**Respiratory Protection during a Pandemic Influenza**

**Preparation and Implementation for Overseas Posts**

**U.S. Department of State**

**[Introduction]{.underline}**

In the event of a pandemic influenza, respiratory protection will be an
important component of a comprehensive plan to protect personnel.

It is important that our personnel understand the options that are
available for respiratory protection and how to make best use of these
options.

In this document "disposable respirator" means an N95 disposable
respirator and "elastomeric respirator" means a reusable elastomeric
respirator with replaceable N95 filters. These are certified by NIOSH to
provide a certain level of protection. Properly fitted, both type
respirators provide equal levels of protection. Surgical masks are
designed to protect against large droplets and are tested for fluid
resistance. Surgical masks do not protect against small inhalable
particles.

**[Assessing Risk]{.underline}**

For most persons, protecting from infection will focus on disinfecting
hands and surfaces and practicing social distancing. Social distancing
means reducing the frequency, proximity, and duration of contact between
people. This will reduce the chances of spreading pandemic influenza
from person-to-person. There are additional protective measures,
including personal protective equipment, which people can use depending
on their exposure risk.

DOL/HHS guidance has categorized specific work tasks into four risk
areas, according to the likelihood of exposure to pandemic influenza.
The areas are depicted in the shape of a pyramid to show how the risk
will likely be distributed.

**Pyramid for Pandemic Influenza\
**![](media/image1.wmf){width="2.6979166666666665in"
height="2.321527777777778in"}

**Very High Exposure Risk**

-   Healthcare personnel (doctors, nurses, and others) performing
    aerosol-generating procedures on known or suspected pandemic
    patients (for example, cough induction procedures, bronchoscopies,
    or invasive specimen collection). Some of these examples would not
    occur at embassy and consulate health units.

-   Healthcare or laboratory personnel collecting or handling specimens
    from known or suspected pandemic patients (for example, manipulating
    cultures from known or suspected pandemic influenza patients).

**High Exposure Risk**

-   Healthcare delivery and support staff exposed to known or suspected
    pandemic patients (for example, doctors, nurses, and other staff
    that must enter patients\' rooms).

-   Medical transporters of known or suspected pandemic patients in
    enclosed vehicles (for example, emergency medical technicians).

-   Those performing autopsies on known or suspected pandemic patients
    (not relevant to post health units).

**Medium Exposure Risk**

-   Persons with high-frequency contact with the general population.

**Low Exposure Risk**

-   Persons who have minimal occupational contact with the general
    public and other employees (for example, office employees).

It is important for overseas posts to fully prepare to respond in the
event of a pandemic flu. To assist posts, MED has supplemented overseas
health units' supplies with both disposable and reusable elastomeric
respirators. But MED realizes that posts may still not have enough
stockpiled respirators and masks to meet the demands of a severe
pandemic. To ensure an adequate supply, posts should review their
inventory and make a determination based on risk regarding what their
actual requirements may be. This assessment should include surgical
masks as discussed below. Posts should plan on purchasing additional
supplies based on their assessments and the availability of funding.

RMOs and FSHPs that have responsibilities for posts without health units
should review the requirements of these posts and put in place plans to
address these requirements.

Note that elastomeric respirators were supplied for health unit medical
personnel use only. Since health care workers will have the greatest
requirement to use respirators, this will conserve the supply of
disposable respirators for others to use. The disposable respirators may
be used by health unit personnel, other mission employees who may be
exposed, and family members who may be caring for infected individuals.

In reviewing the Pyramid for Pandemic Influenza, the following are the
most probable ways into which DOS personnel would fall into the four
risk categories:

[Very High Exposure Risk]{.underline}: It is rare that any DOS employee,
health care worker or otherwise, would fall under the very high risk
category. Any MED personnel that might be exposed at this risk level
should wear their reusable elastomeric respirators or a disposable one.
(The former is preferred to conserve the supply of disposables.)

[High Exposure Risk]{.underline}: Health care workers would fall into
this risk category if they are caring for infected individuals or
examining those who are ill and may be infected. Any MED personnel that
might be exposed at this risk level should wear their reusable
elastomeric respirator or a disposable one. (The former is preferred to
conserve the supply of disposables.)

[Medium Exposure Risk]{.underline}: Employees with high-frequency, close
contact (within 6 feet) with the general population fall into this
category. If such contact is not avoidable, OSHA (the Occupational
Safety and Health Administration) advises the use of a surgical mask. If
there is the expectation of close contact with people who have
symptomatic influenza infection among mission critical employees, then
use of disposable respirator should be considered.

[Low Exposure Risk]{.underline}: People in this risk category will have
minimal contact with the general public and other employees. These
individuals should practice social distancing by conducting business
behind barriers or by maintaining a minimal distance of six feet between
themselves and others. They will not need to wear respirators but should
have disposable respirators available, in the event that their situation
changes.

**[Respiratory Protection Planning Assumptions]{.underline}**

Use the following assumptions to estimate protective equipment use for
planning and stockpiling purposes:

-   Plan for a mitigated pandemic which is expected to occur in 2 waves,
    each lasting up to 12 weeks (24 weeks or roughly 6 months total).
    Assume there are 5 work days per week and thus120 work days per
    employee over the 2 pandemic waves.

-   Efforts to develop and distribute a vaccine will be conducted in
    parallel with non-pharmaceutical interventions, such as respirator
    use. However, the vaccination status of an individual does not
    change the recommendations for use of respirators or masks because
    of the uncertain efficacy of a vaccine.

Respirators and masks will only be used by employees during the 2
pandemic waves in their local community/country and not during the
period between pandemic waves.

**[Estimating Respiratory Protection Requirements]{.underline}**

**Very High Exposure Risk for Pandemic Influenza:**

*Employees Covered:*

-   Healthcare employees performing aerosol-generating procedures on
    known on suspected pandemic influenza patients; and

-   Healthcare or laboratory personnel collecting or handling specimens
    from known or suspected pandemic influenza patients.

If using [elastomeric respirators]{.underline} for aerosol generating
medical procedures (recommended), plan on:

[One elastomeric respirator and 6 pairs of replacement filters (one pair
for each month of use) for each employee.]{.underline}

If using [disposable respirators]{.underline} for aerosol generating
medical procedures, plan on stockpiling:

[One disposable respirator per healthcare worker per aerosol generating
procedure]{.underline}.

**High Exposure Risk for Pandemic Influenza:**

*[Employees covered]{.underline}*

-   Healthcare delivery and support staff working closely with (either
    in contact with or within 6 feet of) people known or suspected to be
    infected with pandemic influenza.

-   Transporters of patients in a closed vehicle who are known or
    suspected to be infected with pandemic influenza (for example
    emergency medical technicians).

Respirators are recommended to protect employees working closely with
people/patients known or suspected to be infected with pandemic
influenza. Such protection can be accomplished with a disposable
respirator or a reusable elastomeric respirator.

If using [elastomeric respirators]{.underline} for employees at high
exposure risk (recommended), plan for:

[One reusable elastomeric respirator + 6 sets of filters (one pair for
each month of use) per exposed employee]{.underline}

If using [disposable respirators]{.underline} to protect healthcare
delivery and support staff, plan for:

[Four N95s/HCW/shift X 5 shifts/week X 12 weeks/wave X 2 waves = 480
N95s per exposed HCW]{.underline}

*[Patients]{.underline}*

It should also be noted that HHS has recommended that healthcare
providers consider distributing [surgical masks]{.underline} to patients
to be used when being visited by a caretaker. Plans for stockpiling
surgical masks for such purposes are in addition to respiratory
protection provided for employees' health and safety. Estimate that 30%
of the population will become sick with the flu and will be sick for
approximately ten days. Thus the number of surgical masks needed would
be:

[0.3 X population served X 10 days X 1 surgical mask/day]{.underline}

*[Family member caring for patient]{.underline}*

Designated family member caring for patients should wear [disposable
respirators]{.underline} to protect themselves. Plan for:

[0.3 X population served X 10 days X 2 N95s/day]{.underline}

**Medium Exposure Risk for Pandemic Influenza:**\
*Employees Covered:*

-   Employees with high-frequency close contact (less than 6 feet) with
    the general population.

Surgical masks are recommended to protect employees with high-frequency
close contact with the general public from sprays of potentially
infectious liquid droplets (from talking, coughing, or sneezing).
However, for additional protection, disposable respirators may also be
used. Plan for

[Two surgical masks/employee/shift X 5 shifts/week X 12 weeks/pandemic
wave X 2 pandemic waves = 240 surgical masks per exposed
employee.]{.underline}

**Low Exposure Risk for Pandemic Influenza:**

Surgical masks and respirator use are not recommended in low exposure
risk work environments.

**[Respirator Fit]{.underline}**

For a respirator to protect an individual properly, it needs to fit
well. Reusable elastomeric respirators must be fitted using the
guidelines provided by the manufacturer and MED/DASHO. Disposable
respirators should be fit tested using instructions provided by the
manufacturers. The use of respirators, although highly recommended, is
at an individual's discretion and is thus considered voluntary. All
users are to be provided with the attached OSHA document.

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  **Regulations (Standards - 29 CFR)**\
  **(Mandatory) Information for Employees Using Respirators When not
  Required Under Standard. - 1910.134 App D**

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  ------------------------ ----------------------------------------------
  **• Part Number:**       1910

  **• Part Title:**        Occupational Safety and Health Standards

  **• Subpart:**           I

  **• Subpart Title:**     Personal Protective Equipment

  **• Standard Number:**   1910.134 App D

  **• Title:**             (Mandatory) Information for Employees Using
                           Respirators When not Required Under Standard.

                           
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  **Appendix D to Sec. 1910.134 (Mandatory) 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, or 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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