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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. Reusable Elastomeric Respirators in Health Care: Considerations for Routine and Surge Use. Washington, DC: The National Academies Press. doi: 10.17226/25275.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

REUSABLE ELASTOMERIC RESPIRATORS IN HEALTH CARE Considerations for Routine and Surge Use Committee on the Use of Elastomeric Respirators in Health Care Linda Hawes Clever, Bonnie M. E. Rogers, Olivia C. Yost, and Catharyn T. Liverman, Editors Board on Health Sciences Policy Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by Contract #200-2011-38807 (Task Order 2) between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25275 Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Reusable elastomeric respirators in health care: Considerations for routine and surge use. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25275. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence- based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/ about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

COMMITTEE ON THE USE OF ELASTOMERIC RESPIRATORS IN HEALTH CARE LINDA HAWES CLEVER (Co-Chair), California Pacific Medical Center M. E. BONNIE ROGERS (Co-Chair), University of North Carolina Occupational Safety and Health Education Research Center GLORIA ADDO-AYENSU, Fairfax County Department of Health GIO BARACCO, University of Miami Miller School of Medicine and Miami Veterans Affairs Healthcare System JIM CHANG, University of Maryland Medical Center CHRISTOPHER FRIESE, University of Michigan School of Nursing ROBERT HARRISON, University of California, San Francisco, School of Medicine SUNDARESAN JAYARAMAN, Georgia Institute of Technology JAMES S. JOHNSON, JSJ and Associates BRUCE LIPPY, The Center for Construction Research and Training ALLISON MCGEER, Mount Sinai Hospital and University of Toronto ANN-CHRISTINE NYQUIST, University of Colorado School of Medicine MIKE SCHMOLDT, Argonne National Laboratory SKIP SKIVINGTON, Kaiser Permanente PATRICIA STONE, Columbia University School of Nursing TENER VEENEMA, Johns Hopkins University Study Staff CATHARYN T. LIVERMAN, Study Director OLIVIA C. YOST, Associate Program Officer KATIE LAWALL, Senior Program Assistant (through July 2018) JUDY ESTEP, Program Associate (from July 2018) DANIEL BEARSS, Senior Research Librarian ANDREW M. POPE, Director, Board on Health Sciences Policy v PREPUBLICATION COPY: UNCORRECTED PROOFS

Reviewers This Consensus Study Report was reviewed in draft form by individ- uals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineer- ing, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objec- tivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integri- ty of the deliberative process. We thank the following individuals for their review of this report: MARY T. BESSESEN, University of Colorado Denver HOWARD J. COHEN, Consultant BARBARA DeBAUN, Cynosure Health TRISH PERL-DeLISLE, UT Southwestern Medical Center ROBERT M. ENINGER, Air Force Institute of Technology RACHAEL JONES, University of Illinois, Chicago WILLIAM H. KOJOLA, AFL-CIO (retired) SUZET M. MCKINNEY, Illinois Medical District Commission JEFFREY C. NESBITT, Mayo Clinic TERRI REBMANN, Saint Louis University MARK SHIRLEY, Sutter Health PRITISH K. TOSH, Mayo Clinic Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ELAINE L. LARSON, vii PREPUBLICATION COPY: UNCORRECTED PROOFS

viii REVIEWERS Columbia University, and LINDA A. MCCAULEY, Emory University. They were responsible for making certain that an independent examina- tion of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully con- sidered. Responsibility for the final content rests entirely with the author- ing committee and the National Academies.

Contents SUMMARY 1 1 INTRODUCTION 19 2 ELASTOMERIC RESPIRATORS 49 3 IMPLEMENTING REUSABLE ELASTOMERIC RESPIRATORS IN HEALTH CARE SETTINGS: ROUTINE AND SURGE USE 117 4 RESEARCH AND DEVELOPMENT 153 5 NEXT STEPS AND RECOMMENDATIONS 175 APPENDIXES A MEETING AGENDAS 187 B COMMITTEE BIOGRAPHICAL SKETCHES 201 ix PREPUBLICATION COPY: UNCORRECTED PROOFS

Boxes, Figures, and Tables BOXES 1-1 Statement of Task, 21 1-2 Historical Context: Diseases of Workers, 25 1-3 Categorizing Respirators, 31 2-1 Case Study: Respirator Use by an International Construction Firm, 56 2-2 Case Study: Respirator Use by a National Remediation Contractor, 58 2-3 Case Study: Respirator Use at the World Trade Center Cleanup, 59 2-4 Case Study: Respirator Use in the Nuclear Industry, 60 2-5 Description of Protection Factor Studies, 63 2-6 OSHA Procedures for Cleaning of Respirators, 87 3-1 Health Care Worker Competencies in Respiratory Protection, 124 3-2 Example of Stockpiling Needs and Comparative Costs for a Single High-Exposure-Risk Employee, 136 3-3 Kaiser Permanente’s Experience with Stockpiled Respirators During the 2009 H1N1 Epidemic, 138 3-4 Key Components of Safety Culture Change, 142 4-1 Phases of Project BREATHE, 162 xi PREPUBLICATION COPY: UNCORRECTED PROOFS

xii BOXES, FIGURES, AND TABLES FIGURES 1-1 Major types of air-purifying respirators currently used in health care, 33 1-2 Hierarchy of controls, 34 2-1 Modern reusable elastomeric respirator, 50 2-2 Reusable elastomeric respirator examples, 51 2-3 Diagram of a half-facepiece reusable elastomeric respirator, 53 2-4 Overview of respirator use in industry, 56 3-1 Use of elastomeric respirators in health care: Viewpoints of stakeholders, 120 4-1 A structured approach to evidence-based performance requirements for health care respirators, 154 4-2 Comfort to compliance: Factors influencing the comfort of elastomeric respirators, 155 4-3 The CleanSpace Ultra powered air-purifying respirator, 167 4-4 FluView weekly influenza surveillance report: Week ending May 19, 2018, 171 TABLES S-1 Routine and Surge Use of Reusable Elastomeric Respirators, 8 1-1 Health Care Workers, Location of Employment, 27 1-2 Comparison of Medical Masks and Respirators, 30 1-3 Hierarchy of Controls in the Context of the Treatment of a Patient with an Aerosol-Transmissible Disease, 36 1-4 NIOSH Efficiency Ratings for Respirator Filters, 38 1-5 Overview of the Strengths and Limitations of Disposable Filtering Facepiece Respirators for Use in Health Care, 42 1-6 Strengths and Limitations of Powered Air-Purifying Respirators for Use in Health Care, 43 2-1 Examples of Jobs and Contaminants That Commonly Involve the Use of Reusable Elastomeric Respirators, 54 2-2 Recent Studies on the Performance of Half-Facepiece Reusable Elastomeric Respirators, 65 PREPUBLICATION COPY: UNCORRECTED PROOFS

BOXES, FIGURES, AND TABLES xiii 2-3 Assigned Protection Factors, 72 2-4 Overview of Research on the Cleaning and Disinfection of Reusable Elastomeric Respirators in Health Care, 77 2-5 Examples of Manufacturer Instructions for the Cleaning and Disinfection of Half-Facepiece Reusable Elastomeric Respirators, 90 2-6 Benefits and Limitations of the Use of Reusable Elastomeric Respirators at the University of Maryland Medical Center, 105 2-7 Benefits and Limitations of the Use of Reusable Elastomeric Respirators at the Texas Center for Infectious Disease, 108 3-1 Annual RPD Pandemic Stockpiling Costs for a Population of 1 Million, per Strategy, 120 3-2 Overview of 2009–2010 H1N1 Policies and Practices Regarding Personal Protective Equipment and H1N1 Influenza, 145 4-1 Project BREATHE’s Major Categories and Desirable Performance Objectives for Health Care Respirators and Respiratory Protection Programs, 163 5-1 Routine and Surge Use of Reusable Elastomeric Respirators, 176 PREPUBLICATION COPY: UNCORRECTED PROOFS

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Protecting the health and safety of health care workers is vital to the health of each of us. Preparing for and responding to a future influenza pandemic or to a sustained outbreak of an airborne transmissible disease requires a high-level commitment to respiratory protection for health care workers across the wide range of settings in which they work and the jobs that they perform. Keeping health care workers healthy is an ethical commitment both in terms of addressing the occupational risks faced by health care workers and of providing for the continuity of patient care and services needed to maintain the health of individuals and communities.

During a public health emergency, challenges will arise concerning the availability of respiratory protective devices (i.e., respirators). Reusable respirators (specifically, reusable half-facepiece elastomeric respirators) are the standard respiratory protection device used in many industries, and they provide an option for use in health care that has to date not been fully explored. The durability and reusability of elastomeric respirators make them desirable for stockpiling for emergencies, where the need for large volumes of respirators can be anticipated. However, they are used infrequently in health care.

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Reusable Elastomeric Respirators in Health Care explores the potential for the use of elastomeric respirators in the U.S. health care system with a focus on the economic, policy, and implementation challenges and opportunities. This report examines the practicability of elastomeric use in health care on a routine basis and during an influenza pandemic or other large aerosol-transmissible outbreak, when demand for respiratory protective devices by U.S. health care personnel may be larger than domestic supplies. The report also addresses the issues regarding emergency stockpile management of elastomeric respiratory protective devices.

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