Unit 7.1. Respiratory protection

TB Infection Control Training for

Managers at National and Subnational Level

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Objectives

After this unit, participants will be able:• To describe the differences between a

surgical mask and a respirator• To name the types of respirators that

protect against TB transmission, and when to use them

• To list the elements of a respiratory programme

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Outline

• WHO recommendations• Surgical mask vs. particulate respirator• Respirator standards• Respirator programme

– Proper use– Fit testing

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WHO recommendations

• When used with administrative and environmental controls, particulate respirators may provide health care workers (HCW) additional protection from TB

• Respirators – Must meet or exceed standards– Be properly used– Be part of a training programme

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WHO recommends particulate respirators for HCWs:

• Caring for patients with confirmed or suspected infectious TB (in particular MDR-TB)

• Performing aerosol-generating procedures on infectious TB patients

– Bronchoscopy, intubation, sputum induction

– Use of high speed devices for lung surgery or autopsy

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Surgical masks

• Reduce the spread of microorganisms from the wearer to others, by capturing large wet particles

• Do not protect the wearer from inhaling small infectious aerosols.

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Particulate respirators

• Protect the wearer from inhaling droplet nuclei

• Filter out infectious aerosols

• Fit closely to the face to prevent leakage around the edges

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Proper wearing of respirators Proper wearing of respirators (N95s and FFP2s) in Santa Cruz, (N95s and FFP2s) in Santa Cruz,

BoliviaBolivia

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Surgical masks(yes for patients)

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Surgical masksdo not protect staff from TB

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Particulate respirators used for TB exposure

N95 (USA)

Filter out > 95% of particles

FFP2, FFP3 (Europe)

Filter out > 94-98% of particles

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USA standards*

Filter efficiency

N (not resistant to oil)

TB protection

95% N95 ✓99% N99 ✓99.97% N100 ✓

*National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC)

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European standards*

Total inward leakage

Filtering Face Piece

TB protection

<25% FFP1 Not adequate

<11% FFP2 ✓

<5% FFP3 ✓

*Comité Européen de Normalisation (CEN)(European Committee for Standardization)

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CEN standards

• Total inward leakage• Initial filter penetration NaCL Paraffin oil

<20%=P1 NA=P1< 6%=P2 <2%=P2< 3%=P3 <1%=P3

• Maximum breathing resistance• Loading test

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Air-purifying respirators

Remove specific air contaminants by passing ambient air through the air-purifying filter, cartridge or canister

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Negative pressure respirators

• air pressure inside the facepiece is negative during inhalation

• contaminated air can avoid the higher-resistance filter and leak in through gaps in the face seal

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Types of air purifying respirators

Non–powered (negative pressure)Powered air-purifying respirators (PAPR)• A blower draws air through the filter and

blows it into the face piece• Pressure inside face piece reduces face-seal

leakage (offers more protection)• Loose fitting PAPRs can be used for people

that cannot achieve an adequate seal

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Respirator programme elements

• Person assigned responsibility • Written procedures• Medical evaluation• Training• Selection of respirators• Fit testing• Maintenance• Programme evaluation

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Why is fit testing necessary?

• Ensure a proper seal between respirator and wearer

• Determine appropriate make/model• Determine appropriate size

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When should fit testing be done?

Employees should pass a fit test:• Prior to initial use• Whenever a different respirator facepiece

(size, type, model or make) is used• Periodically thereafter• Whenever changes in the worker’s

physical condition or job description that could affect respirator fit are noticed or reported

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Sources of facepiece leakage

• Around facepiece/skin interface• Through air-purifying element• Through exhalation valve

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Factors contributing to poor fit

• Weight loss or gain• Facial scarring• Changes in dental configuration

(dentures)• Facial hair• Cosmetic surgery• Excessive makeup• Mood of workers (smiling/ frowning)• Body movements

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Qualitative fit tests:

• Rely on the individual’s response to the test agent to assess the adequacy of respirator fit

• Are scored as pass/fail

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Test solutions for qualitative fit testing

Four methods recognized and accepted• Isoamyl acetate• Irritant aerosol• Saccharin• BitrexTM (Denatonium benzoate)

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Fit tests using saccharin or BitrexTM

• Can be used for all respirators (i.e. 95-, 99- and 100- series and FFP2 and FFP3)

• Uses subject’s sense of taste• Requires the use of small test hood

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Saccharin and BitrexTM

• Subject demonstrates ability to detect weak solution in the test hood

• Subject dons respirator • Strong solution (~100 times) sprayed into

hood• Respirator passes if subject does not taste

aerosol• Assumed fit factor = 100

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Qualitative fit test equipment

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Quantitative fit tests:

• Measure the amount of leakage into the respirator to assess the adequacy of respirator fit

• Are scored with a number

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Maintenance and storage

• Take care of your disposable respirator– Decontamination NO!– Cleaning NO!– Storage Clean & dry place!

• Take care when re-using respirator – closely monitor service life

• Inspect prior to each use• Dispose of the respirator if you question its

performance

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Read the manufacturer’s instructions to don the

respirator properly

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Is this respirator put on properly?

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Post warning sign

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Time to clear the air between patients

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Bronchoschopy room

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DOT room

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Isolation

XDR-TB

tent and DOT

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Summary

• Surgical masks prevent infectious particles from being expelled by the wearer

• Respirators protect the health care worker from inhaling infectious particles

• When used with administrative and environmental controls, N95, FFP2 or FFP3 respirators provide additional protection when HCWs care for infectious TB patients

• Whenever respirators are used, a respirator programme is necessary