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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
PREVENTING TRANSMISSION OF PANDEMIC INFLUENZA AND OTHER VIRAL RESPIRATORY DISEASES
Personal Protective Equipment for Healthcare Personnel
UPDATE 2010
Committee on Personal Protective Equipment for Healthcare Personnel to Prevent Transmission of Pandemic Influenza and Other Viral Respiratory Infections: Current Research Issues
Board on Health Sciences Policy
Elaine L. Larson and Catharyn T. Liverman, Editors
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W.
Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
This study was requested by the National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention and was supported by Contract No. 200-2005-10881 (Task Order #8) between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-16254-8
International Standard Book Number-10: 0-309-16254-8
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. Preventing transmission of pandemic influenza and other viral respiratory diseases: Personal protective equipment for healthcare personnel. Update 2010. Washington, DC: The National Academies Press.
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
COMMITTEE ON PERSONAL PROTECTIVE EQUIPMENT FOR HEALTHCARE PERSONNEL TO PREVENT TRANSMISSION OF PANDEMIC INFLUENZA AND OTHER VIRAL RESPIRATORY INFECTIONS: CURRENT RESEARCH ISSUES
ELAINE L. LARSON (Chair), Professor of Pharmaceutical and Therapeutic Research,
Columbia University
GLORIA ADDO-AYENSU, Director,
Fairfax County Department of Health
ALLISON E. AIELLO, John G. Searle Assistant Professor of Public Health,
University of Michigan School of Public Health
HOWARD J. COHEN, Consultant, Professor Emeritus,
University of New Haven
ROBERT COHEN, Director,
Pulmonary and Critical Care Medicine, Cook County Health and Hospitals System, and
Chair,
Division of Pulmonary Medicine/Critical Care and Occupational Medicine, Stroger Hospital of Cook County
KAREN COYNE, Research General Engineer,
U.S. Army Edgewood Chemical Biologic Center
DAVID M. DEJOY, Professor,
University of Georgia
KEN GALL, Professor,
Georgia Institute of Technology
WILLIAM H. KOJOLA, Industrial Hygienist,
Department of Occupational Safety and Health, AFL–CIO
ALLISON MCGEER, Director,
Infection Control, Mount Sinai Hospital, University of Toronto
PETER PALESE, Professor and Chair,
Mount Sinai School of Medicine
DAVID PREZANT, Chief Medical Officer and Special Advisor to the Fire Commissioner for Health Policy,
Fire Department of the City of New York, and
Professor of Medicine,
Pulmonary Division, Albert Einstein College of Medicine
M. E. BONNIE ROGERS, Director,
North Carolina Occupational Safety and Health Education and Research Center and Occupational Health Nursing Program, School of Public Health, University of North Carolina–Chapel Hill
RICHARD P. WENZEL, Professor and Former Chair,
Department of Internal Medicine, Virginia Commonwealth University
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
Study Staff
CATHARYN T. LIVERMAN, Project Director
ANDREW M. POPE, Director
SARAH CODREA, Associate Program Officer (until July 2010)
LARA ANDERSEN, Research Associate
JUDY ESTEP, Program Associate
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Lisa Brosseau, University of Minnesota
Benjamin Cowling, University of Hong Kong
Lewis R. Goldfrank, Bellevue Hospital Center and New York University Medical Center
Kathleen Harriman, California Department of Public Health
Sundaresan Jayaraman, Georgia Institute of Technology
Mark Nicas, University of California
Daniel R. Perez, University of Maryland
Trish M. Perl, Johns Hopkins University School of Medicine
Peg Seminario, AFL–CIO
Michael Tapper, Lenox Hill Hospital, New York City
David Weber, University of North Carolina–Chapel Hill
Annalee Yassi, University of British Columbia
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the con-
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
clusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Caroline Breese Hall, University of Rochester School of Medicine, and Johanna T. Dwyer, Tufts University School of Medicine. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
Contents
ACRONYMS AND ABBREVIATIONS
xi
SUMMARY
1
1
INTRODUCTION
15
Scope of the Report,
15
Background and Context,
17
Healthcare Personnel and PPE,
21
Overview of Influenza and Other Viral Respiratory Diseases,
23
Defining an Integrated Approach to PPE Research,
25
References,
27
2
UNDERSTANDING THE RISK TO HEALTHCARE PERSONNEL
29
Background and Context from the 2008 Report,
29
Update on Recent Research,
35
Summary of Progress,
57
Findings and Research Needs,
57
Recommendations,
60
References,
60
3
DESIGNING AND ENGINEERING EFFECTIVE PPE
71
Background and Context from the 2008 Report,
72
Update on Recent Research,
74
Summary of Progress,
101
Findings and Research Needs,
102
Recommendations,
104
References,
105
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
4
USING PPE: INDIVIDUAL AND ORGANIZATIONAL ISSUES
113
Background and Context from the 2008 Report,
113
Update on Recent Research,
116
Summary of Progress,
123
Findings and Research Needs,
124
Recommendations,
127
References,
128
5
POLICY RESEARCH AND IMPLEMENTATION: HEALTHCARE SYSTEMS, STANDARDS, AND CERTIFICATION
133
PPE Standards and Certification,
133
Lessons Learned from 2009 H1N1 Policies Relevant to PPE for Healthcare Personnel,
141
Summary of Progress,
148
Findings and Research Needs,
149
Recommendations,
150
References,
152
APPENDIXES
A
Workshop Agenda
157
B
Participants List
163
C
Studies of the Clinical Effectiveness of Personal Protective Equipment During Outbreaks of Severe Acute Respiratory Syndrome and Respiratory Syncytial Virus
173
D
Examples of Relevant Voluntary Consensus Standards
177
E
Committee Biographies
179
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
Acronyms and Abbreviations
AAMI Association for the Advancement of Medical Instrumentation
B.R.E.A.T.H.E. Better Respiratory Equipment Using Advanced Technologies for Healthcare Employees
CBRN chemical, biological, radiological, and nuclear
CDC Centers for Disease Control and Prevention
CFR Code of Federal Regulations
CI confidence interval
CO2 carbon dioxide
DOL Department of Labor
FDA Food and Drug Administration
FFP2 or FFP3 filtering facepiece respirator class P2 or P3
HHS Department of Health and Human Services
ICU intensive care unit
IOM Institute of Medicine
IV intravenous
MPPS most penetrating particle size
NaCl sodium chloride
NIOSH National Institute for Occupational Safety and Health
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Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Personnel - Update 2010
NPPTL National Personal Protective Technology Laboratory
NVHA Northern Virginia Hospital Alliance
NYC New York City
OSHA Occupational Safety and Health Administration
PAPR powered air-purifying respirator
PPE personal protective equipment
PPT personal protective technologies
RNA ribonucleic acid
RSV respiratory syncytial virus
RT-PCR real-time polymerase chain reaction
SARS severe acute respiratory syndrome
SNS Strategic National Stockpile
TICD50 tissue culture infective dose50
TIL total inward leakage
UV ultraviolet
WHO World Health Organization
