The Personal Protective Technology Program at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health (2008)

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5 Recommendations for PPT Program Improvement M illions of working Americans depend on personal protective technologies (PPT) to prevent exposures to occupational health hazards. As described in the preceding chapters, the committee believes that the NIOSH PPT Program has effectively identified and implemented high-priority research and standards-setting efforts and has been thorough and forward thinking in conduct- ing the respirator certification process. Further, the committee finds that the PPT Program has made a substantive impact on improving worker safety and health by ensuring that NIOSH-certified respirators meet rigorous pre-specified criteria and by the formation of strong partnerships with other organizations and agencies working to develop rigorous PPT standards. The NIOSH PPT Program has made effective use of its limited resources and has moved the research, standards-setting, and certification agendas forward, largely with a focus on respirators. However, much still has not been done due to serious budgetary constraints. The committee offers the following recommendations with the goal of improving the ability of the NIOSH PPT Program to broaden its scope and depth of responsibility in order to protect workers more effectively from hazardous workplace exposures, illness, injuries, and disease. 116 

R e c o m m e n dat i o n s for PPT P r o g r a m I m p r o v e m e n t 117 IMPLEMENT AND SUSTAIN A COMPREHENSIVE NATIONAL PPT PROGRAM Recommendation 1: Implement and Sustain a Comprehensive National Personal Protective Technology Program NIOSH should work to ensure the implementation of the 2001 congressional mandate for a comprehensive state-of-the-art federal program focused on personal protective technology. A comprehensive program would build on the current NIOSH PPT Program and would bring unified responsibility and oversight to all PPT-related activity at NIOSH. The National Personal Protective Technology Program should • Oversee, coordinate, and where appropriate, conduct research across all types of occupational PPT and across all relevant occupations and workplaces; • Participate in policy development and standards setting across all types of occupational PPT; • Oversee all PPT certification in order to ensure a minimum uniform standard of protection and wearability. The National Program should collaborate with other relevant government agencies, private-sector organiza­tions, and not-for-profit organizations to conduct an assess- ment of the certification mechanisms needed to ensure the efficacy of all types of PPT; and • Promote the development, standards setting, and certification of ef- fectively integrated PPT components and ensembles in which multiple types of PPT (e.g., eye protection, hearing protection, respirators) can be effectively and seamlessly worn together. The committee was struck by the discordance between the congressional mandate to establish the National Personal Protective Technology Laboratory  Senate Report 106-293 stated “It has been brought to the Committee’s attention the need for d ­ esign, testing and state-of-the-art equipment for this nation’s 50 million miners, firefighters, health- care, agricultural and industrial workers. . . . The Committee encourages NIOSH to carry out ­research, testing and related activities aimed at protecting workers, who respond to public health needs in the event of a terrorist incident. The Committee encourages CDC [the Centers for Disease Control and Prevention] to organize and implement a national personal protective equipment laboratory.” 

118 The Personal Protective Technology Program at N I OSH (NPPTL) in 2001 and the challenges faced by the current PPT Program, which focuses almost solely on respiratory PPT because of limited resources. If NIOSH is to respond fully to its 2001 congressional directive to develop and test state- of-the-art national PPT needs (respirators, protective clothing, gloves, hearing protection, eye protection, and other types of PPT) across all relevant work sec- tors, then a more comprehensive approach is needed. The National PPT Program should be responsible for all PPT efforts within NIOSH, as well as for coordinating relevant efforts with federal agencies (Department of Defense [DoD], Department of Homeland Security [DHS], Food and Drug Administration [FDA], Department of Labor [DoL], and Environmental Protection Agency [EPA]). The designation of the National Personal Protective Technology Laboratory as a laboratory, denotes the important function of research, but does not fully capture the scope of efforts that are needed to improve worker safety through personal protective technologies. Designating these efforts as the National PPT Program emphasizes the goal of coordinating and expanding the full range of certification, standards-setting, and research efforts. As PPT becomes increasingly complex, integration of its many components re- quires scrupulously coordinated development of interfaces and ensembles that are designed, standardized, and certified under the oversight of a single entity within NIOSH, dedicated solely to PPT in the workplace. To promote worker safety by integrating various types of protective equipment requires placing the responsibil- ity for all PPT efforts at NIOSH under a single entity that has the responsibility and the requisite resources to oversee the broad array of PPT and to lead the efforts to provide workers with improved and innovative protective equipment. Further, the consolidation of PPT responsibilities and the focus on the wide array of PPT devices could be leveraged to expand recall authority for defective products (e.g., older models of PASS [personal alert safety system] warning devices). The National PPT Program should examine PPT interface issues and should work with relevant partners to coordinate and oversee the research, certification, and standards setting for all PPT, including multicomponent ensembles. In 2005, NIOSH took a significant first step toward coordinating PPT-related efforts across the institute by establishing the PPT Program and developing a ma- trix approach to management. However, the committee is concerned that the cur- rent matrix structure of PPT efforts at NIOSH may be too ambiguously configured to serve the long-term needs and flexible goals of a comprehensive, coordinated national PPT endeavor. Although designated as a program in name, the directors of the current PPT Program have limited budgetary authority and management responsibility for PPT research and other efforts outside NPPTL. As a result of the lack of a single authority, there are major gaps in the integration, coordination, and consolidation of many types of PPT. The current matrix approach, while a good 

R e c o m m e n dat i o n s for PPT P r o g r a m I m p r o v e m e n t 119 first step, does not bring the full depth and range of NIOSH expertise to bear on moving forward in improving and coordinating PPT at the national level. In exam- ining the PPT needs of one specific workplace sector, a recent Institute of Medicine committee examined the anticipated PPT needs of healthcare workers during an influenza pandemic and recommended that Congress expand the resources pro- vided to NIOSH for expediting the development and approval of improved PPT (IOM, 2008). The National PPT Program, through a much broader focus, propor- tionately increased responsibilities, and more direct lines of coordinated oversight and responsibility would provide the needed impetus for an integrated approach to PPT that encompasses the entire range of protective equipment and technologies and the multiple interfaces between and among them. After evaluating the evidence and hearing from many stakeholders, the com- mittee has concluded that NIOSH certification of respirators (through its exten- sive testing and audit process) has had a significant positive impact on the quality of respirators available in the workplace. However, there is no analogous federal process for ensuring the certification of non-respiratory PPT (e.g., eye ­protection, hearing protection, protective clothing). Currently, third-party certification is an available voluntary option for several specific types of protective clothing, gloves, and helmets, but there is no uniform oversight of the certification process for all PPT. Other types of protective equipment (e.g., protective eyewear, protec- tive footwear) are often manufactured to meet performance criteria specified by consensus standards, which are voluntary. The committee is therefore concerned about the lack of rigorous certification for some types of PPT and encourages a thorough assessment of certification and oversight options. There are several pos- sible ways in which an expanded PPT Program might bring a minimum standard of uniformity to the safety of workers who are dependent on PPT: (1) The PPT Program could be designated with certification responsibilities as is currently done with respirators. (2) An alternative option would be to provide the National PPT Program with oversight authority to ensure that PPT products meet uniform con- sensus standards. The program’s oversight role could include providing support to identify and resolve any procedural or technical issues or conflicts that may arise in the course of certification of personal protective equipment by federally licensed private-sector laboratories. (3) Establishing a set of NIOSH-approved independent testing laboratories is yet another option, such as is done for the testing of bullet- proof vests by National Institute of Justice-approved laboratories. The committee did not have the mandate to examine these or other options thoroughly but urges a detailed assessment of these issues with the goal of developing and implementing a standardized process to certify all types of PPT. The PPT Program has utilized its own laboratory effectively and has nurtured a number of partnerships. These collaborative efforts, particularly as seen in the 

120 The Personal Protective Technology Program at N I OSH work on CBRN respirators, have fostered positive results. Increased collaborations across NIOSH divisions and sectors are needed, as well as efforts to collaborate with additional federal, nonprofit, and for-profit agencies and organizations. The committee urges the PPT Program to continue to assert its role as a resource and to expand its leadership role in initiating dialogue about critical PPT issues and exploring new and innovative technologies. The committee believes that a meaningfully integrated approach to improving all types of occupational PPT would logically require consolidation of the oversight responsibilities for PPT efforts at NIOSH. The committee’s emphasis in response to its charge was on proposing a general strategy intended to optimize the wealth of relevant expertise at NIOSH in order to meet the new challenges of develop- ing fully integrated and coordinated protective ensembles and technologies for worker protection. Approaches could range from maintaining current laboratory and research facilities with changes in reporting and budgetary authority to more major organizational changes. Carrying out the original congressional intent of an effort focused on “the design, testing, and state-of-the-art [personal protective] equipment for this nation’s . . . workers” (Senate Report 106-293) will necessitate a commitment to a broad scope of work and collaborative efforts that will impact workers in all occupations that use personal protective technologies. ESTABLISH PPT RESEARCH CENTERS OF EXCELLENCE Recommendation 2: Establish PPT Research Centers of Excellence and Increase Extramural PPT Research The PPT Program should establish and sustain extramural PPT centers of excellence and work to increase other extramural research opportunities. The PPT Program should • Develop and support research centers of excellence that work closely with the NIOSH intramural research program to improve PPT, increase field research, and explore and implement research to practice interven- tions; and • Work with the NIOSH Office of Extramural Programs to increase other research opportunities and enhance collaboration and awareness of relevant PPT research efforts among intramural and extramural researchers. The community of extramural scientists is a highly valuable resource for im- proving PPT. It is critical that this breadth and depth of expertise is focused on 

R e c o m m e n dat i o n s for PPT P r o g r a m I m p r o v e m e n t 121 important PPT research questions relevant to improving PPT and to transferring PPT research into workplace practice. Successful efforts to address critical issues in many other fields of scientific inquiry have been the result of investing in ex- tramural research centers of excellence. Research centers of excellence allow for interdisciplinary expertise and improved ability to evaluate interventions such as new technologies, while facilitating strong collaborations. Increased intramural research resources and personnel, extramural grants, cooperative agreements, and direct contracts should be balanced to leverage PPT capabilities. Where feasible, the PPT Program should take advantage of existing expertise, laboratory infrastruc- ture, and outreach networks, which may be costly to duplicate in the intramural PPT Program. In addition to expanding the resources dedicated to PPT research and development, a strong extramural community provides the opportunity to extend scientific inquiry into the behavioral sciences and other types of expertise that might not be available within the NIOSH PPT Program. PPT centers of excel- lence should be aligned with one or more of the scientific focus areas of the PPT Program. The centers could be developed to be topic-specific (e.g., heat stress, dermal permeation) or to be sector-specific to explore the unique PPT needs of a particular occupation or set of workers. Several types of centers would be opti- mal. University-based research centers could establish collaborative networks with other universities and with nonprofit organizations and federal agencies focused on research and development of innovative approaches to PPT. Complementary centers of excellence would be those that are centered in nonprofit organizations, state departments of health or labor, or agencies with capabilities and expertise in post-market or field research. These centers, in conjunction with partner organi- zations and universities, could increase field research, and explore and implement research to practice interventions. Multi-year funding and evaluation are critical to build a strong and ever-improving research base. Models of federally supported centers of excellence include those funded by the Department of Homeland Security, such as the National Center for the Study of Preparedness and Catastrophic Event Response, led by Johns Hopkins Univer- sity (DHS, 2008) and the Nursing Centers of Excellence (funded by the National Institute of Nursing Research). Relevant examples of successful university-based centers of research in PPT include the University of Minnesota’s Center for Filtra- tion Research, North Carolina State University’s Center for Research on Textile Protection and Comfort, and the University of Maryland’s research focus on physiological testing. The National Construction Center, which is administered by The Center for Construction Research and Training, is an example of a national nonprofit consortium focused on research to practice. Centers of excellence have advantages that come with developing a strong cadre of extramural investigators who can obtain research support and develop sustained 

122 The Personal Protective Technology Program at N I OSH careers in PPT—opportunities that are now largely nonexistent. Several committee members and workshop speakers noted this as a major impediment to choosing PPT research as a career path. Research support should be available for early career investigators to enable a viable career path for talented scientists. The committee urges the PPT Program to sponsor an annual conference to facilitate interaction and exchange of ideas among intramural and extramural investigators working in PPT and relevant fields. The PPT Program’s public stake- holder meetings, such as the one in March 2008, provide additional opportunity for researchers to discuss innovative research and identify new and emerging issues in PPT. The PPT Program, through the NIOSH Office of Extramural Programs (OEP), has assembled a list of extramural grants relevant to PPT (Chapter 2). PPT Program staff members have also reported increased opportunities for dialogue with OEP in the past year regarding priorities for funding. The committee urges NIOSH to consider ways in which the PPT Program could have greater input into the extra- mural priority process at NIOSH and increased participation in drafting requests for grant applications. Further, the PPT Program and OEP should examine whether the current grant review structure (e.g., study groups) is adequately configured to review applications with expertise relevant to PPT. Collaborative extramural partnerships, exemplified by centers of research ex- cellence in personal protective technologies, would serve to leverage the PPT Pro- gram’s resources and expertise and provide the coordinated intramural-extramural approach necessary for advancing science and technology relevant to protecting workers through PPT. ENHANCE THE RESPIRATOR CERTIFICATION PROCESS Recommendation 3: Enhance the Respirator Certification Process The PPT Program should continue to improve the respirator certification process. The program should • Expedite the revision of the respirator certification regulations. As a part of that effort, NIOSH should revise the respirator certification fee schedules so that certification fees paid by respirator manufacturers fully cover the cost of certification. NIOSH’s research budget for PPT research should not be eroded by the costs of certification. • Develop a mechanism for registering the purchase of NIOSH-certified respirators so that post-marketing notifications and recalls can be ac- complished expeditiously and effectively. 

R e c o m m e n dat i o n s for PPT P r o g r a m I m p r o v e m e n t 123 • Expand the audit programs to ensure that results of the product au- dit program are methodologically and statistically sound and that the site audit program ensures standardized quality of audits whether per- formed by NIOSH staff or contractors. • Disseminate respirator certification test result data (e.g., breathing resistance). Respirator certification has been a significant part of the work of the PPT Pro- gram. In FY 2007, almost half (approximately 48 percent) of the PPT Program’s $13.1 million budget was designated for the certification program (Table 2-2; data include overhead costs); in prior years, certification generally constituted about a third of the program’s total budget. In FY 2007, certification occupied about half of the PPT Program’s full-time equivalent workforce (Table 2-3). As highlighted in Chapters 2 and 3, the NIOSH respirator certification process is highly respected and provides a major contribution to worker safety. The committee believes that although the enhancements to the certification program recommended above will require additional resources, the dividends that will accrue to workers from improved standards, audits, and information dissemination will make such an investment sustainable and well worth the start-up costs. Improving respirators, and thereby reducing exposures to respiratory hazards, is in large part an effort focused on updating, refining, and developing the tests and performance criteria that respirators must meet to provide effective protection in the workplace. These tests are specified through federal regulations, many of which have not been changed significantly in more than 35 years. The PPT Program through NPPTL has developed a modular approach to updating federal regulations. The committee sees these revisions and additions to the regulatory standards as a major opportunity for the PPT Program to improve respirators through updated tests that address current and evolving technologies. It is particularly important for current respirator workplace applications to be considered in the revision of respi- rator certification regulations. The proposed changes and additions to the regula- tions should be moved more expeditiously through the rule-making pipeline. An issue of concern to the committee was the extent of federal resources devoted to the costs of respirator certification, costs that would more appropri- ately be borne by respirator manufacturers as is done for other types of product certification. The Bureau of Mines established the structure of certification fees in the approval schedule for each respirator type when each schedule was put in place. When the respirator certification program was transferred from the Bureau of Mines to the Mining Enforcement and Safety Administration (the predecessor of MSHA) and NIOSH in 1972, the fee structure from the previously existing Bureau of Mines approval schedules was incorporated into the new consolidated 

124 The Personal Protective Technology Program at N I OSH approval regulations without any change to the fees. Because the fee schedule has not been updated for over 35 years, the program covers only a small fraction of the current costs of respirator certification. Less than 10 percent of the cost of testing and certifying traditional respirators is currently recovered through fees charged to manufacturers (see Chapter 2). Recent changes to the regulations have allowed NIOSH to significantly increase the CBRN respirator certification fee schedule because of the high costs of the live agent testing that is required. However, only a small percentage of CBRN fees are remitted to NIOSH. Consequently, similar to the certification of other respirators, CBRN certification is not self-sustaining. The PPT Program is in the early phases of a plan to update the certification fee schedule for all types of respirators, and the committee urges approval of a revised fee structure that would fully recover the costs of certification activities. When cer- tification cost recovery becomes a reality, it will be important that standards-setting efforts—and, most importantly, the expanded research program—are viewed as distinct activities, funded independently and in proportion to their contributions to worker safety and health. The product and site audit programs are important tools to ensure manufac- turer compliance as required by 42 CFR 84. The product audit program, in which respirators are routinely selected for testing from normal sales and distribution out- lets, conducts only 40 to 60 product audit evaluations per year—a number that does not yield a statistically significant sample. The sampling strategy for this program needs to be carefully examined to ensure methodologically and statistically sound results. The site audit program is designed to ensure that manufacturers maintain quality facilities, processes, and products (see Chapter 2). A thoroughly monitored site audit program is needed to ensure that the audits, whether undertaken by PPT Program staff or by outside contractors, are conducted using valid methodology and appropriate data analysis. Product recalls and product defect information are currently posted on the PPT Program’s website. The committee acknowledges the importance of the detailed information that is posted but is concerned about the passive nature of the dis- semination process. Without an effective means of disseminating this information, employers or employees might unknowingly be using products deemed ineffec- tive. The current system for respirator certification does not include provisions for having devices “registered” (e.g., with purchasers’ contact information), which  The certification cost is a one-time cost for each type of respirator submitted for testing. After receiving certification, the manufacturer can produce hundreds to millions of that type of product, and therefore the certification costs are spread out over many items.  CBRN respirator testing is conducted in part by the U.S. Department of Defense using live chemi- cal warfare agents as part of the required testing. 

R e c o m m e n dat i o n s for PPT P r o g r a m I m p r o v e m e n t 125 undermines recall effectiveness. The PPT Program and manufacturers should have a direct and online method for contacting employers and others who purchase res- pirators in order to provide them with notices indicating that a problem or recall has occurred. It should be noted that the Mine Safety and Health Administration (MSHA) has recently begun requiring registration of self-contained self-rescuers (SCSRs) with mine operators. Other potential models include the registration card systems used for many consumer products. Review and adoption of best practices from the Consumer Product Safety Commission should be considered, as should instituting measures of recall effectiveness. The NIOSH website currently provides the Certified Equipment List, a list of the respirators that have passed the certification process (NIOSH, 2008a). Providing certification test result data on the website would also be helpful to purchasers so that they can examine results on specific measures (e.g., breathing resistance). INCREASE RESEARCH ON THE USE AND USABILITY OF PPT Recommendation 4: Increase Research on the Use and Usability of PPT The PPT Program should intensify its research directed at barriers to and facilitators of PPT use by workers. Such research should examine human factors and ergonomics, as well as individual behaviors and organizational behaviors, particularly workplace safety culture. One of the greatest challenges to PPT effectiveness is ensuring that the worker is wearing the equipment and is wearing it correctly. Understanding that comfort is fundamentally a safety issue is a necessary prerequisite to improvement of the materials, design, and engineering of PPT in such a way that critically important human factors are taken into account. Improving usability will require research that focuses on task- and worker-centered design and a more in-depth knowledge of physiologic burdens (often heat stress) resulting from wearing PPT in the work environment. The PPT Program is moving forward in its work with the National Fire Protection Association and other partners in addressing these issues, particu- larly as they relate to physiologic burdens for emergency responders and firefight- ers. However, similar efforts are needed to assess usability issues for the majority of the workforce employed in other occupations. Collaborations with other NIOSH efforts in this area, particularly the work on Research to Practice and on Prevention through Design will be valuable as well as external collaborations. Other important underinvestigated areas include behavior and the induction of behavioral change—specifically, changes by employers, work site managers, and workers that are essential prerequisites to increasing adherence to PPT protocols. 

126 The Personal Protective Technology Program at N I OSH Research directions in this area should focus on improving the safety culture of organizations and individuals—a complex set of issues that involve training, leader- ship, and clarification of work site practices and policies (IOM, 2008). ASSESS PPT USE AND EFFECTIVENESS IN THE WORKPLACE Recommendation 5: Assess PPT Use and Effectiveness in the Workplace Using a Life-Cycle Approach The PPT Program, in collaboration with relevant NIOSH divisions and other partners, should oversee an ongoing surveillance and field testing program to assess PPT use and effectiveness in the workplace. These efforts should emphasize a life-cycle approach by including both pre-market and interval post-market testing of PPT and include data collection on issues ranging from training to decontamination. Enhanced efforts would • Assess and critically appraise PPT use and effectiveness across all types of PPT (e.g., gloves, eye protection, respirators) and across relevant in- dustry sectors and workplace environments; • Require random periodic field testing of an adequately sized sample of PPT to assess effectiveness, usability, and durability with reasonable accuracy and precision; and • Build on existing government and private-sector surveys and surveil- lance activities that collect PPT-relevant data and facilitate linkages to other datasets. Improvements in PPT will be driven both by efficacy data generated in the laboratory and effectiveness data gathered with equal scientific rigor in the work- place. Research priorities for PPT should be based on the prevalence and degree of exposure, modified by the strength of the observed association between these attributes of exposure and long- and short-term outcomes of illness and injury. The committee urges the NIOSH PPT Program to assess the effectiveness and use of PPT in the workplace across all phases of the lifetime of the products. This type of evaluation and surveillance construct could involve an array of approaches and methodologies, including pre- and post-market field testing of PPT products, surveys, on-site observations, focus groups and other end user inputs, as well as outcome and impact evaluations and formal cost-benefit analysis. Obtaining input from the end user of PPT products is particularly important. In considering how best to plan and learn from a life cycle approach to data col- lection that will involve field testing and ongoing surveillance, it will be important 

R e c o m m e n dat i o n s for PPT P r o g r a m I m p r o v e m e n t 127 to keep in mind that the immediate goals will differ with pre- and post-market field testing focused on the effectiveness of a specific product and surveillance focused on an ongoing assessment of PPT use. The committee believes these efforts are a necessary and vital investment for improving PPT and protecting workers from hazardous exposures. By choosing the appropriate methodologies and by building on current data collection efforts, sound investments can be made in obtaining data that are representative of workplace use and useful in improving PPT products and training. With current limits on resources available for certification testing, virtually all of the product testing is now confined to the laboratory. Normal use is simu- lated in the laboratory, and consideration is given to testing under conditions that mimic workplace wear and tear on the product. However, the committee believes that more testing and research needs to be conducted in the field under work- place conditions with workers who depend on the sustained effectiveness of their PPT. The goal is an iterative improvement process that would include pre- and post-market testing plus utilization of other data sources including worker and employer feedback, surveillance, Health Hazard Evaluations (HHEs), and product and site audits. Further, field testing should occur during both the pre-marketing and post-marketing phases. For respirators and some other types of PPT, various pre-marketing certification tests could incorporate a field testing component. For other types of PPT that do not currently undergo a certification process by NIOSH, combined laboratory and field testing overseen by the PPT Program are necessary logical and scientific prerequisites to declaring PPT components and ensembles effective in the workplace. Along the continuum of the life-cycle approach, decontamination, service- ability, and reusability issues need to be considered (IOM, 2006, 2008), especially for expensive and highly specialized CBRN equipment or for circumstances that could require extensive use of PPT, such as an influenza pandemic. Limited re- search efforts examining the safe decontamination and use of PPT are ongoing, but many important engineering and behavioral questions remain unanswered. Further research is also needed to define the trade-offs between disposing of and decontaminating PPT. The PPT Program is currently developing a long-term surveillance action plan that was available to the committee in draft form in early March 2008 (NIOSH, 2008b; Chapter 3). Up to this point, most of the PPT Program’s surveillance focus has been on inhalation exposure and respirator usage. For example, the PPT Pro- gram worked with the Bureau of Labor Statistics on the survey Respirator Usage in Private Sector Firms (BLS and NIOSH, 2003). Follow-up efforts to this survey included an assessment by a National Research Council (NRC) committee that resulted in the report Measuring Respirator Use in the Workplace (NRC, 2007). The 

128 The Personal Protective Technology Program at N I OSH NRC report provided a number of recommendations for improvement of future PPT surveillance efforts. Congruent with other recommendations addressing the future needs of the PPT Program, the committee urges that surveillance efforts extend beyond respi- rators and encompass all types of PPT. A sector-by-sector approach to surveying hazards and personal protective practices may be more efficient, cost-effective, and manageable than a large-scale survey of all workplaces. Although the proposed National PPT Program need not carry out all surveillance across all work sectors, consistent with the committee’s prior recommendations on research, certification, and standards setting, it should have oversight responsibilities to ensure that the surveillance methods are coordinated and focused on relevant PPT issues. Devel- oping a highly relevant PPT surveillance program, that incorporates long-term physiological endpoints, can best be coordinated across the NIOSH matrix of work sectors through the oversight of the expanded PPT Program. Utilizing available data collection mechanisms could be useful in gathering information in the workplace and providing realistic assessments of how PPT is being used. For example, agreements with OSHA and MSHA might allow some gathering of data on the use of chemical protective clothing and other PPT based on inspections, through a sample survey of inspectors’ findings. Collection of work- place data through a coordinated effort with the HHE Program might also prove fruitful. What is needed for true effectiveness research is information gathered from users and from direct observation and surveillance of PPT use in the workplace. The PPT Program has been proactive in involving stakeholders in the de- velopment of changes to standards. Continued use of focus groups is critical to surveillance activity targeted at gaining insights into how PPT products are work- ing and being used in the field. The committee emphasizes data collection on the effectiveness and use of PPT products as a priority for improving the protection afforded through PPT. CONCLUDING REMARKS The committee urges NIOSH to reexamine its commitment to PPT with a focus that is directly proportional to its importance to the safety and health of the millions of workers in the many workplaces where administrative and engineering controls are inadequate, impractical, or simply nonexistent. NIOSH’s Personal Protective Technology Program has made significant strides in improving the PPT available to workers, especially respiratory PPT. It is the committee’s hope that the recommendations in this report will provide the neces- sary impetus for the development of a National Personal Protective Technology Program that conducts, coordinates, and provides national oversight of research, 

R e c o m m e n dat i o n s for PPT P r o g r a m I m p r o v e m e n t 129 standards setting, and certification for all components of PPT and the interface between and among those components. The committee concludes, on the basis of all available evidence, that increasing the protection of workers from hazard- ous workplace exposures through the development and deployment of improved personal protective technologies is not only a critically important and worthwhile goal for workers in the United States and around the world but, with additional resources and thoughtful reorganization, is by no means out of reach. REFERENCES BLS (Bureau of Labor Statistics) and NIOSH (National Institute for Occupational Safety and Health). 2003. Respirator usage in private sector firms, 2001. http://www.cdc.gov/niosh/docs/respsurv/ (accessed January 22, 2008). DHS (Department of Homeland Security). 2008. Homeland Security Centers of Excellence. http://www. dhs.gov/xres/programs/editorial_0498.shtm (accessed March 8, 2008). IOM (Institute of Medicine). 2006. Reusability of facemasks during an influenza pandemic. Washington, DC: The National Academies Press. IOM. 2008. Preparing for an influenza pandemic: Personal protective equipment for healthcare workers. Washington, DC: The National Academies Press. NIOSH. 2008a. Certified equipment list. http://www.cdc.gov/niosh/npptl/topics/respirators/cel/ (ac- cessed March 7, 2008). NIOSH. 2008b. PPT surveillance program action plan. Draft, March 5, 2008 (available through the National Academies Public Access File). NRC (National Research Council). 2007. Measuring respirator use in the workplace. Washington, DC: The National Academies Press.