test. Fit testing is not required for loose-fitting PAPR hoods (which are used primarily by HCW with facial hair that does not allow a proper seal), because the breathing zone environment is under positive pressure and therefore a tight seal is not required for proper function and protection.
Fig. 7 Fit testing N95 mask with PortaCount®.
Fig. 8 Portacount® quantitative fit test device.
Fig. 9 Simple procedure mask with integrated face shield (not an N95). Used by general public. This could be worn on top of N95 for eye protection.