# Guidance on Preparing Workplaces for an Influenza Pandemic/The Difference Between a Surgical Mask and a Respirator

​ The Difference Between a Surgical Mask and a Respirator
It is important that employers and employees understand the significant differences between these types of personal protective equipment. The decision on whether or not to require employees to use either surgical/procedure masks or respirators must be based upon a hazard analysis of the employees’ specific work environment and the differing protective properties of each type of personal protective equipment. The use of surgical masks or respirators is one component of infection control practices that may reduce transmission between infected and non-infected persons.
It should be noted that there is limited information on the use of surgical masks for the control of a pandemic in settings where there is no identified source of infection. There is no information on ​respirator use in such scenarios since modern respirators did not exist during the last pandemic. However, respirators are now routinely used to protect employees against occupational hazards, including biological hazards such as tuberculosis, anthrax, and hantavirus. The effectiveness of surgical masks and respirators has been inferred on the basis of the mode of influenza transmission, particle size, and professional judgment.
To offer protection, both surgical masks and respirators must be worn correctly and consistently throughout the time they are being used. If used properly, surgical masks and respirators both have a role in preventing different types of exposures. During an influenza pandemic, surgical masks and respirators should be used in conjunction with interventions that are known to prevent the spread of infection, such as respiratory etiquette, hand hygiene, and avoidance of large gatherings.
Surgical Masks - Surgical masks are used as a physical barrier to protect employees from hazards such as splashes of large droplets of blood or body fluids. Surgical masks also prevent contamination by trapping large particles of body fluids that may contain bacteria or viruses when they are expelled by the wearer, thus protecting other people against infection from the person wearing the surgical mask.
Surgical/procedure masks are used for several different purposes, including the following:
* Placed on sick people to limit the spread of infectious respiratory secretions to others.
* Worn by healthcare providers to prevent accidental contamination of patients' wounds by the organisms normally present in mucus and saliva.
* Worn by employees to protect themselves from splashes or sprays of blood or body fluids; they may also have the effect of keeping contaminated fingers/hands away from the mouth and nose.
Surgical masks are not designed or certified to prevent the inhalation of small airborne contaminants. These small airborne contaminants are too little to see with the naked eye but may still be capable of causing infection. Surgical/procedure masks are not
Respirators - Respirators are designed to reduce an employee’s exposure to airborne contaminants. Respirators are designed to fit the face and to provide a tight seal between the respirator’s edge and the face. A proper seal between the user’s face and the respirator forces inhaled air to be pulled through the respirator’s filter material and not through gaps between the face and respirator. Respirators must be used in the context of a comprehensive respiratory protection program, (see OSHA standard 29 CFR 1910.134, or www.osha.gov/SLTC/respiratoryprotection/index.html). It is important to medically evaluate employees to assure that they can perform work tasks while wearing a respirator. Medical evaluation can be as simple as a questionnaire (found in Appendix C of OSHA’s Respiratory Protection standard, 29 CFR 1910.134). Employers who have never before needed to consider a respiratory protection plan should note that it can take time to choose a respirator to provide to employees and to arrange for a qualified trainer and provide training, fit testing, and medical evaluation for their employees. If employers wait until an influenza pandemic actually arrives, they may be unable to provide an adequate respiratory protection program in a timely manner.
Types of Respirators Respirators can be air supplying (e.g., the self-contained breathing apparatus worn by firefighters) or air purifying (e.g., a gas mask that filters hazards from the air). Most employees affected by pandemic influenza who are deemed to need a respirator to minimize the likelihood of exposure to the pandemic influenza virus ​in the workplace will use some type of air purifying respirator. They are also known as "particulate respirators" because they protect by filtering particles out of the air as you breathe. These respirators protect only against particles—not gases or vapors. Since airborne biological agents such as bacteria or viruses are particles, they can be filtered by particulate respirators.
    Air purifying respirators can be divided into several types:
* Disposable or filtering facepiece respirators, where the entire respirator facepiece is comprised of filter material. This type of respirator is also commonly referred to as an "N95" respirator. It is discarded when it becomes unsuitable for further use due to excessive breathing resistance (e.g., particulate clogging the filter), unacceptable contamination/soiling, or physical damage.
** Surgical respirators are a type of respiratory protection that offers the combined protective properties of both a filtering facepiece respirator and a surgical mask. Surgical N95 respirators are certified by NIOSH as respirators and also cleared by FDA as medical devices which have been designed and tested and shown to be equivalent to surgical masks in certain performance characteristics (resistance to blood penetration, biocompatibility) which are not examined by NIOSH during its certification of N95 respirators.
* Reusable or elastomeric respirators, where the facepiece can be cleaned, repaired and reused, but the filter cartridges are discarded and replaced when they become unsuitable for further use. These respirators come in half-mask (covering the mouth and nose) and full-mask (covering mouth, nose, and eyes) types. These respirators can be used with a variety of different cartridges to protect against different hazards. These respirators can also be used with canisters or cartridges that will filter out gases and vapors.
* Powered air purifying respirators, (PAPRs) where a battery-powered blower pulls contaminated air through filters, then moves the filtered air to the wearer’s facepiece. PAPRs are significantly more expensive than other air purifying respirators but they provide higher levels of protection and may also increase the comfort for some users by reducing the physiologic burden ​
    associated with negative pressure respirators and providing a constant flow of air on the face. These respirators can also be used with canisters or cartridges that will filter out gases and vapors. It should also be noted that there are hooded PAPRs that do not require employees to be fit tested in order to use them.
All respirators used in the workplace are required to be tested and certified by the National Institute for Occupational Safety and Health (NIOSH). NIOSH-approved respirators are marked with the manufacturer’s name, the part number, the protection provided by the filter (e.g., N95), and "NIOSH." This information is printed on the facepiece, exhalation valve cover, or head straps. If a respirator does not have these markings it has not been certified by NIOSH. Those respirators that are surgical N95 respirators are also cleared by the FDA and, therefore, are appropriate for circumstances in which protection from airborne and body fluid contaminants is needed.
When choosing between disposable and reusable respirators, employers should consider their work environment, the nature of pandemics, and the potential for supply chain disruptions. Each pandemic influenza outbreak could last from 6 to 8 weeks and waves of outbreaks may occur over a year or more. While disposable respirators may be more convenient and cheaper on a per unit basis, a reusable respirator may be more economical on a longterm basis and reduce the impact of disruption in supply chains or shortages of respirators.
Classifying Particulate Respirators and Particulate Filters An N95 respirator is one of nine types of particulate respirators. Respirator filters that remove at least 95 percent of airborne particles during "worst case" testing using the "most-penetrating" size of particle are given a 95 rating. Those that filter out at least 99 percent of the particles under the same conditions receive a 99 rating, and those that filter at least 99.97 percent (essentially 100 percent) receive a 100 rating.
In addition, filters in this family are given a designation of N, R, or P to convey their ability to function in the presence of oils that are found in some work environments.
    "N" if they are Not resistant to oil. (e.g., N95, N99, N100)
    "R" if they are somewhat Resistant to oil. (e.g., R95, R99, R100)
    "P" if they are strongly resistant (i.e., oil Proof). (e.g., P95, P99, P100)
This rating is important in work settings where oils may be present because some industrial oils can degrade the filter performance to the point that it does not filter adequately. Thus, the three filter efficiencies combined with the three oil designations lead to nine types of particulate respirator filter materials. It should be noted that any of the various types of filters listed here would be acceptable for protection against pandemic influenza in workplaces that do not contain oils, particularly if the N95 filter type was unavailable due to shortages.
Replacing Disposable Respirators Disposable respirators are designed to be used once and are then to be properly disposed of. Once worn in the presence of an infectious patient, the respirator should be considered potentially contaminated with infectious material, and touching the outside of the device should be avoided to prevent self-inoculation (touching the contaminated respirator and then touching one’s eyes, nose, or mouth). It should be noted that a once-worn respirator will also be contaminated on its inner surface by the microorganisms present in the exhaled air and oral secretions of the wearer.
If a sufficient supply of respirators is not available during a pandemic, employers and employees may consider reuse as long as the device has not been obviously soiled or damaged (e.g., creased or torn), and it retains its ability to function properly. This practice is not acceptable under normal circumstances and should only be considered under the most dire of conditions. Data on decontamination and/or reuse of respirators for infectious diseases are not available. Reuse may increase the potential for contamination; however, this risk must be balanced against the need to provide respiratory protection. When preparing for a pandemic, employers who anticipate providing respiratory protection to employees for the duration of the pandemic should consider using reusable or elastomeric respirators that are designed to be cleaned, repaired and reused.
​Dust or Comfort Masks Employers and employees should be aware that there are "dust" or "comfort" masks sold at home improvement stores that look very similar to respirators. Some dust masks may even be made by a manufacturer that also produces NIOSH-certified respirators. Unless a mask has been tested and certified by NIOSH, employers do not know if the device will filter very small airborne particles. The occupational use of respirators, including those purchased at home improvement or convenience stores, are still covered by OSHA’s Respiratory Protection standard.
Note: Some respirators have an exhalation valve to make it easier for the wearer to breathe. While these respirators provide the same level of particle filtration protection to the wearer, they should not be used by healthcare providers who are concerned about contaminating a sterile field, or provided to known or suspected pandemic patients as a means of limiting the spread of their body fluids to others.
Note: Additional respirator and surgical mask guidance for healthcare workers has been developed and is available at www.pandemicflu.gov/plan/healthcare/maskguidancehc.html. This document, "Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings during an Influenza Pandemic," provides details on the differences between a surgical mask and a respirator, the state of science regarding influenza transmission, and the rationale for determining the appropriate protective device.