INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

September 1, 2009

Thomas R. Frieden, M.D., M.P.H.

Director

Centers for Disease Control and Prevention

1600 Clifton Road, NE Atlanta, GA 30333

Jordan Barab, M.A.

Acting Assistant Secretary for Occupational Safety and Health, Department of Labor Occupational Safety and Health Administration

200 Constitution Avenue, NW Room S2315 Washington, DC 20210

Dear Dr. Frieden and Mr. Barab:

On behalf of the Institute of Medicine (IOM) Committee on Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A, we are pleased to report our conclusions and recommendations. At the request of the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA) the Institute of Medicine convened this committee to provide recommendations regarding the necessary respiratory protection for healthcare workers in their workplace against novel H1N1 influenza A (nH1N1). The committee was also charged with considering, to the extent feasible, the available evidence regarding the potential for exposure among healthcare workers; the groups of workers at highest risk; the degrees of risk for various patient care activities; and the extent of knowledge of the virus’ transmissibility, severity, virulence, and potential to change. The committee was also asked to pay attention to current guidance documents on personal protective equipment (PPE), particularly those offered by the CDC and the World Health Organization (WHO) for both nH1N1 as well as seasonal influenza. The committee was not charged with considering the economic and logistical considerations regarding PPE. The committee had significant concerns about the level of healthcare workers’ compliance with the use of PPE, recognizing the noteworthy controversy that exists regarding how compliance affects the clinical effectiveness of PPE, and therefore its relevance to clinical



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September 1, 2009 Jordan Barab, M.A. Thomas R. Frieden, M.D., M.P.H. Director Acting Assistant Secretary for Occupational Safety and Centers for Disease Control and Health, Department of Labor Prevention Occupational Safety and Health 1600 Clifton Road, NE Administration Atlanta, GA 30333 200 Constitution Avenue, NW Room S2315 Washington, DC 20210 Dear Dr. Frieden and Mr. Barab: On behalf of the Institute of Medicine (IOM) Committee on Respira- tory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A, we are pleased to report our conclusions and recom- mendations. At the request of the Centers for Disease Control and Pre- vention (CDC) and the Occupational Safety and Health Administration (OSHA) the Institute of Medicine convened this committee to provide recommendations regarding the necessary respiratory protection for healthcare workers in their workplace against novel H1N1 influenza A (nH1N1). The committee was also charged with considering, to the ex- tent feasible, the available evidence regarding the potential for exposure among healthcare workers; the groups of workers at highest risk; the de- grees of risk for various patient care activities; and the extent of knowl- edge of the virus’ transmissibility, severity, virulence, and potential to change. The committee was also asked to pay attention to current guid- ance documents on personal protective equipment (PPE), particularly those offered by the CDC and the World Health Organization (WHO) for both nH1N1 as well as seasonal influenza. The committee was not charged with considering the economic and logistical considerations re- garding PPE. The committee had significant concerns about the level of healthcare workers’ compliance with the use of PPE, recognizing the noteworthy controversy that exists regarding how compliance affects the clinical effectiveness of PPE, and therefore its relevance to clinical 1

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2 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS guideline decision making. More research is needed to better understand and address this issue. To accomplish its charge within the 8-week timeframe, the commit- tee held a 4-day meeting that included a day-and-a-half public workshop (Appendix A). Panel discussions focused on the current clinical experi- ence with nH1N1, influenza transmission, clinical and community stud- ies on preventing seasonal influenza or other respiratory virus transmission, risks to healthcare workers in various settings, the efficacy and effectiveness 1 of respirators and of medical masks, 2 and decision making in infection control. Additionally, 12 individuals provided com- ments during the public comment session. This report also benefits from the work of prior IOM committees and workshops that have examined issues related to PPE and to pandemic influenza (IOM, 2005a,b, 2006, 2007, 2008a,b). This report focuses on the scientific and empirical evidence regard- ing the efficacy of various types of personal respiratory protection tech- nologies as one measure to protect healthcare workers against nH1N1. The committee concludes that an emphasis is needed on implementing a range of strategies across all levels of the hierarchy of controls to mini- mize risk and decrease the number of healthcare workers and other pa- tients exposed to patients with suspected or confirmed nH1N1. The committee provides the following findings and recommendations and provides additional detail in the report that follows. Studies on influenza transmission show that airborne (inhalation) transmission is one of the potential routes of transmission. The commit- tee based its decisions on comparisons of the experimental evidence on the efficacy of respirators and medical masks and not on their effective- ness in the clinical setting due to the fact that the availability of data is quite limited on clinical effectiveness. Further, clinical effectiveness re- quires consideration of numerous implementation factors such as com- pliance and availability of supply. N95 respirators are documented to filter out 95 to 99 percent of relevant particles and have maximum effec- tiveness when properly fitted to the face of users through fit testing (Qian 1 Efficacy is defined as the extent to which a specific intervention produces a beneficial result under ideal circumstances. Effectiveness is defined as a measure of the accuracy or success of an intervention when carried out in an average clinical environment (PDR, 1995). 2 The committee uses the term medical masks to refer to procedure masks and surgical masks. Because of the wide variety in the types of masks referred to in the articles and presentations reviewed by the committee, the committee uses this term to encompass all types of masks used in healthcare facilities.

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3 LETTER REPORT et al., 1998). Research results on the filtration and fit of medical masks show wide variation in penetration of aerosol particles (4 percent to 90 percent) and inadequate fit suggesting that the use of medical masks is unlikely to be effective against airborne transmission (Oberg and Brosseau, 2008). Medical masks are not designed to provide a tight seal to the face, and there was considerable evidence in laboratory studies of leakage of materials under and around the medical mask from the un- fitted margins. The committee found a paucity of studies comparing the clinical effectiveness of respirators versus medical masks in preventing the transmission of influenza viruses. Several studies are underway or in publication. Recommendation 1: Use Fit-Tested N95 Respirators Healthcare workers (including those in non-hospital settings) who are in close contact with individuals with nH1N1 influ- enza or influenza-like illnesses should use fit-tested N95 respi- rators or respirators that are demonstrably more effective as one measure in the continuum of safety and infection control efforts to reduce the risk of infection. • The committee endorses the current CDC guidelines and recommends that these guidelines should be con- tinued until or unless further evidence can be provided to the effect that other forms of protection or other guidelines are equally or more effective. • Employers should ensure that the use and fit testing of N95 respirators be conducted in accordance with OSHA regulations, and healthcare workers should use the equipment as required by regulations and em- ployer policies. Healthcare organizations and workers need consistent and clear nH1N1 guidelines that can be implemented across all healthcare facili- ties. The committee again acknowledges that many implementation is- sues factor into the policy decision-making process for PPE guidance, but the committee was not charged with considering these factors, which include cost, availability of equipment, and other considerations in the implementation of such guidance. For example, policies may be influ- enced by the degree to which healthcare workers are effectively immu- nized with nH1N1 influenza vaccines.

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4 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS It is not the intention of the committee to recommend that all health- care workers use N95 respirators, rather the use of respirators should be for those in initial contact with individuals presenting with unidentified febrile respiratory illnesses and those healthcare workers in close contact with individuals with confirmed or suspected nH1N1. The committee acknowledges that this recommendation, if implemented, could have broader implications for clinical practice, including seasonal influenza and other potential airborne infections; however, the committee was charged only with addressing respiratory protection issues related to nH1N1. As noted throughout the report, the committee emphasizes that respiratory protection is a critical component in the hierarchy of infection prevention and control strategies. The need for research in a number of areas was striking. Due to the lack of a strong and conclusive evidence base, the committee concluded that determination of the relative contribution of each route of influenza transmission is essential for long-term preparedness planning. Further, the committee concluded that a stronger evidence base is needed regard- ing the effectiveness of personal respiratory protection technologies in clinical settings as is the development of improved respiratory protection technologies for healthcare workers. Recommendation 2: Increase Research on Influenza Trans- mission and Personal Respiratory Protection CDC centers (e.g., National Institute for Occupational Safety and Health; National Center for Immunization and Respira- tory Diseases; National Center for Preparedness, Detection, and Control of Infectious Diseases), the National Institutes of Health, and other relevant federal agencies and private insti- tutions should fund and undertake additional research to • resolve the unanswered questions regarding the rela- tive contribution of various routes of influenza trans- mission, • fully explore the effectiveness of personal respiratory protection technologies in a variety of clinical settings through randomized clinical trials, and • design and develop the next generation of personal respiratory protection technologies for healthcare workers to enhance safety, comfort, and ability to per- form work-related tasks.

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5 LETTER REPORT The committee appreciates the opportunity to provide input into the considerable efforts to prepare for nH1N1 that are ongoing at CDC and OSHA. We would be pleased to brief you and your staffs regarding the findings and recommendations provided in this letter report. Kenneth I. Shine, M.D., Chair M. E. Bonnie Rogers, Dr. P.H., Vice Chair Committee on Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A

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6 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS BACKGROUND The risk of influenza to healthcare workers is not a new concern, but the ongoing experience with novel influenza A (nH1N1) makes this issue even more urgent. Among the many considerations for the health and well-being of healthcare workers is the question about what types of per- sonal protective equipment (PPE) (e.g., respirators, gloves, gowns, eye protection, and other equipment) are needed to fully protect these front- line workers. This report focuses on the scientific and empirical evidence regard- ing the efficacy of various types of personal respiratory protective equipment as one measure to protect healthcare workers against nH1N1. The committee was not charged to consider the many factors that may affect policy decisions for PPE guidance including economics, equip- ment supplies, vaccine availability, immunization status, 3 extent of PPE compliance, and logistical considerations in the implementation of such guidance (see Box 1). In this regard, the committee recognizes that while the appropriate choice of PPE may include consideration of worker com- pliance and that PPE comfort and design contribute to clinical effective- ness, the committee focused its examination solely on currently available data on the efficacy of protective respiratory equipment. Further, as dis- cussed below, the committee views PPE as one part of a set of infection control strategies to reduce the potential for nH1N1 infection in health- care workers. In 2008, the Institute of Medicine (IOM) released the report Prepar- ing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers; it examined the research needs in PPE and recog- nized the many issues that need to be addressed to improve PPE use in an influenza pandemic (IOM, 2008b). That committee identified three areas in crucial need of research and policy action: (1) routes of influenza transmission, (2) emphasis on worker safety and the appropriate use of PPE, and (3) development and utilization of innovative PPE technologies and certification processes. That 2008 report, as well as other recent IOM 3 The committee acknowledges that vaccines will provide protection but noted the po- tential variability in immunization response as seen in a small study in the 1957 pandemic in which 35 percent of vaccinated healthcare workers developed influenza compared to 55 to 65 percent of unvaccinated healthcare workers (Blumenfeld et al., 1959).

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7 LETTER REPORT BOX 1 Statement of Task In response to a request from the Centers for Disease Control (CDC) and Prevention and the Occupational Safety and Health Administration, an ad hoc committee of the Institute of Medicine (IOM) will conduct a study and issue a letter report to the CDC director and Assistant Secretary for Occupa- tional Safety and Health by September 1, 2009. The committee will provide recommendations regarding the necessary respiratory protection, as part of personal protective equipment (PPE), for healthcare workers in their work- place against the novel influenza A (nH1N1) virus. Issues to be addressed to the extent feasible given available evidence and within the timeline for this letter report include: the potential for exposure to the nH1N1 virus among healthcare workers, which groups of workers are at risk, which patient care activities pose a risk of exposure and what degree of risk, and what is known and what is unknown about transmissibility, severity and virulence of the cur- rent virus and how transmissibility might change. The committee will base its recommendations on the available current state of scientific and empirical evidence about nH1N1 virus, as well as its expert judgment. Economic and logistical considerations regarding PPE equipment will not be addressed in this letter report. In determining the appropriate respiratory protection for the U.S. healthcare workforce, attention will be given to the current PPE guid- ance documents offered by the CDC and by the World Health Organization for novel H1N1 influenza and for seasonal influenza. reports (IOM, 2005a,b, 2006, 2007, 2008a), served as a basis for this let- ter report, and the committee built on these efforts with information pro- vided at the workshop as well as from recent published literature and the committee’s expert judgment. Healthcare Workers: Defining the Scope of the Term More than 13.6 million workers in the United States were employed in the healthcare field in 2006 with approximately 35 percent employed in hospitals, 23 percent in nursing and residential care facilities; and 17 percent in offices of physicians (BLS, 2009). The 2008 IOM report de- fined healthcare workers to encompass all workers employed by private and public healthcare offices and facilities as well as those working in home healthcare and emergency medical services (IOM, 2008b). The definition also included health professional students who are working at or receiving instruction in healthcare facilities. For this letter report, the committee expanded on that definition to include individuals in profes-

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8 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS sional and support services (e.g., clinical laboratories); individuals in- volved in administration, patient care, and facilities management; and individuals working for private- and public-sector employers, those who are self-employed, and volunteers trained to provide systematic, regu- lated, and licensed healthcare services (including medical emergency responders). PPE in Perspective In the continuum of safety and infection prevention efforts in health- care facilities, PPE is one of many important components. Occupational safety and health measures have traditionally followed a hierarchy of controls—engineering controls, administrative and work practice con- trols, and PPE. Engineering and environmental controls (e.g., ventilation, negative-pressure rooms, isolation rooms) are considered the first line of defense as they are measures that protect or affect multiple workers and patients and do not rely on individual compliance. Administrative and work practice controls include the policies, standards, procedures, and practices established within an organization to limit hazardous exposures and improve worker safety (e.g., cohorting or isolating patients, hand hygiene, cough etiquette, worker immunization policies, training and education, and organizational commitment to creating and sustaining a culture of worker safety). Personal protective equipment includes respi- rators, gowns, gloves, eye protection, and hearing protection. All relevant work situations with the potential for infection risk (such as cleaning pa- tient rooms and delivery of food) must be considered in addition to direct care of the patients. The infection prevention and control precautions outlined by CDC’s Healthcare Infection Control Practices Advisory Committee provide a tiered approach based on routes of transmission (Siegel et al., 2007). The guidelines for airborne precautions call for a range of measures in addi- tion to standard precautions (gloves, gown, hand hygiene, etc.) including patient placement, personnel restrictions, exposure management, and individual respiratory protection measures of a fit-tested N95 or higher- level respirator. During its workshop, the committee heard about many potential en- vironmental and administrative controls that could be effective in reduc- ing the number of healthcare workers exposed to nH1N1. These would include such activities as innovative triage mechanisms for individuals

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9 LETTER REPORT with influenza-like illnesses, separate waiting areas for such patients, and single patient rooms. At the individual level, responsibilities incumbent on the healthcare worker include the use of proper hand hygiene practices, appropriate use of PPE, and obtaining relevant immunizations offered by the employer, as well as adherence to work safety practices. Hand and respiratory hy- giene are examples of proven interventions that decrease the spread of infections. Unfortunately, evidence for compliance of healthcare workers with these measures indicates that these effective measures are signifi- cantly underused, as are most types of PPE (IOM, 2008b). Many factors have been identified as reasons for this underuse including lack of time, lack of ready access to equipment, concerns about interference with pa- tient care, and problems with comfort. The committee emphasizes that PPE needs to be viewed as one part of a continuum of controls to ensure worker and patient safety that range from engineering controls and administrative approaches to pharmaceu- tical measures (e.g., vaccines and antivirals) and personal protective equipment. Further, PPE components (e.g., eye protection, respirators) need to be seamlessly integrated into protective ensembles that effec- tively provide hazard protection for multiple routes of transmission (IOM, 2008a). Current Guidelines Regarding nH1N1 and Use of PPE by Healthcare Workers The committee carefully reviewed the current CDC and WHO infec- tion control guidelines (as well as other relevant guidelines) for health- care workers caring for patients with known or suspected nH1N1 (see Table 1) (CDC, 2009f; WHO, 2009a). These guidelines both recommend the use of hand hygiene, gloves, gowns, and eye protection, but most notably differ in the respiratory protection recommendations. CDC rec- ommends a fit-tested disposable N95 respirator or better for “all health- care personnel who enter the rooms of patients in isolation with confirmed, suspected, or probable novel H1N1 influenza” (CDC, 2009f). For emergency medical responders, the CDC recommends a fit-tested disposable N95 respirator for those workers “who are in close contact” with patients with confirmed or suspected nH1N1, for personnel

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10 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS TABLE 1 Summary of PPE Guidelines for Care of Patients with Novel H1N1 Influenza A Type of PPE—Guidelines Medical Eye Masks Gloves Gowns Protection Respirators Centers for Disease Control and Prevention Isolation precautions1: Stan- X X X X dard and contact precau- (N95) tions plus eye protection should be used for all pa- tient care activities for patients being evaluated or in isolation for novel H1N1 Respiratory protection: All healthcare personnel who enter the rooms of pa- tients in isolation with confirmed, suspected, or probable novel H1N1 in- fluenza should wear a fit- tested disposable N95 respirator or better World Health Organization Per droplet precautions, X when in direct contact with patients Per standard precautions, X3 X3 X X for procedures with a risk for splashes onto the face and body When performing aerosol- X2 X X X generating procedures When completing a nasal X3 X3 X X swab and nasal wash When collecting blood X X NOTE: Hand hygiene should be practiced consistently in all situations. 1 CDC guidelines recommend that patients with confirmed, probable or suspected cases of nH1N1 who present for care at healthcare facilities be placed into individual rooms with closed doors. 2 Types include EU FFP2 and U.S. NIOSH-certified N95 respirators. 3 Guidelines call for using face protection (either a medical mask and eye-visor or gog- gles, or a face shield). SOURCE: CDC, 2009f; WHO, 2009a.

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11 LETTER REPORT “engaged in aerosol generating activities,” and for personnel involved in the “interfacility transfer” of patients with suspected or confirmed nH1N1 (CDC, 2009e). WHO recommends standard and droplet precau- tions (including a medical mask, gown, gloves, eye protection, hand hy- giene) for those working in direct contact with patients and additional precautions for aerosol-generating procedures including wearing a facial particulate respirator (WHO, 2009a). The WHO recommendations take into account the need for sustainability in a variety of countries and allow each country to put forward its own guidelines on the recommended level of protection based on a variety of factors. The recently released Canadian guidelines also provide a tiered ap- proach based on the current behavior of the virus, recommending N95 use for aerosol-generating procedures with direct patient contact only (PHAC, 2009a,b,c,d). The guidelines note an anticipation that only a mi- nority of the patients will need to be cared for at this level, recommend- ing the use of medical masks for direct patient interactions that do not include the potential for procedure-induced aerosol generation. Routine practices are recommended for indirect contact with nH1N1 influenza patients. The guidelines note that hand hygiene and respiratory hygiene should be practiced consistently in all situations. INFLUENZA A Overview of Influenza A Influenza is a serious respiratory illness caused by infection with in- fluenza type A or type B virus. Influenza infections peak during the win- ter months in each hemisphere. In addition to seasonal occurrences of influenza, outbreaks of influenza may result in a global pandemic. The risk of serious illness and death from seasonal influenza is highest at the extremes of age (e.g., among persons 65 years and older and children under 2 years of age) and persons with certain medical conditions. In the United States, an average epidemic season of influenza results in more than 36,000 deaths and 200,000 hospitalizations due to influenza-related causes (CDC, 2009c). Among influenza-related deaths, most of the ex- cess mortality occurs in persons 65 years and older, often from pneumo- nia (Lewis, 2006).

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26 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS transmission of the virus and the efficacy of personal respiratory protec- tive technologies, but it was not tasked with considering the economic and logistical implications, the extent of healthcare workers’ individual factors (e.g., age, immunization status), or compliance issues. BOX 2 Risk Factors and Issues That Affect PPE Decisions Virus Characteristics: • Nature of the hazard—virulence, disease severity, lethality, life (longevity) • Routes of transmission • Ease of transmission The Healthcare Worker: • Natural immunity and immunization status • Age • Underlying health conditions • Personal risk factors (e.g., chronic diseases and personal habits) • Immunoprophylaxis • Compliance with PPE Work Environment: • Setting (e.g., hospital, emergency medical services, direct care) • Volume of patients • Source control • Ambient conditions • Virus load profile • PPE comfort and wearability • Isolation, cohorting, and other environmental and administrative controls The Patient: • Age • Super-shedder, super-spreader • Underlying health conditions/symptoms • Personal risk factors (e.g., chronic diseases and habits)

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27 LETTER REPORT RECOMMENDATIONS On the basis of input from the IOM workshop, previous IOM reports, the expert judgment of the committee members, and review of the litera- ture, the committee provides the following recommendations. Respiratory Protection The committee’s task focused solely on personal respiratory protec- tion. Studies on influenza transmission show that airborne transmission is one of the potential routes of transmission. Research is needed to deter- mine the relative contribution of the transmission pathways. Given the limited information on routes of transmission, the committee found that respiratory protection is indicated at this time. Evidence from NIOSH staff and other researchers provide convinc- ing data on the ability of N95 respirators to filter out 95 to 99 percent of relevant particles and these devices have their maximum effectiveness when properly fitted to the face of users. Research results on the filtra- tion and fit of medical masks show wide variation in penetration of aero- sol particles (4 percent to 90 percent) suggesting that the use of many of these masks is unlikely to be effective to protect against airborne trans- mission. Additionally, there was considerable evidence in laboratory studies of an order of magnitude higher leakage of particles under and around the medical mask from the unfitted margins than respirators. However, it is important to note that controversy exists regarding clinical guideline decision making in regards to the clinical effectiveness of medical masks. That is, some experts assert that factors including worker compliance may significantly affect the clinical effectiveness of various personal respiratory protection technologies and therefore have implica- tions for appropriate clinical guidelines. The committee found a paucity of studies on the clinical effectiveness of respirators versus medical masks for influenza. Several studies are underway or in publication. The few studies available in abstract form or presented at the conference showed mixed results. The committee bases its recommendation on the evidence of airborne transmission and the filtering and fit characteristics of N95 respirators compared to that of medical masks.

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28 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS Recommendation 1: Use Fit-Tested N95 Respirators Healthcare workers (including those in non-hospital settings) who are in close contact with individuals with nH1N1 influ- enza or influenza-like illnesses should use fit-tested N95 respi- rators or respirators that are demonstrably more effective as one measure in the continuum of safety and infection control efforts to reduce the risk of infection. • The committee endorses the current CDC guidelines and recommends that these guidelines should be con- tinued until or unless further evidence can be provided to the effect that other forms of protection or other guidelines are equally or more effective. • Employers should ensure that the use and fit testing of N95 respirators be in accordance with OSHA regula- tions, and healthcare workers should use the equip- ment as required by regulations and employer policies. The committee acknowledges that many issues factor into the policy decision-making process and notes in the recommendation that the guidelines will need to be subsequently reexamined as is generally done for many forms of clinical guidance. It is not the intention of the commit- tee to recommend that all healthcare workers use N95 respirators, rather the use of respirators should be for those in initial contact with individu- als presenting with undetermined febrile respiratory illnesses or those with close contact with individuals with confirmed or suspected nH1N1. The term close contact has generally been defined as being within 6 feet of a patient (CDC, 2009i). In addition, the entrance of a healthcare worker into an enclosed space with a patient (e.g., isolation rooms) has also been identified to pose a higher risk for infection of healthcare workers. However, the committee concluded that there was insufficient evidence at this time to fully define close contact for all settings and situations. As noted throughout this report, respiratory protection is one part of a systematic multipronged infection prevention and control strategy. The goal is to minimize risk and decrease the number of healthcare workers with potential exposure to undetermined febrile respiratory ill- nesses and to accurately and rapidly diagnose patients who necessitate antivirals, antimicrobials, and other essential medical and public health interventions.

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29 LETTER REPORT Future Research It is still unclear what proportion of the spread of influenza virus oc- curs through each of the potential routes of transmission (contact, droplet spray, airborne), as well as the role of respiratory protection devices for each of these routes of transmission. Because of the lack of a strong and conclusive evidence base, the committee noted that determination of the relative contribution of each route of transmission is essential for long- term preparedness planning. Secondly, the committee concluded that a stronger evidence base is needed regarding the effectiveness of personal respiratory protection technologies in clinical settings. As described pre- viously, while some data are available, more research is needed to under- stand the clinical implementation of efficacious technologies, such as how compliance with various technologies can affect their use. Finally, as suggested in the IOM 2008 report (IOM, 2008b), continued collabora- tion and integration between the relevant agencies (e.g., FDA, CDC) are essential to assure the clinical implementation of newer technologies that are both efficacious as well as effective in the clinical setting. The com- mittee bases the following recommendation on its examination of the evidence base, workshop presentations on the newest studies available, previous IOM studies, and its expert judgment. Recommendation 2: Increase Research on Influenza Trans- mission and Personal Respiratory Protection CDC centers (e.g., National Institute for Occupational Safety and Health; National Center for Immunization and Respira- tory Diseases; National Center for Preparedness, Detection, and Control of Infectious Diseases), the National Institutes of Health, and other relevant federal agencies and private insti- tutions should fund and undertake additional research to • resolve the unanswered questions regarding the rela- tive contribution of various routes of influenza trans- mission, • fully explore the effectiveness of personal respiratory protection technologies in a variety of clinical settings through randomized clinical trials, and • design and develop the next generation of personal respiratory protection technologies for healthcare workers to enhance safety, comfort, and ability to per- form work-related tasks.

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30 RESPIRATORY PROTECTION FOR HEALTHCARE WORKERS REFERENCES Aiello, A. E., and A. S. Monto. 2009. Reducing transmission of influenza by face masks and hand hygiene. Presentation to the IOM Committee on Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A, August 12, 2009. Washington, DC. Atkinson, M., and L. Wein. 2008. Quantifying the routes of transmission for pandemic influenza. Bulletin of Mathematical Biology 70(3):820- 867. Australian Department of Health and Ageing. 2009. Australian influenza surveillance report. No.12, 2009, reporting period: 25 July 2009-31 July 2009. Canberra, Australia: Department of Health and Ageing, Australian Government. Balazy, A., M. Toivola, A. Adhikari, S. K. Sivasubramani, T. Reponen, and S. A. Grinshpun. 2006. Do N95 respirators provide 95% protec- tion level against airborne viruses, and how adequate are surgical masks? American Journal of Infection Control 34(2):51-57. Blachere, F. M., W. G. Lindsley, T. A. Pearce, S. E. Anderson, M. Fisher, R. Khakoo, B. J. Meade, O. Lander, S. Davis, R. E. Thewlis, I. Celik, B. T. Chen, and D. H. Beezhold. 2009. Measurement of air- borne influenza virus in a hospital emergency department. Clinical Infectious Diseases 48(4):438-440. BLS (Bureau of Labor Statistics). 2009. Career guide to industries: Health care. http://www.bls.gov/oco/cg/cgs035.htm (accessed Au- gust 10, 2009). Blumenfeld, H. L., E. D. Kilbourne, D. B. Louria, and D. E. Rogers. 1959. Studies on influenza in the pandemic of 1957-1958. I. An epi- demiologic, clinical and serologic investigation of an intrahospital epidemic, with a note on vaccination efficacy. Journal of Clinical Investigation 38(1 Part 2):199-212. CDC (Centers for Disease Control and Prevention). 2009a. 2008-2009 influenza season week 32 ending August 15, 2009. http://cdc.gov/flu/weekly/index.htm (accessed August 26, 2009). ———. 2009b. 2009-10 influenza prevention & control recommenda- tions. ACIP recommendations: Introduction and biology of influenza. http://www.cdc.gov/flu/professionals/acip/background.htm (accessed August 19, 2009). ———. 2009c. Flu symptoms & severity: Influenza symptoms. http://www.cdc.gov/flu/about/disease/symptoms.htm (accessed Au- gust 19, 2009).

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