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By Kelly M. Pyrek

Editor's note: This is a two-part series looking at issues relating to respiratory protection. Part 1 in the September issue examined viral size, transmission of disease, and implications for respiratory protection worn by healthcare workers. Part 2 explores PPE-related research questions, influenza transmission research, and barriers to PPE compliance by healthcare workers.

The 2009 H1N1 pandemic solidified the nation's need for a science-driven approach to preparing healthcare workers for both routine and crisis-related use of personal protective equipment (PPE). To that end, the National Institute for Occupational Safety and Health (NIOSH) Personal Protective Technology Program (PPT) and the National Personal Protective Technology Laboratory (NPPTL) have been working toward the finalization of an action plan to address emerging topics in respiratory protection for healthcare workers. On June 18, 2013, NIOSH held its Stakeholder Meeting on Respiratory Protection for Healthcare Workers, with a theme of improving healthcare worker compliance with respiratory protection. The meeting assembled experts and various healthcare stakeholders -- such as healthcare professionals, policy makers and manufacturers -- to exchange knowledge and ideas. NIOSH sought this stakeholder feedback to provide input to future updates of the NIOSH PPT program research agenda and assess progress toward better respirators for healthcare workers. The meeting included presentations by leading experts in the field to discuss the latest scientific data and moderated roundtable discussions.

In his presentation at the June 18 NIOSH PPT Healthcare Stakeholder Meeting, "Progress Toward Updating the NIOSH PPT Program Action Plan for Healthcare Worker Personal Protective Equipment, Ronald E. Shaffer, PhD, a senior scientist in the Office of the Director of NIOSHs National Personal Protective Technology Laboratory, explained that PPE among healthcare workers is a priority because not only is healthcare the fastest-growing sector of the U.S. economy, employing more than 18 million workers, but that these healthcare workers are at higher risk of exposure to infectious respiratory and bloodborne pathogens than workers in non-healthcare settings.

The H1N1 pandemic during 2009-2010 prompted many unanswered research questions and provided the impetus for NIOSH's NPPTL to ask the Institute of Medicine (IOM) to conduct a study that would update progress on research and identify future directions regarding personal protective equipment (PPE) for healthcare personnel. In a report, "Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases: Personal Protective Equipment for Healthcare Workers: Update 2010," an ad hoc IOM committee composed of experts in the fields of infectious disease, infection control, public health, occupational safety and health, pulmonary medicine, health promotion, microbiology, emergency response and preparedness, epidemiology, nursing, community health, industrial hygiene, attempted to identify new research directions, certification and standards-setting issues, and risk assessment issues specific to PPE for healthcare personnel to prevent transmission of pandemic influenza and other viral respiratory infections.

In discussing the issues relevant to the use of PPE by healthcare personnel, the committee identified a set of criteria as a starting point for decisions on PPE selection and use. PPE for healthcare personnel should:

Effectively reduce risks of disease or injury to healthcare personnel Minimize negative interactions with or effects on patients, their families, and caregivers Be acceptable and usable by healthcare personnel in their daily tasks, including ease of communication and comfort Be practical regarding issues of cost, time and training Be appropriate to the occupational risk being encountered

According to Shaffer, since 2008 the NIOSH PPT program has maintained this action plan for healthcare worker PPE and uses it for research prioritization and discussions with stakeholders. It was last updated in January 2010 and the current action plan was based upon recommendations from a 2009 IOM Letter Report. Current research areas include:

Ensembles -Isolation gowns Filtration - Nanoparticles / Bioaerosols Respirator Fit - Facial anthropometrics

NIOSH Working Toward Answers to Key Respiratory Protection Questions

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- Frequency of fit testing - Respirator fit test research (user seal check, novel methods, multiple donnings) Respirator Comfort - Physiology studies - Project BREATHE Surveillance and Intervention Demo & Sentinel Surveillance Respirator evaluation and interventions Best practices, outreach Respirator Performance and Usability - Simulated healthcare settings - Respirator clinical effectiveness Influenza Pandemic/Reuse - Risks of handling a contaminated respirator - Decontamination of filtering facepiece respirators (FFRs) - Assessing modes of transmission Comments gathered from the June 18 stakeholder meeting will be reviewed and integrated into the final action plan

that will be published in the fall of 2013. It will use the 12 research recommendations from the January 2011 IOM report as the framework as well as incorporate other recommendations from agencies such as HHS, NIOSH and HCSA.

Let's take a closer look at the latest IOM report. The 2010 report acknowledges the individual and organizational Issues associated with "understanding that self-protective behavior in the healthcare settings involves a constellation of interacting and independent components. At a minimum, consideration should be given to the user, the device, the task, and the general work and organizational context. The growing acknowledgment of contextual and organizational factors means that research on PPE and healthcare personnel is closing in on the larger body of occupational safety research, which increasingly emphasizes those factors in understanding occupational safety performance."

The IOM report (2010) also noted that "Although there are clear gaps and deficiencies in our knowledge base about PPE usage in healthcare, existing knowledge is sufficient to recommend a four-pronged strategy for immediate implementation. The four elements are:

- Deliberate planning and preparation at the leadership and organizational levels - Comprehensive training, including supervisors and managers - Widespread and convenient availability of appropriate PPE devices - Accountability at all levels of the organization As the report (2010) notes, "In essence, there should be universal acknowledgement that PPE use is an integral

component of providing quality healthcare. As with other priorities, this aspect of healthcare delivery needs to be carefully planned at the organizational/institutional level. Furthermore, managers and frontline workers alike need to understand and accept their roles and responsibilities, and PPE use needs to be as easy and convenient as possible. PPE should be factored into all decisions involving task design, staffing, and work assignments. Input from frontline workers should be used to facilitate planning and decision making and to maximize acceptance. Environmental/engineering controls should be utilized wherever possible to control exposures, with PPE used as a supplement or alternative when environmental/engineering controls are not sufficient or feasible. The overall implementation of the PPE program should be monitored regularly, with the goals of continuous improvement, adoption of best practices, and accountability of both supervisor and worker."

H1N1: The Pandemic That Changed Everything In his presentation, "Respiratory Protection, Infection Control, and Preparing for Pandemic Influenza" at the June 18

stakeholders meeting, Stephen C. Redd, MD, director of the CDC's Influenza Coordination Unit, discussed the state of PPE and pandemic preparedness before the 2009 H1N1 pandemic, as well as the lessons learned and new actions taken post-pandemic.

Before H1N1, Redd explained that the National Strategy Implementation Plan on PPE called for the provision of guidance to individuals on infection control behaviors they should adopt pre-pandemic, and the specific actions they will need to take during a severe influenza season or pandemic, such as self-isolation and protection of others if they themselves contract influenza. It also noted that HHS, in coordination with DHS, DOL, OPM, Department of Education, VA, and DOD, should develop sector-specific infection control guidance to protect personnel, governmental and public entities, private sector businesses, and CBOs and FBOs. Additionally, in 2007, the guidance document "Interim Public

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Health Guidance for the Use of Facemasks and Respirators in Non-Occupational Community Settings during an Influenza Pandemic" acknowledged the absence of scientific data; the recommendations based on public health judgment and on the historical use of facemasks and respirators in other settings included:

Avoid close contact and crowded conditions during an influenza pandemic (rather than depend on respirators or facemasks).

Consider using a facemask when entering crowded settings, both to protect the nose and mouth from other people's coughs and to reduce the wearers' likelihood of coughing on others.

Consider using a respirator when close contact with an infectious person is unavoidable. This can include selected individuals who must take care of a sick person (e.g., family member with a respiratory infection) at home.

Facemasks and respirators should be used in combination with other preventive measures, such as hand hygiene and social distancing, to help reduce the risk for influenza infection during a pandemic.

Redd reported that during the H1N1 pandemic, 25.4 million respirators and 14 million surgical masks were deployed in April 2009 as part of the initial response; an additional 59.7M respirators were deployed in October 2009 in response to the commercial supply shortage. An IOM Workshop held in August 2009 made the following recommendations for necessary respiratory protection for healthcare workers against novel H1N1 influenza A:

1: Use Fit-Tested N95 Respirators - Use current CDC guidance - Employers should ensure use and fit testing of N95 respirators and healthcare workers should use the equipment as

required 2: Increase Research on Influenza Transmission and Personal Respiratory Protection - Relative contribution of various routes of influenza transmission - Effectiveness of personal respiratory protection technologies in a variety of clinical settings through randomized

clinical trials - Design and develop the next generation of personal respiratory protection technologies for healthcare workers to

enhance safety, comfort, and ability to perform work-related tasks Redd pointed out that after the H1N1 pandemic, the 2009 H1N1 Retrospective and Improvement Plan issued by HHS

noted that there was an insufficient evidence base to support guidance on the appropriate level of respiratory protection (N95 respirators or surgical masks) to prevent occupational acquisition of 2009 H1N1 influenza by healthcare workers, as well as fit testing issues and challenges from apparent disagreement among federal agencies. This H1N1 Improvement Plan determined stockpiling requirements for RPDs; encouraged NIOSH and FDA approval; called for the monitoring of the safety, effectiveness and shortages of RPDs; called for more research to better understand transmission; mandated that RPD design, use, testing and certification be strengthened; and called for the development and revision of respirator use/reuse policies, among other action items.

Moving forward, Redd noted a number of next steps in respiratory protection, infection control and pandemic preparedness, including:

Better evidence base for protection / transmission, including data on the infectious dose/filtering requirement New products Administrative and engineering controls Emphasize source control (masks on ill persons) Stockpile to bridge the gap from current supplies to increased production Measure and improve infection control practice

The 2010 IOM report acknowledges that "H1N1 influenza brought into sharp focus the efforts by healthcare professionals, emergency planners, professional associations, healthcare facilities, policy makers, government agencies, labor unions, and others to address PPE policies and logistics. Articles continue to be published on the recent experience and the challenges and successes in providing face masks, respirators, and other PPE to healthcare personnel. As lessons learned during that experience continue to add to the body of knowledge, incorporating this information into research, policy, and practice efforts will be important. In the initial phases of an epidemic or pandemic when there are many unknowns about the virus or agentone of the challenges is to determine PPE policy and then to adapt those policies as information is gained on the severity, transmission, and nature of the disease, with an emphasis on communicating the changes. Standards setting, regulatory, training, and research efforts continue to move toward improved respiratory protection, and recent work has begun to focus on the specifics of how to tailor PPE devices and PPE training to address the specific needs of healthcare personnel."

The 2010 IOM report makes the following recommendations to advance research and transfer these into practice across the spectrum of research opportunities.

1. Develop Standardized Terms and Definitions The Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration

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(OSHA), in partnership with other relevant agencies and organizations, should work to develop standardized terms, definitions, and appropriate classifications to describe transmission routes and aerodynamic diameter of particles associated with respiratory disease transmission. This effort should involve a consensus from the industrial hygiene, infectious disease, and healthcare communities.

2. Develop and Implement a Comprehensive Research Strategy to Understand Viral Respiratory Disease Transmission The National Institutes of Health, in collaboration with other research agencies and organizations, should develop and

fund a comprehensive research strategy to improve the understanding of viral respiratory disease transmission, including, but not limited to, examining the characteristics of influenza transmission, animal models, human challenge studies, and intervention trials. This strategy should include: an expedited mechanism for funding these types of studies and clinical research centers of excellence for studying influenza and other respiratory virus transmission.

3. Continue and Expand Research on PPE for Healthcare Personnel NPPTL and other agencies, private-sector companies, and other organizations should continue to advance research in

designing and evaluating the effectiveness of respirator protection for healthcare personnel and expand its research efforts to improve and evaluate the effectiveness of gloves, gowns, eye protection, face shields, and face masks in preventing the transmission of influenza or other viral respiratory diseases. Areas of focused research needs include

effectiveness in preventing fomite, droplet spray or aerosol transmission; decontamination and reusability comfort, fit, and usability impact on task performance development of technologies specifically for healthcare personnel. 4. Examine the Effectiveness of Face Masks and Face Shields as PPE NPPTL should investigate the effectiveness of face masks and face shields in preventing transmission of viral

respiratory diseases. 5. Improve Fit Test Methods and Evaluate User Seal Checks NPPTL should develop novel, simpler fit test methods and evaluate the effectiveness of performing user seal checks

on N95 respirators. 6. Explore Healthcare Safety Culture and Work Organization NIOSH and other relevant agencies, such as the Agency for Healthcare Research and Quality, and professional

organizations should conduct research to better understand the role of safety culture and other behavioral and organizational factors on PPE usage in healthcare settings. These efforts should include: conducting human factors and ergonomics research relevant to the design and organization of healthcare work tasks to improve worker safety by reducing hazardous exposures and effectively using PPE (e.g., reduce unnecessary PPE donning and doffing); exploring the links between patient safety and healthcare worker safety and health that are relevant to the use of PPE; and identifying and evaluating strategies to mitigate organizational barriers that limit the use of PPE by healthcare personnel.

7. Identify and Disseminate Effective Leadership and Training Strategies and Other Interventions to Improve PPE Use NIOSH and other relevant agencies and professional organizations should support intervention effectiveness research

to assess strategies, including innovative participatory approaches to training, for healthcare and supervisory staff at all levels to improve PPE usage and other related outcomes across the range of healthcare settings. To identify best practices, efforts should be made to: conduct observational studies of PPE use by healthcare personnel in different types of work settings; develop, implement, and evaluate comprehensive leadership and training strategies and interventions that go beyond simple knowledge-based training; design training interventions specifically for supervisory and managerial personnel in different types of healthcare settings; examine long-term practice change and safety culture implementation related to educational interventions; improve use and understanding of PPE by home and community healthcare personnel; develop assessment tools and metrics that take a broader approach to PPE and acknowledge the interaction of worker, task and environmental factors; and be informed by a lessons-learned summit on PPE use by healthcare personnel during the 2009 H1N1 experience.

8. Develop and Certify Powered Air-Purifying Respirators (PAPRs) for Healthcare Personnel NPPTL should develop certification requirements for a low-noise, loose-fitting PAPR for healthcare personnel. 9. Move Forward on Better Fitting Respirators NPPTL should continue rulemaking processes for total inward leakage regulations that require respirators to meet fit

criteria. To improve consumer and purchaser information on fit capabilities, NIOSH should establish a website to disseminate fit test results for specific respirator models on an anthropometric (NIOSH) test panel, where such data exist.

10. Clarify PPE Guidelines for Outbreaks of Novel Viral Respiratory Infections NIOSH, other divisions of CDC, OSHA, and other public health agencies should develop a coordinated process to

make, announce and revise consistent guidelines regarding the use of PPE to be worn by healthcare personnel during a verified sustained national/international outbreak of a novel viral respiratory infection. The agencies should tailor their

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guidance in a timely and coordinated manner as the virulence, contagiousness, and affected populations are further characterized.

11. Standards and Certification for Face Masks and Face Shields NIOSH, OSHA and standards-development organizations should develop the standards and certification processes

needed to assess the performance of face masks and face shields as PPE. The development of standards and certification processes should be guided by research regarding their efficacy as PPE:

OSHA and CDC should clarify that face masks are governed by the general PPE standard (29 CFR 1910.132) and not by the respiratory protection standard (29 CFR 1910.134).

NIOSH should work with other agencies and standards-setting organizations to develop voluntary consensus standards and independent third-party testing and certification processes for face shields and face masks with specific tests for assessing prevention of transmission of viral respiratory diseases.

12. Establish PPE Regulations for Healthcare Personnel CDC, including NIOSH, and OSHA should develop and promulgate guidelines and regulations that are consistent

regarding the use of PPE by healthcare personnel for influenza and other viral respiratory diseases: To assist employers in complying with the OSHA PPE standard, OSHA should specify the voluntary consensus

standards that are required to be met for non-respirator PPE (e.g., gowns, gloves, face shields, face masks) in the event of influenza and other viral respiratory diseases.

OSHA, with input from CDC and other agencies and organizations, should work toward promulgating an aerosol-transmissible diseases standard that would include prevention of the transmission of influenza and other viral respiratory diseases.

Influenza Transmission Research Institute of Medicine reports have examined research studies conducted on the modes of influenza transmission and

highlighted the paucity of data on the relative contributions of each to the risk of illness in the community or clinical setting. And as the IOM explains, "Much of the discussion regarding influenza transmission has focused on the continuum between droplet spray and aerosol transmission, as well as on the role of contact transmission and the potential for transmission through inoculation of the conjunctivae. Aerosol transmission, an issue in healthcare settings where patients have diseases such as tuberculosis and measles, can occur at a short range between persons but can also involve infectious agents carried for longer distances by air currents ... One of the main reasons why there is no clear understanding of long-range transmission is because aerosol transmission of influenza and other respiratory viruses is difficult to study in human populations. To study long-range aerosol transmission properly, the background prevalence of the disease would need to be low in the community, and many other factors would need to be controlled to rule out other transmission routes, such as droplet spray and contact. Production of aerosols also varies by individual; some individuals produce large amounts of bioaerosols in coughs, sneezes, and even tidal breathing, while others do not. Therefore, some individuals may be more or less likely to transmit influenza infection or other viral respiratory diseases via aerosols. Context is likely to play an important role in shaping the importance of these transmission pathways in relation to illness occurrence. Researchers have shown that contextual factors may include environment, humidity, temperature, number and types of fomites, air flow, age of susceptible and infected populations, and number of individuals and their interactions within space. Biological factors that may influence transmission include virus strain characteristics, human physiology, immune status, and genetic susceptibility of the host."

The 2008 IOM report emphasizes that establishing how influenza is transmitted and understanding the contribution of each mode of transmission is critical to preventing its spread and reducing morbidity and mortality due to influenza infection, especially in healthcare settings. The report outlined a number of questions that remained to be addressed regarding influenza transmission (IOM, 2008):

Questions regarding transmission mode, including: What are the major modes of transmission? How much does each mode of transmission contribute individually or with other modes of transmission? What is the size distribution of particles expelled by infectious individuals, and how does that continuum of sizes affect transmission? Is the virus viable and infectious on fomites, and for how long? Are fomites a means of transmission, and are some more able to transmit than others?

Questions regarding infectivity, including: Can infection take place through mucous membranes or conjunctiva exposure? What is the time sequence of infectivity?

Questions specific to transmission in healthcare settings, including: What activities in the healthcare setting are associated with minimal or increased transmission? How distinct is transmission in different venues including health care, schools, and households?

Questions specific to the role of PPE in preventing or reducing transmission, including: How effective is each type of PPE in reducing the risk of influenza transmission? How effective are face masks? What innovations regarding PPE are

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needed to enhance effectiveness? What is the impact on transmission risk when patients wear face masks? Questions specific to other potential forms of prevention, including: What is the role of ultraviolet (UV) light, humidity,

temperature, pressure differentials, air flow and exchange, and ventilation in preventing transmission? In a NIOSH Science Blog entry, "Catching the Flu: NIOSH Research on Airborne Influenza Transmission," William G.

Lindsley, PhD, a research biomedical engineer in the NIOSH Health Effects Laboratory Division, summarizes what NIOSh scientists are studying that may have direct bearing on answering these questions. As Lindsley notes, "A better understanding of influenza transmission could help improve the infection control procedures and equipment used by health care workers. NIOSH has been conducting research for several years to learn more about the underlying science of influenza transmission, with a particular focus on airborne transmission and the protection of health care workers during a future pandemic."

In his blog entry, Lindsley shares some of the questions that are being addressed: Is there a correlation between exposure to airborne influenza and illness among healthcare workers? A combination

of three approaches is being used to better understand worker exposure to influenza and its consequences. First, aerosol sampling will be conducted in a health care clinic. Second, the amount of genetic material (RNA) from influenza virus on surgical masks, respirators and gloves worn by health care workers and on the surfaces of equipment and furniture in the clinic will be measured. Third, the health status and any occurrences of influenza among the workers in the study will be monitored.This project is part of a large multi-hospital study to compare the relative effectiveness of surgical masks and respirators in preventing influenza among healthcare workers.

Can better methods be developed to detect infectious airborne influenza virus? The current methods for determining the infectivity of influenza arent sensitive enough to work with the small amounts of virus in a typical aerosol sample. NIOSH researchers are developing new, more sensitive methods of measuring influenza virus viability. One technique is a hybrid system called a viral replication assay that combines PCR with a more traditional culture method for increased sensitivity. A second technique uses genetically modified cells that glow faintly when they are infected with the influenza virus. This luminescence can be detected using standard laboratory equipment.

How well do different types of personal protective equipment perform under different exposure scenarios? To explore this, NIOSH researchers constructed a simulated medical examination room containing a custom-built coughing machine that can cough an influenza-laden aerosol into the room much like a patient would, and a breathing machine that can simulate a healthcare worker treating the patient. The breathing machine can be outfitted with personal protective equipment (PPE), such as surgical masks, respirators, face shields, and powered air-purifying respirators (PAPRs). The simulated exam room is now being used to study how well different types of PPE and combinations of PPE protect from large spray droplets and small aerosol particles at shorter and longer distances.

Healthcare Worker Compliance with PPE While researchers continue to work toward addressing these questions, the best that infection preventionists can do is

ensure that healthcare workers comply with the appropriate guidance in routine and pandemic use of PPE. It can be a daunting task. The Occupational Safety & Health Administration (OSHA) requires the use of personal protective equipment to reduce employee exposure to hazards when engineering and administrative controls are not feasible or effective. Yet, data from the Bureau of Labor Statistics (BLS) show that of the workers who sustained a variety of on-the-job injuries, the vast majority were not wearing PPE. Given the importance of PPE in ensuring worker safety, the survey examined the reasons for such high levels of noncompliance. Of those respondents who observed PPE noncompliance in the workplace, 69 percent said the primary cause was workers thinking that PPE wasn't needed. This was followed by PPE being uncomfortable, too hot, a poor fit, not available near work task, and unattractive-looking. The top strategies taken by safety managers to encourage greater PPE compliance were: improving existing education and training programs (61 percent) and increased monitoring of employees (48 percent), as well as purchasing more comfortable PPE tying compliance to individual performance evaluations, purchasing more stylish PPE, and developing incentive programs. When it comes to compliance with PPE protocols, eye protection was found to be the "most challenging" PPE category, according to 24 percent of respondents. This was a disturbing though not unexpected finding considering that nearly three out of five workers who experienced eye injuries were found not to be wearing eye protection at the time of the accident or were wearing the wrong kind of eye protection for the job. Add to this the fact that that thousands of workers are blinded each year from work-related eye injuries that could have been prevented and the magnitude of the problem becomes clear. The next highest category for noncompliance was hearing protection (18 percent), followed by respiratory protection/masks (17 percent), protective apparel (16 percent), gloves (14 percent) and head protection (4 percent).

While the aforementioned survey does not reflect the experience at all places of employment, it indicates the need for constant vigilance, especially during seasonal influenza season, a pandemic or other outbreak scenario. The importance of PPE and its inherent compliance challenges are summed up nicely by a 2008 report from the National Academies: "Personal protective equipment is one of the vital components of a system of safety controls and preventive measures

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used in healthcare facilities. The recent heightened awareness of patient safety issues has opened up opportunities to improve worker safety with the potential to benefit workers, patients, family members and others who interact in the healthcare setting. Because PPE works by acting as a barrier to hazardous agents, healthcare workers face challenges in wearing PPE that include difficulties in verbal communications and interactions with patients and family members, maintaining tactile sensitivity through gloves, and physiological burdens such as difficulties in breathing due to respirators. For healthcare workers this may affect their work and the quality of interpersonal relationships with patients and family members. As manufacturers continue to develop PPE that can reduce the job-related constraints, healthcare institutions and individual healthcare workers need to improve their adherence to appropriate PPE use. Healthcare employers need to provide a work environment that values worker safety, including provision of PPE that is effective against the hazards faced in the healthcare workplace. In turn, healthcare workers need to take responsibility to properly use PPE, and managers should ensure that the staff members they supervise also make proper use of PPE."

Despite recommendations in numerous guidelines and the prevalence of high-risk conditions, healthcare workers still exhibit low rates of PPE use, and the National Academies (2008) says that "assessments of the explanations for noncompliance and the solutions to these issues need to focus beyond the individual and address the institutional issues that prevent, allow or even favor non-compliance."

A number of studies have documented the barriers to PPE compliance: - Lack of time - Perception that using PPE interferes with the ability to perform the job - Physical discomfort/difficulty communicating when wearing masks - PPE not available when needed PPE compliance does not happen in a vacuum; instead, it is part of a number of other safety-related interventions

including environmental and engineering controls, administrative or work practice controls (such as protocols to ensure early disease recognition, vaccination policies, disease surveillance, infection control guidelines for patients and visitors, decontamination of healthcare equipment and patient-care rooms, risk assessment education programs for healthcare workers). According to the National Academies (2008), "The hierarchy of controls is meant to address hazards through direct control at the source of the infection and along the path between the infectious source and the employee. PPE is implemented at the individual level and is one component of effective infection prevention and control measures that particularly emphasize hand hygiene as a critical action for reducing disease transmission. When all of these measures are integrated and implemented, a continuum of safety exists; deploying evidence-based improvements at any level can enhance the safety culture."

Gershon et al. (2000) explain that a factor analysis of the results of a survey of 789 healthcare workers identified six organizational factors underlying the hospital safety climate: senior management support for safety programs; absence of workplace barriers to safe work practices; cleanliness and orderliness of the worksite; minimal conflict and good communications among staff; frequent safety-related feedback and training by supervisors; and availability of PPE and engineering controls. Three of these factors -- senior management support, absence of workplace barriers, and cleanliness or orderliness -- were associated with significant adherence to safe work practices.

The National Academies (2008) identified four key factors in promoting a culture of safety within healthcare facilities that are pertinent to PPE:

- Provide leadership, commitment, and role modeling for worker safety - Emphasize healthcare worker education and training - Improve feedback and enforcement of PPE policies and use - Clarify worksite practices and policies Researchers have studied the triggers that invoke behavioral changes. For employees, engaging in the proper use of

PPE may be motivated by the desire to protect themselves from occupational hazards, while for institutions, change might be provoked by the desire to attain accreditation, preserve funding or realize cost-savings related to reduced worker illness and absenteeism. Either way, healthcare institutions are encouraged to identify healthcare workers who fall into distinct categories -- innovators who are focused on being first and leading the way; early adopters who are opinion leaders; the early majority who want to remain competitive and are influenced by peer groups and more developed performance data; the late majority who bow to competitive pressures; and the laggards who adopt change only after it is mandated or regulated (Rogers, 1995; Weinstein et al., 2007).

Whether a healthcare worker uses PPE or not has everything to do with their perceived risk inherent in any job-related task. As various researchers have demonstrated, perception or risk depends upon the worker's education/awareness level, experience and propensity for adherence to safety measures; if occupational risk is not perceived to be real, use of risk reduction measures is far less probable. For example, DeJoy, et al. (2000) found that healthcare workers who had repeated occupational exposures to blood and body fluids but who did not acquire infection, had poorer PPE compliance

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and may have perceived a decreased risk of acquiring infection compared to those who had not been exposed. This experience may lead to a false sense of invulnerability, resultant noncompliance with standards, and increased risk taking, which ill prepare the worker for the next unknown infectious disease.

As a solution to this potential bravado, the National Academies (2008) emphasize, "Training and continuing education efforts focused on understanding risks and engraining the rationale and policies of the institutions safety culture are needed. Further, ongoing work to delineate the critical elements of risk communication relevant to the use of PPE should be conducted. Healthcare facilities need to develop strong and culturally competent risk communication resources as part of pandemic planning for the diverse communities and employees that they serve. Moreover, risk communication materials should be available in formats accessible to individuals with disabilities and/or limited English proficiency and should also target the educational level of the intended audienceMandatory training is needed across all levels of the organization to communicate the institutions safety rules. Significant portions of training resources should be devoted to training managers and supervisors in techniques that can be used to promote and manage good safety practices. Further, training should involve peer educators and draw from a range of healthcare occupations and professions as well as involving workers proficient in various languages. Best practices have to be identified for tailoring the training efforts to provide various types of healthcare workers with the practical information they need to appropriately use PPE while completing their daily work tasks."

NIOSH scientists are sympathetic to infection preventionists' plight in trying to boost healthcare worker compliance with PPE. In a recent NIOSH Science Blog, Ronald E. Shaffer, PhD, Debra Novak, DSN, RN, and Jaclyn Krah, MA, addressed improving respirator use and compliance among healthcare workers and where NIOSH should conduct research to address this issue. As Shaffer, et al. (2013) note, "Like many other public health or occupational safety and health interventions (e.g., the use of seat belts, hand hygiene, vaccines, personal flotation devices, etc.), respiratory protection requires the user to comply with various state or federal requirements and recommended best practices to receive the full benefits of the intervention. Studies have shown that failure to implement all aspects of a respiratory protection program can result in inhalation of higher than anticipated airborne hazards. A respiratory protection program has many recommended components including initial and annual fit testing and training on proper use practices. Examples of proper use procedures may include using the recommended sequence of taking off gloves, gowns, and respirators; correct technique for putting on a respirator; and wearing the respirator during all periods of exposure. The best practice for ensuring respirator compliance among healthcare professionals during a pandemic or outbreak is to demonstrate compliance day to day. However, observational studies and surveys of healthcare professionals demonstrate that users often put on or take off their respirators incorrectly or, even worse, fail to use them at all. The reasons for poor compliance are complex and multifaceted, but have been linked to poor safety culture, workload issues, time constraints, risk perception, concerns that the equipment is not effective, lack of understanding of proper use, availability, interference with patient care, communication difficulties, and discomfort (e.g., heat, sweating, facial pressure, breathing resistance)."

References Health and Human Services (HHS). 2009 H1N1 Retrospective and Improvement Plan. Worker protection guidance for

an influenza pandemic, June 15, 2012. Accessed at: https://www.phe.gov/Preparedness/mcm/h1n1-retrospective/Pages/default.aspx

Institute of Medicine (IOM). Preventing Transmission of Pandemic Influenza and other Viral Respiratory Diseases:

Personal Protective Equipment for Healthcare Personnel, Update 2010.

Liverman CT, Harris TA, Rogers MEB and Shine KI, editors. Committee on Respiratory Protection for Healthcare

Workers in the Workplace Against Novel H1N1 Influenza A, Institute of Medicine. September 2009. National Academies Press. Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases:

Personal Protective Equipment for Healthcare Workers: Update 2010. National Academies Press. Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare

Workers (2008). Committee on Personal Protective Equipment for Healthcare Workers During an Influenza Pandemic. Goldfrank LR and Liverman CT, eds. Washington, D.C.

Pyrek, KM. Addressing the Challenges of PPE Non-Compliance. Infection Control Today. Accessible at:

http://www.infectioncontroltoday.com/articles/2011/10/addressing-the-challenges-of-ppe-non-compliance.aspx

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Shaffer RE, Novak D and Krah J. Improving Respirator Use and Compliance in Healthcare An Invitation. NIOSH

Science Blog. May 8, 2013.