Respiratory Protection For Health Care Workers Exposed to MTB

1
Respiratory Protection For Health Care Workers
Exposed to MTB

• Stephen Born, MD, MPH
• Medical Director, San Francisco General Hospital
  Occupational Health Service
• Associate Professor, UCSF Division of
  Occupational and Environmental Medicine

2
Introduction

• History-Development of legislation
• Current OSHA Standards
• Federal 1910.134, full compliance 10/5/98, 01/99
  for small businesses APFs added 2006
• California 5144, adopted by Standards Board with
  a 11/22/98 startup date and fully effective
  5/22/99 APFs added 2007
• Future Cal OSHA TB Standard
• Aerosol Transmissible Diseases 5199, May 21,
  2009 to Cal OSHA Standards Board

3
Introduction

• Employers must first try to implement feasible
  engineering controls or administrative controls
  before relying on respiratory protection
• When effective engineering controls are not
  feasible or while they are being implemented,
  respiratory protection shall be used

4
OSHA Requirements

• Written Standard Operating Procedures
• Program Administrator-qualified by appropriate
  training or education
• Hazard Assessment of respiratory hazards in the
  workplace-reasonable estimate of exposure
• Procedures for Selection of Respirators

5
OSHA Requirements

• Medical Examinations
• Fit-testing procedures for tight-fitting
  facepieces, both air-purifying and air-supplied
• Procedures for proper use of respirators in
  routine and emergency use
• Procedures for cleaning, maintenance, storage,
  repairs

6
OSHA Requirements

• Training of employees in respiratory hazards, the
  proper use of respirators, limitations on their
  use, and maintenance
• Procedures for program evaluation

7
NIOSH Certification

• NIOSH has sole responsibility for respirator
  approval under 42 CFR Part 84
• All approvals issued by NIOSH except for
  self-contained self-rescuers, for mine rescue,
  which are certified by both NIOSH and MSHA

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Voluntary Use of Filtering Facepieces-Dust Masks

• Employers are not required to include in the
  written program employees whose only use of
  respirators involves the voluntary use of dust
  masks. Must supply the info in Cal OSHA
  Respiratory Standard, Appendix D

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Appendix D to Sec. 1910.134 Information for
Employees Using Respirators When Not Required
Under the Standard

• Respirators are an effective method of
  protection against designated hazards when
  properly selected and worn. Respirator use is
  encouraged, even when exposures are below the
  exposure limit, to provide an additional level of
  comfort and protection for workers. However, if a
  respirator is used improperly or not kept clean,
  the respirator itself can become a hazard to the
  worker. Sometimes, workers may wear respirators
  to avoid exposures to hazards, even if the amount
  of hazardous substance does not exceed the limits
  set by OSHA standards. If your employer provides
  respirators for your voluntary use, of if you
  provide your own respirator, you need to take
  certain precautions to be sure that the
  respirator itself does not present a hazard.
• You should do the following 1. Read and heed
  all instructions provided by the manufacturer on
  use, maintenance, cleaning and care, and warnings
  regarding the respirators limitations. 2.
  Choose respirators certified for use to protect
  against the contaminant of concern. NIOSH, the
  National Institute for Occupational Safety and
  Health of the U.S. Department of Health and Human
  Services, certifies respirators. A label or
  statement of certification should appear on the
  respirator or respirator packaging. It will tell
  you what the respirator is designed for and how
  much it will protect you. 3. Do not wear your
  respirator into atmospheres containing
  contaminants for which your respirator is not
  designed to protect against. For example, a
  respirator designed to filter dust particles will
  not protect you against gases, vapors, or very
  small solid particles of fumes or smoke. 4.
  Keep track of your respirator so that you do not
  mistakenly use someone else's respirator

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Hazard Assessment

• Employer shall identify and evaluate the
  respiratory hazards in the workplace
• This shall include a reasonable estimate of the
  employee exposure(s) and identification of the
  chemical state and physical form

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Selection of Respirators

• Employer shall select respirators based on
  respiratory hazards and workplace and user
  factors which affect respirator performance and
  reliability
• Employer must select NIOSH-certified respirators
• Must have a sufficient number of respirator
  models and sizes so that respirator fits and is
  acceptable to the user

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Types of Respirators
13
Air-Purifying Respirators

• Come in quarter, half, and full face
• Filter air by passing it through a cartridge or
  filter
• Come in tight-fitting facepieces or loose-fitting
  hoods or helmets
• PAPRs- powered air-purifying respirators
• Cannot be used in IDLH atmospheres

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Tight -Fitting Coverings
Quarter Mask
Half Mask
Full Facepiece
Mouthpiece/Nose Clamp (no fit test required)
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Loose-Fitting Coverings
Hood
Helmet
Loose-Fitting Facepiece
Full Body Suit
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High Efficiency Particulate Air Filter (HEPA)
Filter that is at least 99.97 efficient in
removing mono-dispersed particles of 0.3
micrometers in diameter. Equivalent NIOSH 42
CFR 84 particulate filters are the N100, R100,
and P100 filters.
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Filtering Facepiece(Dust Mask)
A negative pressure particulate respirator with a
filter as an integral part of the facepiece or
with the entire facepiece composed of the
filtering medium.
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Air Purifying Respirators-Particulates

• Generally not recommended beyond 8 hours use,
  unless evaluations in specific workplace can
  demonstrate filter not degraded or that mass
  loading of filter is less than 200 mg

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Air-Purifying Respirators - Tuberculosis

• In 2004, OSHA withdrew published proposed rules
  for exposure to TB, falls now under general
  respirator standard
• Minimum respiratory protection N 95
• Can be reused provided the respirators have not
  been damaged, soiled, or the breathing resistance
  becomes great enough to cause discomfort to the
  wearer

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Air-Purifying Respirators-Avian/Swine/Pandemic
flu

• Respiratory protection depends on task
• N-95 may be used
• For potentially high risk tasks the minimum
  recommended is an elastomeric facepiece with
  P-100 filters and gas/vapor cartridges if
  ammonia, or other gases/vapors present

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Powered Air-Purifying Respirators

• Come with half face and full face tight fitting
  facepieces and with loose fitting hoods and
  helmets or bonnets
• Use blower to pull air through filters and push
  air into wearers breathing zone
• 4cfm for tight fitting facepieces 6 cfm for
  loose-fitting
• Must be supplied by employer if PLHCP determines
  that employee cannot wear a negative pressure
  respirator but can wear PAPR

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Tuberculosis
An atmosphere-supplying respirator for which the
source of breathing air is not designed to be
carried by the user. Also called airline
respirator.

• Controls
• LEV
• Dilution ventilation
• UV lights
• Negative pressure rooms
• PPE
• N,R,P-95,99,99.9 masks

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Medical Evaluations

• Employers must provide a medical evaluation
  before employee is fit tested or required to wear
  a respirator
• Required
• Identify a PLHCP-physician or other licensed
  health car provider
• Do initial medical examination or medical
  questionnaire- see Appendix C, OSHA annual
  review is not mandatory
• New proposed Aerosol Transmissible Disease
  Standard Medical Questionnaire is shorter and
  easier to complete

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Medical Evaluations

• Follow-up examinations for those giving positive
  responses to questions 1-8 in section 2, part A
  of Appendix C, or whose initial exam demonstrates
  need for a follow-up exam
• Consists of medical tests, consultations, or
  diagnostic procedures deemed necessary by PLHCP

29
Medical Evaluations

• Medical exam and questionnaire administered
  confidentially during employees normal working
  hour or at a time and place convenient for
  employee.
• Employee must understand content of medical
  questionnaire
• Employee shall be able to discuss questionnaire
  and exam results with the PLHCP

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Medical Evaluations

• Information the employer must provide PLHCP
• Type and weight of respirator
• Duration and frequency of use
• Expected physical work effort
• Additional protective equipment
• Temperature and humidity extremes encountered
• Written respirator program from employer

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Medical Evaluations

• The PLHCP must supply the employer
• Any limitations on respirator use related to
  medical condition of employee or relating to in
  the workplace conditions, including if the
  employee is medically able to wear the respirator
• The need for any follow-up medical evaluations
• A statement that the PLHCP has provided the
  employee with a copy of their written
  recommendation

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Medical Evaluations

• If employee cannot wear a negative pressure
  respirator due to health considerations, the
  employer must supply a PAPR if the PLHCPs
  evaluation finds the employee can wear a PAPR.
• No requirement in new standard for annual exams

33
Medical Evaluations

• Additional medical exams
• If an employee reports medical signs or symptoms
  related to ability to wear a respirator
• A PLHCP, supervisor, or the respirator program
  administrator informs the employer that an
  employee needs to be reevaluated
• Information from the program indicated a need for
  reevaluation or a change in workplace conditions

34
Assigned Protection Factors

• OSHA revised the APFs for respirators in 2006.
• NIOSH and ANSI protection factors differ for same
  facepieces, eg. APFs for PAPRs

35
Assigned Protection Factors

• OSHA Definition
• APF means the workplace level of respiratory
  protection that a respirator or class of
  respirators is expected to provide to employees
  when the employer implements a continuing,
  effective respiratory protection program as
  specified by the standard.

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OSHA Assigned Protection Factors

• 1/2 FF Hel/hood Loose-fit
• APR 10 50 ------ -------
• PAPR 50 1000 25/1000 25
• SAR
• -demand 10 50 ------ ------
• -CF 50 1000 25/1000 25
• -Pres.Dem 50 1000
• SCBA
• -demand 10 50 50 ------
• -Pres. Demand ------ 10,000 10,000

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Fit testing

• Must be fit tested prior to use of any negative
  or positive pressure tight-fitting facepiece
• Must be same make, model, style, and size as one
  to be used.
• Must pass a qualitative (QLFT) or quantitative
  (QNFT) fit test
• Must be fit tested prior to initial use, whenever
  a different facepiece is used and annually
  thereafter.

38
Fit testing

• Additional fit tests whenever employee reports or
  PLHCP, employer, or program administrator makes
  visual observations of changes in the employees
  physical condition that could affect respirator
  fit, including facial scarring, dental changes,
  cosmetic surgery, or obvious change in body weight

39
Fit testing

• QNFT modify facepiece to allow sampling inside
  facepiece in the breathing zone of user, midway
  between nose and mouth.

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Fit testing

• QLFT Protocols-Appendix A, OSHA
• Irritant smoke
• Saccharin
• Isoamyl acetate
• Bitrex

42
Fit testing

• QNFT Protocols - Appendix A, OSHA
• Generated Aerosol
• Ambient Aerosol
• Condensation Nuclei
• Counter-CNC-e.g.
• PortacountTM
• Controlled Negative
• Pressure-e.g. Dynatech
• Nevada

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Use of Respirators

• Employers must establish and implement procedures
  for proper use
• Facepiece seal protection
• No facial hair between sealing surface of the
  respirator and face or that interferes with valve
  function
• Corrective glasses must fit without interfering
  with seal
• Must do seal check each time used

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Maintenance,Cleaning, Inspection, and Storage

• Must provide clean, sanitary respirators in good
  working order
• Clean and disinfect according to
• Appendix B-2, OSHA, or procedures
• recommended by manufacturer
• For individual use, clean as necessary
• For multiple users, before each use
• For emergency use, after each use

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Training

• Topics include
• Why respirator necessary
• What its limitations and capabilities are
• How to use effectively in emergency situations
• How to inspect, don, remove, use, and check seals
• Procedures for maintenance
• Medical signs/symptoms which may limit use

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Training

• Needs to be done in manner understandable to
  employee
• Shall provide initially and annually thereafter
  or more frequently when changes in workplace or
  type of respirator make previous training
  obsolete
• Information in Appendix D, OSHA, to employees
  voluntarily wearing respirators

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Program Evaluation

• Conduct evaluations to make sure the respirator
  program is properly implemented
• Employer should regularly consult employees to
  ensure respirators used properly
• Respirators fit properly
• Appropriate respirators are used
• Proper maintenance

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Recordkeeping

• Medical evaluations-retain per 29 CFR 1910.1020
• Fit testing-name, type of test, make model, size
  of respirator,date, fit test results-keep until
  next test
• Written copy of the program retained by employer

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References

• Respiratory Protection A Manual and Guideline,
  3rd Edition, 2001, AIHA Press
• ANSI/AIHA Z88.10-2001, American National Standard
  for Respirator Fit Testing Methods, 2001, AIHA
  Press
• NIOSH Respirator Selection Logic 2004, NIOSH Pub.
  No.2005-100

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Selected Websites

• OSHA www.osha.gov/SLTC/etools/respiratory/index.h
  tml
• NIOSH http//www.cdc.gov/niosh/npptl/topics/resp
  irators/
• NIOSH Certified Equipment list
  www.cdc.gov/NIOSH/npptl/topics/respirators/cel/

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Selected Websites

• 3M-
• http//solutions.3m.com/wps/portal/3M/en_US/Healt
  h/Safety/Solutions/One/

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Draft Cal/OSHA Aerosol Transmissible Diseases Std

• http//www.dir.ca.gov/oshsb/atd0.html

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Acknowledgements

• Thanks to Patty Quinlan, MPH, CIH for help in
  developing this presentation and the industrial
  hygiene staff at SFGH and UCSFtrue experts in
  the art and science of respiratory protection