Access the recorded webinar here: https://attendee.gotowebinar.com/
recording/6725411770768669448
Access speaker bios here: https://files.asprtracie.hhs.gov/documents/aspr-tracie-covid-19optimizing-healthcare-ppe-and-supplies-webinar-bios.pdf
Access webinar transcript here: https://files.asprtracie.hhs.gov/documents/aspr-tracie-covid-19optimizing-healthcare-ppe-and-supplies-webinar-transcript.pdf
Access the Q and A here: https://files.asprtracie.hhs.gov/documents/aspr-tracie-covid-19optimizing-ppe-and-supplies-webinar-q-and-a.pdf

TRACIEHEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAY

COVID-19: Optimizing Healthcare PersonalProtective Equipment and Supplies
September 24, 2020

ASPR
ASSISTANT SECRETARY ~-OR

Unclassified//For Public Use

Unclassified//For Public Use

PREPAREDNES S AND RESPONSE

The opinions expressed in this presentation and on the following
slides by non-federal government employees are solely those of thepresenter and not necessarily those of the U.S. Government. The
accuracy or reliability of the information provided is the opinion of theindividual organization or presenter represented.

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I NfORMATIO N GATEWAY2

ASPR TRACIE: Three Domains

l!!lir..LIIP'
r

TECHNICALRESOURCE$__II_.
, CENTERASS ISTANCE

J~

,

~

INFORMATIONEXCHANGE

Unclassified//For Public Use• Self-service collection of audience-tailored materials• Subject-specific, SME-reviewed “Topic Collections”• Unpublished and SME peer-reviewed materials
highlighting real-life tools and experiences

asprtracie.hhs.gov• Personalized support and responses to requests for
information and technical assistance• Accessible by toll-free number (1844-5-TRACIE),
email (askasprtracie@hhs.gov), or web form
(ASPRtracie.hhs.gov)• Area for password-protected discussion among
vetted users in near real-time• Ability to support chats and the peer-to-peer
exchange of user-developed templates, plans, andother materials

1-844-5-TRACIE

askasprtracie@hhs.gov

ASPR
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I NfORMAT IO NGAIEWA'f

3

Resources• ASPR TRACIE COVID-19 Page
• ASPR COVID-19 Page
• CDC COVID-19 Page
• FDA COVID-19 Page
• NIOSH COVID-19 Information for the Workplace Page
• NIOSH National Personal Protective Technology
Laboratory (NPPTL)• Coronavirus.gov

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4

TRACIE
HEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAY

Leslie Hintz, MS, COVID-19 Response Deployment Team Lead, Supply
Preservation Support Team, Healthcare Resilience Working Group
Joselito Ignacio, MA, MPH, CIH, CSP, REHS, Captain, US Public HealthService; Deputy, Healthcare Resilience Working Group (Available for Q&A)

ASPR
ASSISTANT SECRETARY ~-OR

Unclassified//For Public Use

Unclassified//For Public Use

PREPAREDNES S AND RESPONSE

TRACIE
HEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAY

Moderator- John Hick, MD
Hennepin Healthcare

ASPR
ASSISTANT SECRETARY ~-OR

Unclassified//For Public Use

Unclassified//For Public Use

PREPAREDNES S AND RESPONSE

TRACIE
HEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAYMaryann D’Alessandro, PhD
Director, National Personal Protective Technology Laboratory,
National Institute for Occupational Safety and Health (NIOSH)ASPRASSISTANT SECRETARY ~-OR

Unclassified//For Public Use

Unclassified//For Public Use

PREPAREDNES S AND RESPONSE

Three Topics will be Addressed in this Presentation• Federal authorities and COVID-19• NIOSH activities supporting respirator supply optimization• Healthcare and related applications standards gaps
supporting supply optimization

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8

NIOSH National Personal Protective Technology
Laboratory
VISION: Our vision is to be the leading
provider of quality, relevant, and timely
personal protective technology research,training, and evaluation
MISSION: The mission of the PersonalProtective Technology Program and the
National Personal Protection Technology
Laboratory is to prevent work-related
injury, illness and death by advancing thestate of knowledge and application of
personal protective technologies

Unclassified//For Public Use

ASPR.. ,.,tT,.,.T HCUTloU H>a

PHUl!D'fUI A'fD O[INl'fH

HUllHCAH tMUGENCY HE•OCONlSS
INFOlMAllON GATEWAt

9Three Agencies have Respirator Authorities in U.S.
Occupational Settings
NIOSH CERTIFIES RESPIRATORSAND
OSHA OVERSEES WORKPLACE COMPLIANCE

ALL RESPIRATORY PROTECTIVE DEVICES(RPDs)

All
N95 Respirators
All Surgical
N95 Respirators

ALL
SURGICALMASKSFDA CLEARSMEDICALDEVICES

Unclassified//For Public Use

ASPR

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10FDA has Requirements for Surgical
N95 Filtering Facepiece Respirators
in Healthcare Settings•

Additional tests that must be performed at a qualified laboratory– Fluid penetration– Flammability– Biocompatibility
–
–
–

•

Cytotoxicity
Sensitization
Irritation

Based on a Memorandum of Understanding between FDA and NIOSH,
NIOSH is responsible for the conformity assessment of theserequirements––

Photo cred it : 3M

https://www.fda.gov/about-fda/domestic-mous/mou-225-18-006
https://www.cdc.gov/niosh/npptl/resources/pressrel/letters/conformitymanuf/CA-2018-1010R1.html

Unclassified//For Public Use

ASPR
~o•

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11

COVID-19 Has Led to an Increased Use of NIOSH-Approved
Air Purifying Respirators in Healthcare

Photo credit: 3M

Filtering facepiece respirators

Photo credit: MSA

Elastomeric respirators

Photo credit: Honeywell International
Inc.

Powered air purifying respirators (PAPRs)

Photo credit: 3M

Unclassified//For Public Use

Photo credit: University of Maryland

Photo credit: Ford Motor Company•

12

CDC Authorized the Use of Respirators Conforming to Other
International Standards as a Crisis Capacity Measure
May Be U sed in Lieu of•

NIOSH evaluated imported products–•

Substandard products–•~60% of international respirators provide below 95%
filtration efficiency

Counterfeit/Mis-Use of NIOSH Approval‒•>380 Reports Posted

Compare submitted records with approved application

Potential Standards Need–Country

Performance Sta ndard

Au tral ia

AS/N Z$ 1 71 6:] Ul 2Braii lPeople's Repu blicof China

EuropeGB 2626-2006
GB 2626 20 19
GBJ9083 -JUJO( N 149-7001

Japan

JMHLW-2000

Korea

KMOf L-]0 17-64

Should there be a standard for evaluating international
products?
Mc• ico–

ABNT/NBR l 3698 :lOt 1

NIOSH evaluates these products to an abbreviated
NIOSH standard test procedure

NOM-116-2009

Acceptable Product Classification

NIOSH-Cenified Products
Cl asslfled as

P2

N95

P3

N99or lower

PrF2

N95

PFF3

N99or lower

KN/KP95

N95

KN/KPlOO

N95

P2

N95

P3

N99or lower

OS/OL2N95

OS/OL3

N99or lower

Special 1SI

N95

N95

N95

R95

R95or lower

P95

P95or lower

N99

N99 or lowcr

R99

R99or lower

P99

P99 or lower

N100

N100 or lower

Rl OO[1100 or lowerPl OO

PlOO or lower

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/international-respirator-purchase.html
Unclassified//For Public Use

13

Respirators with Exhalation Valves Protect the Worker,
but the Level of Source Control Provided is Unclear• In the absence of data, CDC posted guidance regarding
exhalation valves––

Wear a respirator without an exhalation valve when both source control
and respiratory protection are required
If only a respirator with an exhalation valve is available and source
control is needed, cover the exhalation valve with a surgical mask,
procedure mask, or a cloth face covering that does not interfere with therespirator fit

Exhalation valve

Photo credit: Moldex• Science-based standards are needed to improveguidance–

Some elastomeric respirators have a diverter exhalation valve cover–More research is needed to evaluate what is coming out of theexhalation valve–

NIOSH is currently conducting several studies to quantify this to provide
additional guidance

Photo credit: Honeywell Northhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/elastomeric-respirators-strategy/index.html

Unclassified//For Public Use

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CDC Provides Elastomeric Disinfection
Guidance for Crisis Capacity Scenarios•

Routine operations
–
–
–

•

Crisis capacity guidelines
–
–
–

•

Disinfection is not part of the NIOSH approval, NIOSH points to the manufacturers’
instructions
OSHA permits employers to use the cleaning recommendations provided by the
respirator manufacturer
Bessessen protocol used by several facilities
Example of filter enclosed in a cartridge
Photo credit: MSA

CDC and NIOSH provide guidelines for disinfection, including the Bessessen protocol
Enclosed filter cartridges recommended
EPA authorized disinfectants are identified

Science-based standards are needed for routine operations––––

Lawrence et al. found that PAPRs could be cleaned up to 150 times without significant
degradation or performance and functionality
Integrity of filter media should not degrade
Ancillary components should not degrade
Off-gassing should not be an issue in the facepiece?

https://www.cdc.gov/coronavirus/2019-ncov/hcp/elastomeric-respirators-strategy/index.html

Example of “pancake” filter
Photo credit: MSA

Unclassified//For Public Use

15

CDC Provides PAPR Disinfection Guidance for Crisis
Capacity Scenarios••

Routine operations–

Disinfection is not part of the NIOSH approval, NIOSH point to the
manufacturers’ instructions–

OSHA permits employers to use the cleaning recommendations provided by the
respirator manufacturer

Crisis capacity guidelines–•

CDC Guidance provides recommendations for crisis capacity scenarios

Science-based standards are needed for routine operations–

Lawrence et al. found that PAPRs could be cleaned up to 150 times without
significant degradation or performance and functionality–

Integrity of filter media should not degrade–

Ancillary components should not degrade–

Off-gassing should not be an issue in the facepiece?

Photo credit: Honeywell Northhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/powered-air-purifying-respirators-strategy.html

Unclassified//For Public Use

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NIOSH is Involved in Several Initiatives to Address Gaps in NonOccupational Respiratory Protection and Source Control• National Academy of Medicine workshop (August 2020)– Discussed non-occupational respirator use and initiated follow-on
comprehensive consensus study– Need for a conformity assessment approach for a consistent way toevaluate respiratory protective devices for protection and source
control for the general public

Current Issues In the Assessment of Respiratory Protective
Devices: A Workshop

Current Issues in theAssessment ofRespiratory
Protective
Auaust4•S.:zo20
Devices
A V,rtuul Wo1bhop

HIAJII.

fV'

In -:l'SC IENCES
ENGINEERINGMED :CINE

I ·.,.

• American Society of Testing & Materials Standard:“Specification for Barrier Face Coverings”– Barrier Face Coverings are disposable or reusable protective devices
for general public use that are neither a respirator nor a surgicalmask– Standard will provide a consistent way to benchmark products to
inform user selection decisions and will define performancerequirements for source control and protective capability

Particulate filtration efficiency

Fit

ComfortReuse– NIOSH studies will validate the minimum performance requirements

Unclassified//For Public Use

17

The COVID-19 Response has Revealed Several
Standards and Conformity Assessment Gaps
Potential standards tooptimize increase supply

Input Activities

Direct Activities

Aid in deciding the level of rigor and independence
necessary in CA program

Direct actions of program owner toensure appropriate CA activities• FFR exhalation valves• Elastomeric exhalation valves• Elastomeric disinfection• PAPR disinfection

Identify hazards
and risk toworkers

Identify PPE
types needed toaddress hazards

Identify& Sl!lect

STEP 1

STE P 2

STEP 3standards t hat
address hazards

Define the CA
requirements

Perform CA
activities

and activitie5 inconsideration ofrisk to workers

STEP4

STEPS

L Evaluation and Surveillance Continualfy Improve Program - - - ~NIOSH Conformity Assessment Framework, NIOSH Pub. 2018-102

Unclassified//For Public Use

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18

TRACIE
HEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAY

Aftin Ross, PhD
Senior Project Manager and Senior Science Health Advisor, Center for
Devices and Radiological Health, U.S. Food and Drug Administration (FDA)

ASPR
ASSISTANT SECRETARY ~-OR

Unclassified//For Public Use

Unclassified//For Public Use

PREPAREDNES S AND RESPONSE

FDA’s Regulation of Respirators• The FDA, NIOSH, and OSHA collaborate to assure safe use of
respirators by healthcare personnel– FDA's oversight of respirators for use in healthcare spans the total productlifecycle from premarket review, postmarket surveillance, and compliance• The FDA has authorized the emergency use of certain respiratorsand decontamination systems. FDA also has issued guidance on
enforcement policies. Together these approaches help facilitate
access to critical, quality medical supplies.
• Decontamination systems and decontaminated respirators
require an EUA and are not covered by enforcement policies

Unclassified//For Public Use-ASPR.... , ....ANT •lCatr.t•~ ~o•

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FDA’s Emergency Use Authorization (EUA)• EUA authority allows the FDA to help strengthen the nation’s publichealth protections by facilitating the availability and use of critical medical
products during public health emergencies when certain criteria are met.
• Criteria for issuance– Serious or Life-Threatening Condition– Evidence of Effectiveness (“May be Effective”) in diagnosing, treating, orpreventing the serious or life-threatening disease or condition– Risk-Benefit Analysis– No Adequate, Approved, Available Alternatives (includes if there are insufficient
supplies)
Emergency Use Authorization of Medical Products and Related Authorities

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Face Masks and Respirators Guidance
Enforcement Policy for Face Masks and Respirators During theCoronavirus Disease (COVID-19) Public Health Emergency• Provide regulatory flexibility while assuring products are appropriate
for their use• Enforcement discretion as to certain FDA requirements• Policy in effect for the duration of the public health emergency• Policy applies to respirators not intended for a medical purpose• States that FDA clearance or EUA authorization is necessary for
respirators to be marketed in the U.S. for healthcare personnel use

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What to use

Considerations forselecting respirators foryour healthcare facility

NIOSHaeeroved air
euriflt'.ing
reseirators
under EUA

*Exhibit 1 refers to FDA EUA Authorized
Imported, Non-NIOSH Disposable Filtering
Facepiece Respirators

I

How to identify a
respirator

Before selecting a
respirator, review thisSee NIOSH
CertifiedEquiement
List

See NIOSHCounterfeit
Reseirators

See Exhibit 1 *See CDC's
Factorsto
ConsiderWhen Planningto PurchaseRespirators from
Another Country**Appendix A refers to FDA EUA Authorized
Imported, Non-NIOSH Approved Respirators
Manufactured in China

See CDC's

Available at:https://www.fda.gov/medicaldevices/coronavirus-covid-19-and-medicaldevices/considerations-selecting-respiratorsyour-health-care-facility

Unclassified//For Public Use

FDA EUAauthorized
non-NIOSH­
aeeroved
reseirators

manufactured
mChma

NPPTL
Reseirator­
lnternational
Assessment
1-----1.. See Appendix A** .,__..,.,.
Filtration Results­
Not NlOSH­
approved

Including KN95

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FDA’s Actions• FDA continues to identify and implement agile regulatory approaches toexpand access to respirators by health care professionals• As the pandemic continues, FDA’s policy is refined to facilitate
development and availability of essential devices• FDA is engaging with public health and industry stakeholders tomonitor respirator supply and demand and communicate current statusof supply and mitigation actions undertaken to facilitate access• FDA.gov website has educational resources for all stakeholders:
medical device industry, health professionals, and the general public,
covering Emergency Use Authorizations, Guidance, and Frequently
Asked Questions

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FDA Resources• CDRH N95 Respirators, Surgical Masks and Face Masks• Enforcement Policy for Face Masks and Respirators During the Coronavirus
Disease (COVID-19) Public Health Emergency• Personal Protective Equipment EUAs
• PPE Decontamination System EUAs
• Umbrella EUA for Surgical Masks (Authorized Surgical Masks)• FDA EUA Authorized Imported, Non-NIOSH Disposable Filtering Facepiece
Respirators (Authorized Imported Non-NIOSH-Approved FFRs)• FDA EUA Authorized Imported, Non-NIOSH Approved Respirators
Manufactured in China

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25

-

COVID-19: Optimizing

Healthcare Personal Protective
Equipment and Supplies

ASPR TRACIE Webinar
September 24, 2020
Nikki McCullough, PhD, CIH
Jessica Hauge, MPH, CIH, CSP
Shared with ASPR 9/16/20
21 September© 3M 2020. All Rights Reserved. 3M Confidential.
Unclassified//For Public Use

26

-- . ---

3M’s COVID Response• Increasing capacity• Providing technical information• Highlighting government guidance• Conducing research
3M=--·• Supporting FEMA imports• Media response.,___ ..---------~---!':-...:. ____...___... ...._------·-----____.... ......___,________----•-D_.AI_,.
________. _·--------. -----~--­-----..--.-•----J•----.
. . --­... _--....--. --. ---~___
__ _
_____
-----.....

,._

_,

._,

...
_... .. ._,.-r...- .............
--,-•---;,.-••---_ _ _ i..L _ _ _ _ _ _ _ _ _ _ _ ..., _ _- - - ~ - - - - .......... , _ _ _ io.. ..

-.-r_ _ _ _ _ _ _ _ _ _ _,,..,_i,,___,-.,
..
..,_
__ ,_
.............. .........
..,.,_..__i,, ___,. ___ .
-:,,,

.,

------·----. ·---· _...
_..,_·------~_. . ___. . __-------·, . . . . . . --.. .--.... .~-.~"·-------...
...·------·--·----·-­-------·...-----·-. ---·---.._....

....-...,..,_.,._--,.-·_. ._-'"-"'"""""'"'"------~-----. . ...,_,,__,.______________. . . .-~--·""'"'"--'""--=--..·-·--•t.•--.
. . . -.....
3M R1t1pirnor1 in lnlernational P1K:kagi"9 MM<ffl Availobl• in US duriniJ COVlD •19....

© 3M 2020. All Rights Reserved.
21 September

3M

Unclassified//For Public Use

27

Respiratory Protection.

How N95s work

• FFRs contain many layers of crisscrossing, non-woven, fibrous filter material that capture particles• As the airstream flows through the layers of filter media, particles are trapped/captured, by several
mechanisms:–

Very large particles in the airstream will settle out due to gravity–

Other particles may impact a fiber and be captured–

Very small particles are captured by diffusion

Airstream

3M™ N95 Filter Media

21 September© 3M 2020. All Rights Reserved.

Unclassified//For Public Use

3M

https://multimedia.3m.com/mws/media/1792732O/respiratory-protection-faq-healthcare.pdf
https://multimedia.3m.com/mws/media/1820270O/respiratory-protection-in-healthcare-qrg-n95-respirators.pdf
https://multimedia.3m.com/mws/media/409903O/respiratory-protection-against-biohazards.pdf
https://multimedia.3m.com/mws/media/1833770O/filtering-of-bioaerosols-by-filtering-facepiece-respirators.mp4

28

Masks and Respirators.

Options[][•

Procedure Mask

Disposable,
simple mask
used to covernose and mouth

][
•

•

Surgical Mask

Disposable,mask used tocover nose andmouth
Provides a fluid
barrier

Filtering Facepiece
Respirators(FFRs), such as
N95

•

•

Disposable,
respirator used
to cover noseand mouth
Provides fluid
barrier (surgicalN95’s)

21 September© 3M 2020. All Rights Reserved.

3M

][
•
•

•

Elastomeric
Respirator
Reusable
respirator
Half & full
facepiece
offerings
Multi-piece:
facepiece anddisposable filters][

Powered Air
Purifying
Respirator (PAPR)

•
•

•

]

Reusable
respirator
Multipleface/head coverofferings
Multi-piece: head
cover, tube,
battery pack andbelt

Unclassified//For Public Use

29

Masks and Respirators.

Differences

Procedure Mask

Reusable Elastomeric
Respirator

Surgical Mask

Fitment

Loose

Loose

Recommended* as source
control, to help capture spit or
mucous expelled by the wearer

•

•
•
•

FDA cleared for use in surgery
Provides fluid barrier (link)
Reduces wearer’s exposure
to airborne particulate hazards
At least 95% filtration efficiency
against particulates
Some components can becleaned/disinfected and reused
21 September© 3M 2020 . All Rights
Reserved.
*Recommended
by CDC
and/or FDA as source control in healthcare setting.

--Powered Air Purifying
Respirator (PAPR)

Filtering Facepiece
Respirators (FFRs) (e.g.: N95)

3M

Tight

•
•
•
•
•

Guidance for valves (link)

Tight

Loose

•

Guidance for valves (link)

Surgical N95s only (link)
Surgical N95s only*•

Not FDA cleared

•
•

*•
•
•

Not FDA cleared

Unclassified//For Public Use

30

Respiratory Protection.

Other respirator classes

FFRs are subject to various regulatory standards around the world. Some are considered very similar to N95.

Country & Governing Body

Respirator Type

United States, NIOSH-42CFR84

N95

Europe, EN 149-2001

FFP2

China, GB2626-2006

KN95

Australia/New Zealand, AS/NZA 1716:2012

P2

Korea, KMOEL - 2017-64

Korea 1st class

Japan, JMHLW-Notification 214, 2018DS

• OSHA says respirators meeting certain other countries’ standards may be used in place of N95s when
respirators are in short supply during COVID-19 Public Health Emergency.
• CDC calls this practice a Crisis Capacity Strategy.
21 September© 3M 2020. All Rights Reserved.

3M

Unclassified//For Public Use

31

N95 Respirator Use.

CDC recommendations

Conti
ngency and cns1s
risis strategies include:
Contingency
nclude.
• us
e of N95s
95s paspastt thei
theirr shelf lifeuse
• extended us
e of N95s
extendeduse• us
e of other ty
pes of rrespirators
espirators
types
use
• us
e of respirators fr
om other countries
use
from
• re
-use of rrespirators
espirators
re-use…B
EFORE dec
ontamination of rrespirators
espirators.BEFOREdecontamination

Contingency capacity strategies
During expected shortages (CDC)

Crisis capacity strategies
During known shortages (CDC)© 3M 2020. All Rights Reserved.
21 September

3M

Unclassified//For Public Use

32

CDC Recommendations. Decontaminated FFR precautions prior to use
Recommendations.
Even after decontamination, these FFRs should be handled carefully~®>

Wash hands before and after
touching or adjusting the FFR

Cl

(S)

Avoid touching the inside of the
FFR

I

Use a pair of clean (non-sterile)
gloves when donning andperforming a user seal check© 3M 2020. All Rights Reserved.
21 September

Unclassified//For Public Use

DD
I
3NI

Visually inspect the FFR to
determine if its integrity has been
compromised
If integrity is compromised, or if can’t
perform successful user seal check,discard the FFR and try another FFR

Perform a user seal check
immediately after donning each FFR,
if unsuccessful, don’t use that FFR
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html
- - -

33

Decon Compatibility.

Evaluation of compatibility with 3M N95s

Four key aspects of successful decontamination of N95s

Efficacy• Must inactivate target organism

Safety!

• Must be safe for person wearing respirator

Filtration• Must not damage respirator’s filtration

Fit•Must not negatively affect respirator’s ability to seal to thewear’s face

© 3M 2020. All Rights Reserved.
21 September

Developer of
proposeddecontamination
method and EPA
confirm germicidal
efficacy of method

3M

If filtration isdamaged or the
respirator does not
fit, it will not help
reduce exposure toairborne particles atthe level indicatedUnclassified//For Public Use

34

Decontamination.
Recommendations.

Can N95s be decontaminated?
Science.
Applied to Life.'"• Per OSHA, and the FDA< decontamination of
FFRs is only permissible for healthcare
workplaces.

Tech nical Bulletin
August, 2020
Revision 10

Decontam ination of 3M Fil teri ng Facepiece Respirat ors, such as
N95 Respirators, in the Unit ed Sta tes - Considerat ionsIntroduction• https://multimedia.3m.com/mws/media/182486
9O/decontamination-methods-for-3m-n95respirators-technical-bulletin.pdf

NOTE: Rease revisit this document often fOf frequent update~
The purpose o f this documenl is lo comrn.micate infex mat ion related to the impact of deconlamination methods on certain
3M filtet"ing faoepiece respirato r (FFR) models - the purpose iSa not to recommen d the practice of decontamination o, tocomment on the efficacy o f the decontaminatio n meth od on the virus t ha t causes COVI0-19 or the safety of thedecontamination methods fOf FFR wearers.
Ourin:g this COVl0-19 pandemic, i.everal go'lel'nmental agenc:ie:si have recommended that decontamination may be pan of areuse BPPfoach to optimize the use of available FFR&. 3M cannot recommend decontamination of FF Rs. because FFR:s are
oot designed to be decartamioated. and doi ng so vo ids.the regulato,y approYBl(see details in the Bacl!:ground section .
However. since certain decontamina tion methods have been recommended by Urited States Centers for Disease Control
and Prevention (CDC), US Occupational Health and Safety Adrrinistration (OSHA), and US Food and Drug Administlatioo(FDA). 3 M has.evaluated the impact of select decontamination method& oncertain3M FFRmodels. and ts.p ublishing th isS1formation to help cus.tomers who choose to implement decontamination to d o so in such a way lhat they are 111likety todamage FFRs. as such damage may result in the FFR5 not providi"!l the indicated level ot e:,q:J051Jre reduction. wc:h as N 9 5.

• 3M does not recommend decontaminating
FFRs.

Background• Decontamination does not extend life of FFRs.

During this pubic health emerge,.::y of the C0\110-19 pandemic: outbrealt, many healthcare ins.titutKXls are experiencing:shortagE!<!I of FFRs such asi N 95 respirators.

The CDC has is.sued StrategJe'S tor Optimizing ttle Supply of N95 Respirators. lnlhi!!.document the CDC recommends
convention al c apacity strategies. co ntinge,.::y capacity strategies{during expected shortages) and crisis slrategies (during
known short&!ge:s). Contingency and cri.is m ategi:es include use of N95s past their shelf lite, extended use of N ~use ofother types of respirators. use of respirators from other countries. and re-use of respirators. ahead of decontamination of
respira tors.
The COC discusses reuse and extended use cf N 95s Bil a CJ"i&is strategy at Recommended Guidance for Extended Use andUmite<:I Reuse of N9!i F~1ering Facepll!Ce Respirators in Heahhcare Senings endhas published guideineson Decontamine1Klfl
and Reuse of F1lteJing Facepiece Respirators.. COC is recommeoding a wa it an d reuse approa ch before consideration of otherdec:ootaminatioo approaches.
Key excerpt from CDC guide~rle!.: " Ona t t ra teg y to reduce th e ritk of c:ontac-t tr ntfe r of p  thogent from the FFRto thewearer du ri ng FFA reuH it to inue f ive N95 FFRt to e  c:h heah hc:  r e  tatl member who c:  re for p  t ien t t w ith
1u11pected or con fir med COVID -19. The healthcar e 1taff member can wea r one N95 FFA eac:h day an d sto re it in abreathable paper bag at the end of eac:h shih w i t h a m inimum of f iVi!I days betwe,en &ae h N 9 S FFA ute, rotati ng the ut eeach day between N95 FFR t . Thi11 will pr o vide tome t ime to, pathogen 1, on it to ~die off"' d uring storage.~© 3M 2020. All Rights Reserved.
21 September

3M

Unclassified//For Public Use

35

Summary• N95 respirators help reduce airborne exposures to particles• Elastomeric reusable respirators and Powered Air Purifying Respirators
are options• OSHA, CDC/NIOSH and FDA offer guidance for selection and use• As CDC contingency and crisis strategies are implemented for respiratory
protection, it is important to consult all applicable government guidance aswell as the manufacturer for model-specific information.

© 3M 2020. All Rights Reserved.
21 September

3NI

Unclassified//For Public Use

36

N95 Filtering Facepiece Respirators
Ultraviolet Germicidal Irradiation(UVGI) Process for Decontamination
and Reuse
John-Martin Lowe PhD
Assistant Vice Chancellor for Interprofessional Health Security Training and
Education, Director of Research for Nebraska Biocontainment Unit,
University of Nebraska Medical Center

Unclassified//For Public Use

N95 Respirator UVGI Process for
Decontamination and Reuse
Warnings
Last Resort—first apply Strategies for Optimizing the Supply of N95 Respirators:
Crisis/Alternate Strategies
Voids the NIOSH approval
Decontamination technologies should be used cautiously• UVGI, vaporized hydrogen peroxide, warm moist heat, etc.
Should only be done by the organization and trained professionals
This was the result of multiple tests, a review of the scientific literature, and incorporation ofcurrent institutional practiceUnclassified//For Public Use

38

N95 Respirator UVGI Process for
Decontamination and Reuse
No one likes that we have to do this
CDC Crisis/Alternate Strategies
Personal Protective Equipment and Resp iratory Protection
HCP use of non - NIOSH approved masks or homemade masks
In se tt ings w here N95 respirato rs are so lim ited t hat routinely pract iced sta n da rds of ca re for wea ring N95 r es pirato rs andeq uiva lent or higher leve l of protect ion res pirators are no longe r possible, and su rgica l mas ks are n ot ava ilab le, as a lastr eso rt, it may be necessary fo r HCP to use masks t hat have neve r been evalua ted or app roved by NIOS H o r home m ademasks. It may be co nside red to use t hese masks fo r ca re of patients w it h COVID- 19, t ube rcu losis, meas les, and va r ice lla.
Howeve r, caut ion should be exer cised w hen co nsider ing th is option.1·2
39
Unclassified//For Public Use

https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html

N95 Respirator UVGI Process for
Decontamination and Reuse
Number of methods previously evaluatedFood and Drug Administration (FDA)• Optimizing Respirator Decontamination to Ensure Supplies for Emergency Preparedness• Assessed UGVI on 15 FFR models•

http://www.fda.gov/emergency-preparedness-and-response/mcm-regulatory-science/optimizing-respirator-decontamination-ensuresupplies-emergency-preparedness• Assessing VHP on FFRs for up to 50 disinfection cycles•

https://www.fda.gov/emergency-preparedness-and-response/mcm-regulatory-science/investigating-decontamination-and-reuserespirators-public-health-emergencies

National Institute of Occupational Safety and Health (NIOSH), CDC• Reusability of Filtering Facepiece Respirators• https://www.cdc.gov/niosh/topics/flu/respiratory.html
Unclassified//For Public Use

40

N95 Respirator UVGI Process for
Decontamination and Reuse

Unclassified//For Public Use

N95 Respirator Decontamination and
Re-Use Process

Trust

Key Points:

Discussion with HCW
•
•
•
•
•

InitialProcess Design
Process Evaluation
Operationalization
Feed Back

Communication• Strategy•

All N95 Respirators MUST be labeled 'M1h your first inrtial, last name, date of firstuse and department location (this is im portant to en sure return of YQ!!!: mask)•

Please limit the daily donning of new respirators as much as possible (extended
use, per policy, is strongly encouraged)•

All Used N95 Respirators are to be discarded in your broiMJ "dirty" paper bag•

Respirators sent for decontamination will be returned to you in a new white"clean· paper bag stapled at the top
o It will include a new brown bag to be used as your "dirty" discard bag.
Tall y marks will be added to the respirator by decontamination staff
each time the mask undergoes the decontamination process. Ensure
your name and return k>cation are on supplied brovm bag•

All decontaminated N95 Respirators will be kept in the wMe "clean· paper bag•

Note the location of your department/unit/site "dirty drop off" and "clean pick up"
stations•

Each health care professional rs responsible for ensuring the proper frt andintegrity of each respirator upon re-use

No te to Floa t Staff -Safety• Those Processing• Those Using

Y o u ca n ch oose to n ote your return location .as yo ur lastw orked unil/dep a rt m ent/siteORYo u can de:signate your return location as "Float· in wh ich
c ase you can re tli e~ you r c lean whi~ bag from the  econ.
Unit's ho ld ing .are.a o n 7111 fioo r UT (old Adull Crisis Unit)

3/21/2020

More deta iled informatio n, inc luding adetaile-d t raining documen t, can be­found o n the lin k below o r by scann ing
t his Q R code with you r phone :http s :{lwww.ne b ras kamed .comfco v id

l!IM: .. I!]

Nebraska·
Medicine 41

N95 Respirator UVGI Process for
Decontamination and Reuse

Unclassified//For Public Use

42

N95 Respirator UVGI Process for
Decontamination and Reuse
Why we use UVGI – Possibility and Familiarity
Effects of Ultraviolet Germicidal Irradiation (UVGI) on N95 Respirator
Filtration Performance and Structural Integrity

Effects. of U lt,-avio let Germicidal Irradiation (UVGI) on N95
Re.spirEttor FiltrEttion Performance and Structural Integritys,.,,.....

,,in

e.

W illl Q , l,.ll'\Cl•l..y, >$. ....
J , ... Rober!
Tt>ewtl• , 1 Kh.ch • · -84,fklllil•ft.• Ju11.,., o _Nwakb,-4 K•..,n...h R . ~Ad,1• _.,d Jbh.., D. Na!l1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699414/

Ultraviolet Germicidal Irradiation of Influenza-contaminated N95 Filtering
Facepiece Respirators

https://www.ajicjournal.org/article/S0196-6553(18)30140-8/fulltext

Inactivation of Viruses on Surfaces by Ultraviolet Germicidal Irradiation
https://www.tandfonline.com/doi/full/10.1080/15459620701329012?scroll=top&needAccess=true&

Ultraviolet (UV)-reflective Paint with Ultraviolet Germicidal Irradiation (UVGI)Improves Decontamination of Nosocomial Bacteria on Hospital Room Surfaces
https://www.ncbi.nlm.nih.gov/pubmed/28278065

Nebraska Biocontainment Unit Patient Discharge and Environmental
https://www.ajicjournal.org/article/S0196-6553(14)01375Decontamination After Ebola Care
3/abstract

Unclassified//For Public Use...l1-::'::::'."._":::'...-

=:.:::-::.==.:.":.::"-"'---·'---~--~-_____ _-~----,__

lnac11vation of Viruses on Surfaces by Ultraviole1
Germicidal Irradiation
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Ne l) 1'.)S k.'l 8ICH."Qn~,1ln men1 Unir p,'l1ie m d ischJ:rg.e ,)nd env l 1·onmem.:t ld(•c..Xm l<.l 11lin.lli(n'I ,"lrter Ebol.'.'1. Ctm"!'l(.i. r-c-ly r'I C'. ~(l(' 1l RS ~, Sh~- ,, G, (; , 1.)1.), PhD -.'' . l'h , 1,p ~Y, 5 ,1- 11h M () i..' .
Michel l<' M. SchWl"CUldm M SN b.d. l'<'l ~rIWot'n l'h 0 c, Lllubelh L 1Jt',11m M !ioN b.'•A., I(,,-,,, H .;t,y('J ~ N ... N-('(lr.;r, ti.'1,1 ..11),1 Ml"A ~. Cl r'iij{<)l)h('r J, K,;, rc,,:h,..,l M IJ 1' ,l(J,t hlttr'I C. SO ul!('t llA 11 , Ar'1.3el.1 L IIC'Wlffl MD '"'' . JM.ilJ. LO\ve l"'h D "·b.-43

N95 Respirator UVGI Process for
Decontamination and Reuse
Process Map

Process Map
Principles
Clear
Step by Step
Flow from each use through reprocessing through reuse
Everyone knows their role
Refresher training on Donning and Doffing
Principles
Unclassified//For Public Use-

44

N95 Respirator UVGI Process for
Decontamination and Reuse
Optimizing Process
Trial and error• Placement• Exposure times
Surface decontamination
process not entire FFR

UV
Meter

UVGI is measured by room UV meter
Unclassified//For Public Use

45

N95 Respirator UVGI Process for
Decontamination and Reuse
Process Confirmation
Organism Kill
• Used BSL2 bacterial and viralsurrogates seeded on FFR
surface to refine dosage inroom• Staphylococcus aureus• Chikungunya virus• 10 FFR at each UVGI exposure
route• 10^6 organism kill at each round

FFR Fit•Ran 5 FFR through qualitative
fit tests to assure maintained
filtration efficiency and fit• Didn’t use quantitative as it
would destroy FFR• Don’t know how many UVGI
cycles the mask can take.
• Others indicate in unpublisheddata — filter loading fromspittle46

Unclassified//For Public UseGuidance for Respiratory and Eye Protection: ExtendedUse, Reuse & Reuse After Decontamination

Extended Use

Wearing the same N95 for extended periods••••

Good condition
Not soiled
Free from defects or damage
MUST be capable of forming aseal to the wearer’s face

Unclassified//For Public Use

47

Guidance for Respiratory and Eye Protection: ExtendedUse, Reuse & Reuse After Decontamination

N95 Reuse
Reuse N95s
Store between use
Same person, several times, one day only

SEAL CHECK

Limited reuse – restrict the amount of reuse
When reusing – must be functional, not soiled,free from defects and the wearer must obtain asuccessful seal check
Unclassified//For Public Use

48
https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html

Guidance for Respiratory and Eye Protection: ExtendedUse, Reuse & Reuse After Decontamination

N95 Reuse
Discard after aerosolizing procedures
Discard if grossly contaminated withblood or other bodily fluids
Discard if used for a patient co-infectedwith another respiratory infection
Protect the N95 with a face shield orprocedure mask
Unclassified//For Public Use

49
https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html

Guidance for Respiratory and Eye Protection: ExtendedUse, Reuse & Reuse After Decontamination

N95 ReuseStore used N95s in a clean breathable container
Hand hygiene

Unclassified//For Public Use https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.htm
l50

TRACIE
HEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAY

Neil Carlson, MS, CIH
Industrial Hygienist, Department of Environmental Health &Safety, University of Minnesota
Content presented by this speaker is for informational
purposes only and does not necessarily express the views
or approval of the U.S. GovernmentASPR
ASSISTANT SECRETARY ~-OR

PREPAREDNES S AND RESPONSE

Unclassified//For Public Use

Unclassified//For Public Use

Testing for the State of Minnesota
Type of Respirator

Total Number
testedTotal # Passed
Fit factor > 100

Total # Failed

N-95/N99

39

8/20%

31/80%• TSI Portacount fit test – One subject – fit factor of 100
through standard fit protocol• N-95s vary widely in quality

Unclassified//For Public Use

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Reuse of Respirators Fitted Using a TSI Portacount- Aluminum tape

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Respirator DecontaminationRx• 5 x 5 rule
• 5 days (7days) for 5 times• Store in paper bag withdesiccant. Include nameand dates used.

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54

Portable UVC Decontamination Device

Unclassified//For Public Use

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55

UVC UVGI Meter with 254 nm Wavelength

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56

Measuring UVC Light Dose
Condition

RatemJ/cm2/minute

Time to 216 mJ/cm2

1 Sensor pointed at UVC light– Cabinet with verticalorientation

156

1.4 minutes

2 Inside respirator, The UVClight was underneath. The
sensor was pointed at theceiling – Worse case
exposure. Cabinet inhorizontal orientation

39.6

5.5 minutes

Unclassified//For Public Use

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Repurpose Eye Glass Decontamination Cabinet

Unclassified//For Public Use

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I NfORMATIO N GATEWAY

58

M3 Mask – Origami Mask
• Available in kits of over 100
masks. Self assemble withbands and staples.
• Cummings filter material• Fit factor depends on assembly• Generally performs as well or
better than KN-95 respirator• Decontaminate by heating at
75C in oven for 30 minutes

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I NfORMATIO N GATEWAY59

Nano PAPR Research• Several
manufacturers makebattery powered filter
units to supply
filtered air to a
respirator or a hood
• Currently problems
with QC some filter
very well others
average• It makes wearing a
respirator more
comfortable

Unclassified//For Public Use

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60

Hole Punch for Nano PAPR

Unclassified//For Public Use

61

Options for Testing Cloth Face Covering
1. Portacount – real time fit
factor test
2. Portacount – inject highly
filtered air inside
covering and determine
how well the facecovering holds the
reduced particle count
3. Tissue/candle test

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62

Face Shields and Gaiters (Tissue Test)
Caution: Gaiters & Face Shields
Evaluation is on-going but
effectiveness is unknown at
this time

Evaluation is on-going but
effectiveness is unknown at
this timehttps://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-facecoverings.html?deliveryName=USCDC_2067-DM36401

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Tissue Test for Cloth Face Covering – Layers andType of Fabric Matter

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Tissue Test for Cloth Face Covering – Layers andType of Fabric Matter – Type is Less Important

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65

TRACIE
HEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAY

Philip Madvig, MD, Interim Chief Medical Officer, Kaiser Permanente
Mary Beth Lang, ScD, Chief Supply Chain and Procurement Officer,
Kaiser Permanente

ASPR
ASSISTANT SECRETARY ~-OR

Unclassified//For Public Use

Unclassified//For Public Use

PREPAREDNES S AND RESPONSE

COVID-19: Acquiring, Distributing, &Managing Use of PPE• Kaiser Permanente overview• National Command Center & COVID-19 response• Implementation & innovation

Unclassified//For Public Use

67

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I NfORMATIO N GATEWAYThe Nation’s Largest Integrated Health System
23,371
physiciansdeliver highquality care

12.4 Mmembers
served in 8 markets$84.5Brevenue

63,30639
hospitals

CARE
AND

COVERAGE
TOGETHER

217K +
employees
improve health forpeople and communities

Unclassified//For Public Use

nursesare at the centerof our care715
medicaloffices

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Responding to COVID-19• Activated national incident command structure• Established COVID-19 Executive group with physician andorganizational leaders, and convened expert groups• Created tracking system and published daily tracker ofcases, bed use, supplies, regulatory issues

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Responding to COVID-19 (cont.)• Instituted scenario planning for potential surge• Forecast and planned for needs for space, staff, and stuff• Reduced non-COVID-19 demand• Disseminated policies

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Pursuing Additional Supplies
Global supply chains are fragile and no longer capable of responding to increasing
numbers of unplanned disruptions in complex environments
PPE Shortage Assessment

Shortage of gloves
from distributor

PPE shortages due
to pandemic

Inadequate supplyof N95 surgicalrespirators

Shortage of hospitalgowns andventilators

Unclassified//For Public Use

Malaysia is
primary source ofgloves (67%)

KP facilities
located inpandemic hot
spots

L.A. port
disruption stalls
PPE from China

71

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Sourcing Considerations
Buy To Pay Command Center

Unclassified//For Public Use

NIOSHAuthenticity/Certification

FDA/CDC/OSHA

Trade Barriers

Clinical Acceptance

Delivery Date

72

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Supply Channel Considerations
PPE
Manufact.

Competitor
Connector

KP NCalMember /Patient
Supplier

Distributor

Forwarder
KP SCalSupplier
Member /Patient
PPE
Manufact.

Unclassified//For Public Use

SC asa Service
Logistics
Contractor

KP Others73

Facing Constraints• Partnered with infectious disease chiefs on clinical acceptability;
partnered with Labor on implementation• Asserted systemwide supply control, including security, redistribution• Modified use guidelines including mask policies, extended use,
reprocessing• Developed communications and job tools• Daily Supply Update• Rolling 12-week Current Inventory and Resupply
Tracker• Ventilator/Disposables Surge Modeler• Supply Inventory, Days Inventory on Hand and74
Consumption Trends• Re-Entry Supply Impact of OR and Non-OR
Procedures

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Factors Guiding Resumption of Standard Use
Supply Chain
Security• Supply Chain
Resiliency
Measures• PPE Contracts
Based on
Product Access• Reserve
Warehouse

Adequate Supply
on Hand• Conservation
Reuse
Reprocessing
Extended Use• EUA• Testing
Protocols• COVID/PUI
Procedures

Forecast Demand• Mini-surges• COVID-19 plus Flu
Surge• 90-day Reserve at
40% Attack Rate

75

Adoption of critical indicators - ability to act if change in demand, use, supply
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Question & Answer

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76

Contact Us

asprtracie.hhs.gov

Unclassified//For Public Use

1-844-5-TRACIE

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TRACIE
HEALTHCARE EMERGENCY PREPAREDNESSI NFORMATION GATEWAYADDITIONAL SLIDESASPRASSISTANT SECRETARY ~-OR

Unclassified//For Public Use

Unclassified//For Public Use

PREPAREDNES S AND RESPONSE

N95 Respirator UVGI Process for
Decontamination and Reuse
Process Map: Healthcare Professionals

On exterior «respiratcr, clea rly
w rt,e ~ rf irst
inite l anrl fu ll s:
n8Tle, unit; anddated fiist use in
perIT11nent mar~.

EnGurc full n,o mel:liid n:-tum loc:,ation,.o rr on br=n fl0fl'Cf_Dolf 9:i. \ 'i!>ul:llly
lflG~ for :,oilin;f;!>lltura1ion, end ''bag. K~p tl1i!> botfor ~ r=p ratol!.

5lrlK;t un1I intetri1y _au mgsMt.

Cerefu ll_y pa De
respirata f)!lissi n1vr;;u,3 I nsl)eCliw 1n1
bRYIVn ba,1; fl:f UVGIproces;,i ng . Brni.w R
bai!swill be
oo lected in tot-es or
C!I rts. Do no stack
blD'lm bats. H81dle
brown be~ with

epeol pre\'iOOGs;eps untl end o f:sh ft - -=-.t end of ~ it:,plate ~rown ti.i ,gconle1ini rg IJ:!,,_-'IJ
ro pirotor:1 e1t u rit'~
JSrtl respi rctl Or
col l=-c":ion p:iinl.

l!l~-es\lisuill 1\1 in&pect
respira:or, ard drn
Cm:fu lyopen bai:andl "indlreplOCosed
respiratorswi hnel\' brown be:!!
ercl~ .

Unclassified//For Public Usel]el'" poli

Er1sure ~u rn ist
ini1ill I c ndl b!.1
mime , andl ~um

1oc1:nt1n are ~rlr:enon new browr bag.

R'C'lricv-c r15pmror
with Dkfcs! ' fir.stuse daiefrorn Dilg.

. r,,/al,·,eup
mey cis-:olor but

this is OK. Dr;.ca rd if
eastic ba1d br6il ks
when strached, isot~erwise isibtl,·
sci led . sa:u rated, or
f tarnP€Ff{lrm S!lfl I Cll ~k.
Di!>U!Pllcnd
n=tnc-,,~ diffr~nt
respirarcr if sea l
cha:kfa ls.

t: rc::,pi f"dtor f-'<=p,tj~•e111d u:s.e new
rc,pirat « on~,-.-hen e1II

I~ rif..lfSs,e-{]1opirfil1Jrs r1:11 1
IFlSpEC: IOfl.

79

N95 Respirator UVGI Process for
Decontamination and Reuse
Process Map: Courier

Coll ect brmvr oogs
oontaini ng IISi!~
respiratas fnm
dcsi:n.atcd pckup

poi rt.

N'llt ify WGI

o~io~ fldel~·eiy.

Collect w hit~ begs,
s'.a pied e1 t q1, ivi1h
owner'5 nome~lea r1 y mit!En o

1hcoutsi:le.

Unclassified//For Public Use

Note dflivel)I

IC'Cction and lwd
whitet):l~ in1D
delrvery vehice.

Transport
respirators to U\.JGI
Cell {lfn iversit)·

l =, Roor7, MU
for re-p1DD1!5Si re.

I Depos:t brmm bf\~
COOt flirinj1 us.ed
respirators in soiled
ut l ity room.

Ddf ~ lo\es an clf)l!rform hand,h~imeat s irk
nm=t:scilcd utility
room.

Log delivtry !lf tote
a n:11i;icfi.u p lo::a~ion
onslteet outside d
sci led uti lily room.

C'fl rv~r reproce;;,e,j
respi·ators in white t~
to de;;lgJ1ateil cean a~a
in a ppropnfil= ~nit
js,,__cr.-a rBtffl tom ~stdpi~k.up roi1t}.

80

N95 Respirator UVGI Process for
Decontamination and Reuse•.:-."·-.;.' ...
:,-.-_,·_• __:.:.:·.. •. ..-. : . :. ·-_


Process Map: UVGI Associate
_.

•

•

.

,.

'.

•

'

'

I

...

·--

•

Cor.tinueh8llgint
t:ag isemll)'.
En:sure resi:iiraors
00 net to;.ich eech

Carefu llyfoldemrtYbrown be~ in half.
lhendis.caldi'ltras.hcm, andocntim~ wth ne:ibrow, bnt L.rti l CM

otterd!Jinl!:erl)

il.errpty

respira<n<mea:atime i..iti l brown.

lhO!OU;ghlywipe
errpt)' t«e anda,nWllllOAh lr<' 1
ff pc>

I.

;1. , , .:

'

-

•

,

I

VerfytwoCIOfDiSys
To ro hcsand W
scnsor.o~ plu,gg«Iin ond positone<I in~ llo.,pmit km

txP.es.. verrynotlg«:b b!odl. lined'•

strui.tU"al inrgit}.
Do n<Xtll"n n~dc

I

G61t ly pas.ition
elastic bards

bd:mxnrm.eoodc.hin pancl5o.

°"·

Ddf govnMO
i!lotesetthreshdj

Tumdf.8 111ghts
irside. e.">li t room .

ofd)Of.

endshJtd:ior .

OJllect res prtfor;
from line. ore

Deposit res.pirators'51Ct1 between
ror;~oro
tmtint~uatOl5.

'"'"'

rep111C.i!5A:i"t

McnitorD<Y--si,:;eonCort ro-1P«lcl. P=~
P1:shSl AITT on
rerncte. and push
"St,11rtl<JU:in1!' 01
rema:etDx.B.'.>thlN Tordles. willbiiginl:Je.Epirig

itside room,
po~otiw!-~•fM.tPr
for -60W11:0nck

Whil2-Wm&ehine
is. r1.a1nh g - 5
mnute. ~ lc t imc,

fold~ new brown
lxg:!>w ill be p~
il'ISlde J"lel'I' wt"lte
tiaEs.Ame:allc!:.met l 15 norm11 1

dUlllt! UVTorthopr-raum.

STOP-on ieroow
ond -St-0 p Lo.r,ging•
wil d! w Dma.@e
ret:ielesa 16:ISt 50

m.J/c:rn2 (-5-{s rninsu,n 1osto,:it. Note
10tal d~onproc~IO£Slleel:.
N<Jle: Pr:>lonfed~

Don g lwo t'nyO'ld
ertetlf'tfjlroorn.

owner Bt 8 ti re andp8cet11 ll~rre r~ ,tWibttumd re!.pirao,
to reoon::lthede:o~<>«•in.toa new \,hiteba:. indce:inE:owne-ran(I n:-turnlocatonor.; eJterior

ohhrtebei! Staplt
wh t@MQV11.,1

eJq>Q5ure 1'118~

Cleir&deel8i-t lC""•-

Tr611Sf-er
ra:rocess.ed
r25,p1ra0f'S in~spledwhitebseot

to courier pickup........

1o::&•ioninl\/GI

Unclassified//For Public Use

Retu rn c:lci:rno:irtto
de.11.e nclna:fy

p it;hupbci:ltiw

oourieifoon:.oclj
leadthtt
re.pl'"a.orsore
res(trorp101upror
lt lacatlOn.

lrdi¢6te P"OCf'SS
fini!:.htime.nurroer
ofrespiretors
pRX~, Sndother no-:tsas
ifldicatedon
P~btVIM:

81