Evaluation of Respiratory 

Protection Practices for 

Employees at Federal 

Immigration and Customs 

Agency Workplaces – 

Nationwide

Marie A. de Perio, MD

R. Todd Niemeier, MS, CIH

Bradley S. King, MPH, CIH

Health Hazard Evaluation Report

HETA 2009-0184-3126

April 2011

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

Workplace

Safety and Health

 National Institute for Occupational 

Safety and Health

This Health Hazard Evaluation (HHE) report and any recommendations made herein are for the specific 

facility evaluated and may not be universally applicable. Any recommendations made are not to be 

considered as final statements of NIOSH policy or of any agency or individual involved. Additional HHE 

reports are available at http://www.cdc.gov/niosh/hhe/

Charles A. Mueller, MS
The employer shall post a copy of this report 

for a period of 30 calendar days at or near 

the workplace(s) of affected employees. The 

employer shall take steps to insure that the 

posted determinations are not altered, defaced, 

or covered by other material during such 

period. [37 FR 23640, November 7, 1972, as 

amended at 45 FR 2653, January 14, 1980].
Health Hazard Evaluation Report 2009-0184-3126 Page i

Appendix A

Report Abbreviations................................................................................................ii

Highlights of the NIOSH Health Hazard Evaluation........................iii

Summary .........................................................................................................v

Introduction ...................................................................................................1

Assessment.....................................................................................................4

Results..............................................................................................................6

Discussion.................................................................................................... 18

Conclusions................................................................................................. 23

Recommendations.................................................................................... 23

References.................................................................................................... 27

Contents

Airborne Infectious Agents.................................................................... 30

Respirators................................................................................................... 38

Acknowledgments

Appendix B

Acknowledgments and Availability of Report................................ 42
Page ii Health Hazard Evaluation Report 2009-0184-3126

Abbreviations

μm Micrometer

CDC Centers for Disease Control and Prevention

CFR Code of Federal Regulations

DO Deportation officer

DHS Department of Homeland Security

DRO Detention and Removal Operations

FOD Field office director

FOH Federal Occupational Health

FPS Federal Protective Service

HEPA High efficiency particulate air

HHE Health hazard evaluation

IEA Immigration enforcement agent

NAICS North American Industry Classification System

NIOSH National Institute for Occupational Safety and Health

NIRU National Incidence Response Unit

OI Office of Investigations

OSHA Occupational Safety and Health Administration

PAPR Powered air-purifying respirator

pH1N1 2009 pandemic influenza A (H1N1)

PPD Purified protein derivative

PPE Personal protective equipment

RAC Resident agent in charge

SA Special agent

SAC Special agent in charge

SCBA Self-contained breathing apparatus

TST Tuberculin skin test
Health Hazard Evaluation Report 2009-0184-3126 Page iii

The National Institute 

for Occupational Safety 

and Health (NIOSH) 

received a health 

hazard evaluation 

request from the 

American Federation of 

Government Employees 

in July 2009. The union 

was concerned about 

respiratory protection for 

employees of a federal 

immigration and customs 

agency.

Highlights of the

NIOSH Health

Hazard Evaluation

What NIOSH Did

● We reviewed the agency’s written respiratory protection 

procedures.

● We observed a respirator fit-testing session at agency 

headquarters.

● We surveyed employees across all agency workplaces about 

respiratory protection practices.

What NIOSH Found

● The agency’s written respiratory protection procedures were 

comprehensive. However, written programs were reportedly 

not available at some agency workplaces.

● The quality of the respirator fit-testing procedures we 

observed was good. However, we did identify some areas that 

could be improved.

● Most employees who responded to the survey have faceto-face contact with immigrants in their current job. This 

contact puts them at risk of getting respiratory infections.

● Most employees who responded to the survey completed all 

required steps of the respirator fit-testing process. However, 

we did find some gaps between medical clearance and 

respirator training.

● Few employees reported being screened for tuberculosis in 

the last year.

What Managers Can Do

● Ensure that the written respiratory protection program is 

available at all agency workplaces.

● Follow all requirements in the OSHA Respiratory Protection 

standard.

● Require and arrange fit testing for employees at least 

annually.

● Develop and maintain clear written procedures for the use of 

respirators.

● Improve training provided to fit testers. Include more 

information on the technical capabilities of respirators and 

more specific instructions for the fit-testing procedure. 

● Recommend tuberculosis screening for employees at least 

once a year.

● Recommend the influenza vaccine for employees every year.
Page iv Health Hazard Evaluation Report 2009-0184-3126

Highlights of the

NIOSH Health

Hazard Evalution

(continued)

What Employees Can Do

● Follow workplace procedures on use of respirators.

● Do a face seal check each time before you use a respirator.

● Get screened for tuberculosis at least once a year.

● Get the seasonal influenza vaccine every year.
Health Hazard Evaluation Report 2009-0184-3126 Page v

NIOSH investigators 

assessed the respiratory 

protection program at 

federal immigration 

and customs agency 

workplaces nationwide. 

Overall the agency’s 

respiratory protection 

program adequately 

protects employees 

from airborne infectious 

agents. However, several 

areas could be improved.

Summary

In July 2009, NIOSH received an HHE request from the American 

Federation of Government Employees. The union was concerned 

about respiratory protection for federal immigration and customs 

agency employees during the pH1N1 pandemic. NIOSH 

investigators reviewed the agency’s written respiratory protection 

procedures, observed a respirator fit-testing session for employees 

at agency headquarters, and surveyed employees nationwide about 

respiratory protection practices.

We found that the agency’s respiratory protection policy, the 

respirator medical evaluation questionnaire, the qualitative fittesting protocol, and the slide presentation serving as training 

for fit testers were comprehensive. The quality of the observed 

respirator fit-testing procedures was good. However, we identified 

several areas that needed improvement.

Though the response rate for our survey was suboptimal with 

2,218 responding employees, we found that that most respondents, 

particularly those from DRO and OI, have face-to-face contact with 

immigrants in their current job. This contact places them at risk 

for exposure to airborne infectious agents, including Mycobacterium 

tuberculosis, influenza virus, rubeola virus, and varicella zoster virus. 

Most respondents completed all of the steps required for respirator 

use (medical clearance, respirator training, respirator fit testing). 

However, some gaps between medical clearance and respirator 

training existed. We also found low employee compliance with 

respirator usage and annual tuberculosis screening. The written 

respiratory protection programs were not readily available in some 

workplaces.

The agency should maintain a written respiratory protection 

program for all workplaces to protect against airborne infectious 

agents and other respiratory hazards. The agency should require 

and arrange fit testing for employees at least annually and verify 

medical clearance prior to the fit test. Clear written procedures 

for the use of respirators should be developed and maintained, 

and specific indications for respirator usage should be included 

in training. Annual evaluations of the workplaces to ensure that 

the written respiratory protection program is being properly 

implemented should be conducted. Training provided to 

employees and fit testers should be improved to include more 

information on the technical capabilities of respirators and more 

specific instructions for performing face seal checks and for 

donning and doffing respirators. Employees who should undergo 
Page vi Health Hazard Evaluation Report 2009-0184-3126

Summary (continued)

Keywords: NAICS 928120 (International Affairs), tuberculosis, TB, 

immigration facility, influenza, H1N1, measles, rubeola, chicken pox, 

varicella, infections, respirators, respiratory protection 

routine tuberculosis screening should be identified and informed. 

Finally, annual influenza vaccination should be recommended to 

all employees.
Health Hazard Evaluation Report 2009-0184-3126 Page 1

Introduction

On July 7, 2009, NIOSH received an HHE request from the 

American Federation of Government Employees. The request 

concerned the potential transmission of airborne infectious agents 

at federal immigration and customs agency workplaces nationwide. 

The union was concerned about respiratory protection provided to 

its employees during the pH1N1 pandemic. Though the initial focus 

of the request by the union was on DRO, employer representatives 

asked that we expand our evaluation to include all other divisions of 

the agency.

We discussed the request with union and employer representatives. 

We learned that the DHS issued interim guidance concerning 

PPE use by its employees in 2009 during the pH1N1 pandemic. 

Specifically, it provided guidance concerning voluntary use of an 

N95 respirator for employees in contact with persons known or 

suspected to have pH1N1 infection. It stated that managers and 

supervisors must provide their employees with a copy of Appendix D 

of the OSHA Respiratory Protection standard [29 CFR 1910.134].

While fit testing is not required for voluntary use of the N95 

respirator, the agency launched a campaign, through NIRU, to 

qualitatively fit test more than 13,000 employees in July 2009 in 

anticipation of potential exposures to pH1N1 virus during the 

pandemic. This fit-testing campaign was completed in September 

2009. All mission-essential personnel, defined by the agency, were 

required to be fit tested. Employees were required to complete 

an online respirator medical evaluation questionnaire through 

FOH. The total number of employees who underwent fit testing 

nationwide during this campaign was 13,777. The total number of 

employees successfully fitted for a respirator was not known at the 

national level.

Immigration and Customs Agency

The agency, part of DHS, is charged with protecting national security 

by enforcing the nation’s immigration and customs laws. This agency 

employs approximately 19,000 persons in more than 400 offices 

nationwide and around the world. It is comprised of four main 

operational divisions: Office of Detention and Removal Operations, 

Office of Investigations, Office of Intelligence, and Office of 

International Affairs. Effective October 28, 2009, FPS, formerly an 

operational division of the agency, was placed under the National 

Protection and Programs Directorate of DHS.
Page 2 Health Hazard Evaluation Report 2009-0184-3126

Introduction 

(continued) DRO is the primary enforcement arm within the agency for the 

identification, apprehension, and removal of illegal, fugitive, and 

criminal immigrants from the United States. Approximately 7,600 

employees work in DRO out of detention facilities, field offices 

and subfield offices, holding areas, and staging locations. OI is 

responsible for investigating, deterring, and interdicting threats 

arising from the movement of people and goods into and out of 

the United States. OI employs approximately 7,900 individuals. 

The Office of Intelligence collects, analyzes, and shares strategic 

and tactical data for use by the agency and the DHS management 

and operational units. The Office of Intelligence employs 

approximately 300 individuals. The Office of International Affairs 

employs approximately 300 individuals in more than 60 locations 

around the world. These international attaché offices coordinate 

investigations and law enforcement duties with international 

partners. The Office of State/Local Coordination, the National 

Firearms and Tactical Training Unit, the Office of Training and 

Development, and NIRU are also considered operational offices 

within the agency. NIRU develops, implements, and oversees 

key preparedness, prevention, response and recovery programs, 

and projects. It also supports and establishes uniformity of 

agency incident management and response efforts. The agency’s 

management divisions employ more than 800 individuals, while 

the leadership offices within the Office of the Assistant Secretary 

employ more than 2,100 individuals.

Occupational medical clinical services, including immunizations, 

tuberculosis screening, and medical clearance for respirator use are 

provided to employees in partnership with the U.S. Public Health 

Service/FOH. Employees may be exposed to a variety of respiratory 

hazards while conducting law enforcement activities, emergency 

responses, or special operations.

Airborne Infectious Agents

Airborne transmission of infectious agents occurs by dissemination 

of either airborne droplet nuclei or small particles in the respirable 

size range (≤ 10 μm) containing agents that remain infective over 

time and distance. These particles may remain suspended in air 

for long periods and may be widely dispersed by air currents. The 

microorganisms in these particles may be inhaled by susceptible 

individuals who have or have not had face-to-face contact with the 

infectious individual. Infectious agents that are transmitted by the 
Health Hazard Evaluation Report 2009-0184-3126 Page 3

Introduction

 (continued) airborne route include Mycobacterium tuberculosis [Riley et al. 1959; 

Haley et al. 1989; Beck-Sagué et al. 1992], rubeola virus (measles) 

[Bloch et al. 1985], and varicella zoster virus (chickenpox) [Leclair 

et al. 1980]. Although influenza viruses are thought to be mainly 

spread by droplet transmission (i.e., large respiratory droplets 

generated by coughing or sneezing and propelled over short 

distances), evidence for airborne transmission also exists [Bridges 

et al. 2003; Blachere et al. 2009; Lindsley et al. 2010a,b]. Detailed 

information on these airborne infectious agents can be found in 

Appendix A of this report.

A comprehensive program to prevent the spread of pathogens 

transmitted via the airborne route consists of engineering, 

administrative, and personal respiratory protection controls. 

Engineering controls such as the use of special air handling and 

ventilation systems are often used to help remove infectious 

agents in potentially high exposure areas such as isolation rooms 

or cells. Administrative controls include training employees on 

infectious control practices and medical surveillance programs for 

tuberculosis. In addition, respiratory protection is recommended 

for healthcare personnel and correctional and detention facility 

staff for protection against airborne infectious agents such as 

tuberculosis [CDC 2005, 2006]. More information on these 

controls can be found in Appendix A of this report.

Background on Respirators and 

Regulations

An estimated 5 million workers in 1.3 million U.S. workplaces 

are required to wear respirators at least some of the time while 

performing their job functions [OSHA 2010]. A respirator is a 

personal protective device that is worn on the face, covers at least 

the nose and mouth, and is designed to protect the wearer from 

inhaling hazardous airborne particles (including dust particles and 

infectious agents), gases, or vapors. Respirators should only be used 

as a “last line of defense” when engineering and administrative 

controls are not feasible or before these controls are implemented. 

Detailed information on respirators can be found in Appendix B 

of this report.

The current OSHA standard 29 CFR 1910.134, or Respiratory 

Protection standard, was implemented in April 1998 [29 CFR 

1910.134]. It requires employers to provide respirators when they 
Page 4 Health Hazard Evaluation Report 2009-0184-3126

are necessary to protect the health of the employee. It also requires 

that employers develop and implement a written respiratory 

protection program when respirators are required. The standard 

contains requirements for program administration, worksitespecific procedures, respirator selection, employee training, fit 

testing, medical evaluation, respirator use, respirator cleaning, 

maintenance and repair, and other revisions. Employers must 

provide respirators, training, and medical evaluations at no cost to 

employees [29 CFR 1910.134]. The OSHA Respiratory Protection 

standard can be found at http://www.osha.gov/pls/oshaweb/

owadisp.show_document?p_id=12716&p_table=standards.

Introduction

 (continued)

Our evaluation had three components: a review of the agency’s 

written respiratory protection procedures, observation of 

a respirator fit-testing session at agency headquarters, and 

administration of an electronic survey about respiratory protection 

practices across all agency workplaces.

Review of Written Respiratory Protection 

Procedures

We reviewed the agency’s respiratory protection policy, Directive 

Number 70005.1 dated January 31, 2007. FOH granted us access to 

the online respirator medical evaluation questionnaire for agency 

employees. We evaluated its components and compared it to the 

information mandated in Appendix C of the OSHA Respiratory 

Protection standard [29 CFR 1910.134]. We also reviewed the 

agency’s qualitative fit testing protocol, including the fit-test 

checklist and instructions for fit testers. In addition, we reviewed 

the slide presentation that served as training given by FPS for fit 

testers.

Observation of a Respirator Fit-testing 

Session

A NIOSH investigator observed a qualitative respirator fit testing 

session at agency headquarters in August 2009. He observed a 

number of fit testers at various stations throughout the day and 

observed individual fit testers over successive fit tests. He listened 

to fit-tester instructions to employees being fit tested, noted specific 

Assessment
Health Hazard Evaluation Report 2009-0184-3126 Page 5

Assessment

 (continued) procedures used for qualitatively fit testing the respirators, and 

gauged the level of understanding of the fit-testing procedure 

shown by both the fit tester and the employee being fit tested.

Electronic Survey

We surveyed employees about the implementation of respiratory 

protection and other infection control measures for airborne 

infectious agents at workplaces nationwide. Our objectives were 

to assess the completeness of employee coverage of the recently 

completed fit-testing campaign, identify barriers to undergoing 

and completing respirator fit testing, determine the success rates 

of respirator fit testing and reasons for unsuccessful tests, and 

assess adherence to other infection control measures for airborne 

infectious agents. We also looked at the role of the designated 

health and safety officer in the respiratory protection program and 

the respirator fit testers’ attitudes towards the fit-testing process.

In January and February 2010, we disseminated an electronic 

survey to 19,424 current employees. The electronic questionnaire 

was sent to employees by agency managers through two broadcast 

e-mails. The survey was also placed on the agency intranet website. 

All employees were invited to participate. The questionnaire was 

anonymous and included no personal identifying information. 

Respondents had the option of returning the completed 

questionnaire directly to NIOSH investigators electronically or by 

fax. Surveys were collected over 6 weeks. The agency management 

and union sent multiple e-mail reminders to employees during 

the survey period. The survey included questions about work 

history, the recent respirator fit-testing campaign, tuberculosis 

screening, influenza vaccination, and workplace exposures to 

airborne infectious agents. Questions also addressed beliefs about 

and attitudes towards workplace practices and risk of acquiring 

infection, health and safety officers’ knowledge about the 

respiratory protection program, and attitudes of fit testers towards 

the fit-testing process.

We summarized survey results using medians, ranges, and 

proportions as appropriate. Responses to questions about 

attitudes and beliefs were categorized as “expressed agreement” if 

respondents marked “agree” or “tend to agree,” and as “expressed 

disagreement” if respondents marked “disagree” or “tend to 

disagree.” Responses of “neither agree nor disagree” were left as is.
Page 6 Health Hazard Evaluation Report 2009-0184-3126

Results Review of the Written Respiratory 

Protection Procedures

The agency’s respiratory protection policy, Directive Number 

70005.1 dated January 31, 2007, provides guidelines for 

establishing and implementing a respiratory protection program. 

The policy states that the Health, Safety, and Environment Section 

within the Facilities Branch of the Office of Asset Management 

shall establish, implement, and maintain a respiratory protection 

program for employees. The program contains all of the basic 

elements required by OSHA including respirator selection, medical 

evaluation, respirator training, fit testing, respirator use, respirator 

cleaning, and maintenance and repair [29 CFR 1910.134]. It 

also clarifies the responsibilities within the program. While the 

Health, Safety, and Environment Section is responsible for overall 

coordination and implementation, NIRU is responsible for 

ensuring compliance with new or updated policies and guidance, 

specifically in the area of pandemic influenza. FPS is responsible 

for supporting the agency’s programs in fit testing and training. 

However, it is uncertain if FPS maintains this responsibility 

because of organizational changes. Each program is responsible 

for ensuring that appropriate employees are identified, trained, 

and provided with PPE, and for developing standard operating 

procedures and/or guidance.

The agency’s fit-testing procedures included all the elements 

required by the OSHA Respiratory Protection standard [29 CFR 

1910.134] (Appendix B). The program requires medical clearance 

prior to fit testing. The online respirator medical evaluation 

questionnaire contains all questions found in the OSHA 

Respirator Medical Evaluation Questionnaire, Appendix C, to the 

OSHA Respiratory Protection standard [29 CFR 1910.134]. It also 

contains specific follow-up questions for “yes” answers to specific 

symptoms or problems. Upon completing the questionnaire, 

employees are immediately informed whether or not they have 

been medically cleared to wear a respirator. Employees are able to 

print a copy of the letter, and the system provides the clearance 

to the employee’s Program Office and the Health, Safety, and 

Environmental Officer at headquarters. Employees who are not 

medically cleared by the questionnaire are sent for a follow-up 

medical evaluation.

The agency’s fit-testing procedures incorporated respirator 

training during the fit-testing procedure; no separate training 

session existed for employees. The agency employed qualitative 
Health Hazard Evaluation Report 2009-0184-3126 Page 7

Results

 (continued) fit testing consisting of a sensitivity test and a fit test. Fit testers 

were instructed about giving directions on proper donning and 

seal checking. The qualitative fit testing protocol contained the 

procedures for the sensitivity test and the fit test. Saccharin or 

Bitrex® was used as the challenge agent. Employees were required 

to perform eight simple tasks while wearing the respirator. The fit 

testing overview document stated that “if an individual detects the 

test solution at any time during the eight tasks, the N95 respirator 

will be refitted and retested. If the individual detects the taste a 

second time, he or she may be tested on another model of the 

N95 respirator. If an appropriate facial seal is not achieved with 

the second model, the individual cannot wear an N95 respirator 

and should be assigned to duties that would not expose him or 

her to airborne hazardous conditions.” Fit testers were also given a 

checklist of instructions and actions for the fit-testing process. This 

checklist is comprehensive and contains the necessary details for 

each step of the process.

The slide presentation for training fit testers was thorough in the 

topics covered. It addressed the selection of respirators, general 

information on particulate filtering facepiece respirators, medical 

evaluation, and the details of administering a qualitative fit test. 

The training presentation also included the necessary equipment 

and materials, pretest preparations, and instructions for individuals 

being tested.

Observation of Respirator Fit-testing 

Session

On August 7, 2009, a NIOSH investigator observed the third of 3 

days of qualitative respirator fit testing. Employees were fit tested 

for N95 filtering facepiece respirators in anticipation of potential 

exposures to pH1N1 virus during the pandemic.

Eleven fit-testing stations were set up, with each station’s table 

approximately 8 feet from the next table. As employees arrived for 

testing after having been medically cleared to wear a respirator, they 

were checked in and directed to one of the fit-testing stations. Though 

the agency’s fit testing overview document stated that employees 

would have two respirator model options during fit testing, three N95 

respirators were available to employees on the observed testing date: 

3MTM8210, 3M8511, and 3M 8110S (Figures 1–3). The 3M 8210 and 

8110S models are similar respirators and only vary in size.

Figure 1. The 3M 8210 N95 respirator 

for which employees were fit tested. 

Photo © 2011 3M Company. All rights 

reserved.

Figure 2. The 3M 8511 N95 respirator 

for which employees were fit tested. 

Photo © 2011 3M Company. All rights 

reserved.

Figure 3. The 3M 8110S N95 respirator 

for which employees were fit tested.

Photo © 2011 3M Company. All rights 

reserved.
Page 8 Health Hazard Evaluation Report 2009-0184-3126

Results

 (continued) The fit testers followed the qualitative fit-testing checklist developed 

by the agency for the saccharin sensitivity test and the respirator fit 

test. A 3MTM FT-10 fit-test apparatus was used for the qualitative fit 

tests. Bitrex® solution was available for employees who were not 

sensitive to saccharin. Depending on the agency program, the fit 

tester chose either the 3M 8210 model or the 3M 8511 model for 

fit testing. For example, OI employees were offered the 3M 8210 

model; DRO employees were offered the 3M 8511. The reasoning 

behind this selection was practical; DRO agents were more likely to 

encounter pH1N1 exposures and to wear their respirators longer. 

The 3M 8511 model respirator has an exhalation valve that may 

make it more comfortable. 

If the fit test failed, the employee was asked to wait 15 minutes, 

and the fit test was repeated using the same model respirator. If 

the fit test failed a second time, the smaller 3M 8110S model was 

tried. If the employee was successfully fit tested in one of the three 

respirator models, he or she was provided three respirators of that 

model to personally keep and store until needed.

Instructions Provided By the Fit Tester

The pertinent and required instructions provided by the fit testers 

were typically comprehensive and closely followed the agency’s 

qualitative fit-testing checklist. Similar information was relayed 

to employees as they were being fit tested, irrespective of the 

particular fit tester. However, the NIOSH investigator noted a few 

deficiencies.

First, in a few instances, he observed that the top strap of the 

respirator was placed below the crown of the fit-test subject’s 

head. The manufacturer’s instructions state that the top strap is 

to be placed high on the top back of the subject’s head, effectively 

crossing the crown of the individual’s head [3M 2001]. While 

seemingly minor, incorrect placement of straps may result in a poor 

fit test.

Second, every fit tester observed required that the fit-test subject 

check for leakage around the face seal. However, the instructions 

on how to perform the face seal check did not often conform to 

instructions provided by the respirator manufacturer. For example, 

fit-test subjects were told to place the thumb and forefingers of 

both hands in C-shaped positions around the seal of the respirator 
Health Hazard Evaluation Report 2009-0184-3126 Page 9

and then inhale to identify any leaks. The fit testers did comment 

if they observed dimpling of the respirator, indicating a negative 

pressure was being achieved inside the respirator. However, these 

directions differ from the manufacturer instructions that state “To 

check the respirator-to-face seal, place both hands completely over 

the respirator and inhale sharply. Be careful not to disturb the 

position of the respirator. A negative pressure should be felt inside 

the respirator” [3M 2001].

Finally, in Part 1, Section A.6. of Appendix A of the OSHA 

Respiratory Protection standard, the OSHA-accepted Fit Test 

Protocol requirements, state “If the test subject is not familiar with 

using a particular respirator, the test subject shall be directed to 

don the mask several times and to adjust the straps each time to 

become adept at setting proper tension on the straps” [29 CFR 

1910.134]. The NIOSH investigator observed that subjects were 

instructed to don the respirator a single time.

Qualitative Fit-testing Procedures

The fit-testing procedures generally followed Appendix A of 

the OSHA Respiratory Protection standard [29 CFR 1910.134]. 

However, in some instances, agency protocols differed from the 

OSHA-mandated procedures. First, the NIOSH investigator 

observed that some male agency employees with facial hair crossing 

the respirator sealing surface were fit tested and provided with 

the N95 respirators. Part 1, Section A.9 of the OSHA Respiratory 

Protection standard Appendix A, specifically states that “The test 

shall not be conducted if there is any hair growth between the skin 

and the facepiece sealing surface, such as stubble beard growth, 

beard, mustache, or sideburns which cross the respirator sealing 

surface” [29 CFR 1910.134].

Second, he observed that a selection of respirators was not 

available for each employee being tested. Due to logistical concerns, 

the model of respirator that the employee was fit tested on was 

preselected by the fit tester according to the division in which the 

employee worked. Part 1, Section A.1 of the OSHA Respiratory 

Protection standard states that “The test subject shall be allowed 

to pick the most acceptable respirator from a sufficient number of 

respirator models and sizes so that the respirator is acceptable to 

the user” [29 CFR 1910.134].

Results

 (continued)
Page 10 Health Hazard Evaluation Report 2009-0184-3126

Results

 (continued) Finally, no mirror was available during the fit-testing procedures for 

the subjects to evaluate the positioning of the respirator on their 

face. Part 1, Section A.1 of Appendix A of the OSHA Respiratory 

Protection standard, states that “A mirror shall be available to assist 

the subject in evaluating the fit and positioning of the respirator” 

[29 CFR 1910.134].

Level of Understanding of the Fit-testing 

Procedure Shown by the Fit Tester

The NIOSH investigator learned that some fit testers did not have 

a solid understanding of the aerosols against which respirators are 

meant to protect the wearer. For example, many fit testers explained 

that an N95 respirator will filter 95% of particles down to 3 μm, 

which would include 100% of viruses, but may not be effective 

against smaller biological agents. In fact, N95 respirators are tested 

against and are at least 95% efficient in filtering particles with a 0.3 

μm diameter, the size of particles that most easily passes through 

particulate filters. Although viruses and other particles may indeed 

be smaller, contrary to expectations, they do not penetrate the 

respirator filters as readily as particles with a 0.3 μm diameter, mainly 

because of capture mechanisms such as diffusion or electrostatic 

attraction. Therefore, the N95 respirator will effectively filter 

particles with diameters larger and smaller than 0.3 μm.

Cross-sectional Survey

We received 2,251 completed surveys by e-mail and by fax. Of this 

total, 33 respondents were excluded from our analysis because they 

reported working for FPS, which was no longer a program within 

the agency. Thus, we received 2,218 valid surveys out of 19,424 

employees who were reported by management to have received the 

broadcast e-mail, a response rate of 11%. Of the 2,218 respondents, 

1,648 (74%) were male, and 564 (26%) were female. The median 

age was 40 years, with a range of 21–74 years.

Work Characteristics

Employees from OI (49%) and DRO (45%) made up the majority 

of respondents. The largest number of respondents primarily 

worked in SAC or RAC offices (40%) and DRO field offices 

or suboffices (31%). Respondents working in all 50 states, the 
Health Hazard Evaluation Report 2009-0184-3126 Page 11

District of Columbia, Puerto Rico, and Guam were represented. 

In addition, three employees working in Hong Kong, Italy, and 

Mexico responded. The most commonly reported job titles 

were SA or other investigations employee (37%), IEA (17%), 

administrative employee (17%), and DO (10%). The median 

number of hours worked a week was 50 (range: 16 to 110 hours). 

Other work characteristics of respondents are shown in Table 

1. Seventy-six (3%) respondents reported being the local union 

representative at their workplace.

Results

 (continued)

Of the 2,208 respondents who answered the question, 1,654 (75%) 

respondents reported having face-to-face contact with immigrants 

in their current job. Most employees in DRO (82%) and OI (74%) 

reported face-to-face contact with immigrants. Face-to-face contact was 

high among IEAs (99%), DOs (93%), DRO supervisors (87%), and 

SAs and other OI employees (83%), all job titles within DRO and OI. 

Respondents (n = 1,569) reported the median hours worked per week 

with face-to-face contact with immigrants was 6 hours (range: 0.15 to 60 

hours).

Respirator Fit Testing Process Results

Respiratory protection characteristics of all respondents, DRO 

respondents, and OI respondents are shown in Table 2. Most (85%) 

respondents reported having undergone medical clearance to wear 

a respirator in the previous year. Of the 1,839 respondents who 

underwent medical clearance, most (98%) reported they were medically 

cleared.

Most (84%) respondents reported having had training on the proper 

use of respirators, and most (88%) reported having undergone 

respirator fit testing at their current workplace during the previous 

year. The most common reasons cited for not having respirator fit 

testing in the previous year were “I was not informed that fit testing was 

occurring,” “I am a new hire,” and “I don’t know.” Of the respondents 

who reported having face-to-face contact with immigrants, 88% 

reported undergoing medical clearance, 87% reported undergoing 

respirator training, and 92% reported undergoing respirator fit testing.
Page 12 Health Hazard Evaluation Report 2009-0184-3126

Results

 (continued)

Table 1. Work characteristics of survey respondents

Work Characteristic No. Respondents (%)

n = 2,031–2,213*

Agency program

 OI 1,078 (49)

 DRO 996 (45)

 Office of the Principal Legal Advisor 59 (3)

 Office of Intelligence 40 (2)

 Other 40 (2)

Type of primary workplace

 SAC, deputy SAC, assistant SAC, RAC office 892 (40)

 DRO field office or suboffice 687 (31)

 Other federal government building 259 (12)

 Service processing center 111 (5)

 Contract detention facility 90 (4)

 Staging facility 23 (1)

 Other 143 (6)

Location of primary workplace

 South region† 615 (30)

 West region‡ 573 (28)

 Northeast region§ 505 (25)

 Midwest region¶ 338 (17)

Job title

 SA, other investigations employee 810 (37)

 IEA 383 (17)

 Administrative employee 368 (17)

 DO 210 (10)

 DRO supervisor 179 (8)

 Investigations supervisor 138 (6)

 Attorney 59 (3)

 Intelligence officer, specialist, supervisor, director 29 (1)

 Other 35 (2)

*Samples sizes ranged 2,031–2,213 due to missing values.

†South region includes District of Columbia, Virginia, North Carolina, South Carolina, Georgia, Florida, 

Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Texas, Oklahoma, New Mexico, and Puerto Rico.

‡West region includes Colorado, Wyoming, Montana, Idaho, Utah, Nevada, Washington, Oregon, California, 

Arizona, Hawaii, Alaska, and Guam.

§Northeast region includes Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New 

York, New Jersey, Pennsylvania, West Virginia, Maryland, and Delaware.

¶Midwest region includes Michigan, Ohio, Wisconsin, Illinois, Indiana, Kentucky, Missouri, Nebraska, Minnesota, 

Iowa, North Dakota, South Dakota, and Kansas.
Health Hazard Evaluation Report 2009-0184-3126 Page 13

Results

 (continued) Most (97%) of the 1,943 respondents who underwent fit testing and 

reported whether or not they were successfully fitted for a respirator 

reported they were successfully fitted. The most common reasons cited 

for not being successfully fitted were “I could not get a tight seal of the 

respirator on my face,” “the correct size respirator for my face was not 

available,” “I have facial hair,” and “I could not smell/taste the test 

aerosol used for fit testing.”

Most (75%) of the 2,161 respondents who answered all questions 

related to the respirator fit-testing process reported completing all 

steps of the process (i.e., medical clearance, respirator training, and 

fit testing) and were successfully fitted for a respirator. Of the 2,161 

respondents, 30 (1%) completed all steps but were not successfully 

fitted for a respirator. A total of 189 (9%) respondents reported 

completing none of the three steps of the respirator fit testing 

process while 313 (14%) respondents reported not completing one 

or two steps of the process.

Respirator Access and Usage

A total of 1,968 (89%) respondents reported having access to an 

N95 filtering facepiece respirator at their current workplace, with 

96% of DRO respondents and 89% of OI respondents reporting 

access. Of those who reported having face-to-face contact with 

immigrants, 92% reported having access to an N95 respirator.

Regarding respirator usage, 235 (11%) respondents reported 

ever wearing an N95 filtering facepiece respirator, and 25 (1%) 

respondents reported wearing another type of respirator (type 

unspecified) at their current workplace in the previous year. Of 

those respondents who reported wearing an N95 filtering facepiece 

respirator, 79 (34%) reported wearing it for contact with someone 

with tuberculosis, while 144 (61%) reported wearing it for contact 

with someone with pH1N1or other influenza-like illness. Other 

reasons not listed in the survey but written in by respondents 

included for precautionary use (n = 8) and contact with narcotics 

(n = 7). Of those respondents who reported wearing another type 

of respirator, 5 (20%) reported wearing it for contact with someone 

with tuberculosis, while 2 (8%) reported wearing it for contact with 

someone with pH1N1 or other influenza-like illness. Other reasons 

not listed in the survey but written in by respondents included for 

training (n = 5) and hazardous material exposure (n = 6).
Page 14 Health Hazard Evaluation Report 2009-0184-3126

Results

 (continued)

Table 2. Respiratory protection characteristics of survey respondents

Practice

Number Total 

Respondents (%)

Number DRO 

Respondents (%)

Number OI 

Respondents (%)

Underwent medical clearance to 

wear respirator

1,878 of 2,211 (85) 883 of 994 (89) 948 of 1,075 (88)

Cleared to wear respirator* 1,802 of 1,839 (98) 855 of 867 (99) 905 of 926 (98)

Had respirator training 1,852 of 2,209 (84) 898 of 993 (90) 912 of 1,074 (85)

Underwent respirator fit testing 1,955 of 2,216 (88) 949 of 996 (95) 964 of 1,077 (90)

Successfully fitted† 1,885 of 1,943 (97) 925 of 945 (98) 925 0f 957 (97)

*The denominators include those respondents who underwent medical clearance. 

†The denominators include those respondents who underwent respirator fit testing.

When broken down by agency program, 176 (18%) of 994 DRO 

respondents reported ever wearing an N95 filtering facepiece 

respirator, and 14 (1%) of 991 DRO respondents reported wearing 

another type of respirator at their current workplace in the 

previous year. Fifty-five (5%) of 1,078 OI respondents reported 

wearing an N95 filtering facepiece respirator, and 11 (1%) of 1,076 

OI respondents reported ever wearing another type of respirator 

at their current workplace in the previous year. Job titles with the 

highest percentages of respondents reporting ever wearing an N95 

respirator in the previous year were IEA (26%), DO (16%), and 

DRO supervisor (16%).

Of the 235 respondents who reported ever wearing an N95 

filtering facepiece respirator at their current workplace in the 

previous year, 214 (91%) had undergone respirator training during 

the previous year. In addition, 225 (96%) reported undergoing 

respirator fit testing in the previous year. Of the 223 respondents 

who reported ever wearing an N95 respirator and undergoing a 

respirator fit test in the previous year and reported whether or not 

it was successful, 218 (98%) reported having a successful fit test.

Most (69%) respondents expressed agreement that their workplace 

does its best to have respirators available when they are needed, 

and most (62%) respondents expressed agreement that the 

appropriate respirator is always available for them when they need 

it. A smaller percentage of respondents (46%) expressed agreement 

that their workplace has clear written procedures for the use of 

respirators.
Health Hazard Evaluation Report 2009-0184-3126 Page 15

Infectious Diseases Exposures and Infection 

Control Practices

Most (59%) respondents expressed agreement that their workplace 

does its best to protect workers from exposure to respiratory 

infections. Although most (62%) respondents expressed agreement 

that they were at risk of catching influenza, tuberculosis, or other 

respiratory infection due to their job, fewer (33%) respondents 

expressed agreement that they frequently worry about catching 

influenza, tuberculosis, or other respiratory infection due to their 

job.

The numbers of respondents who reported having face-to-face 

contact with persons with known infections in the previous year 

were 403 (18%) for tuberculosis, 28 (1%) for measles, and 96 (4%) 

for chicken pox. The number of respondents who reported having 

face-to-face contact with persons with known pH1N1 between 

April 2009 and survey administration was 376 (17%). Of the 403 

respondents who reported having face-to-face contact with persons 

with known tuberculosis, 68 (17%) of them reported wearing an 

N95 respirator during contact.

Regarding tuberculosis screening practices, 466 (21%) respondents 

reported having had a tuberculosis skin test or PPD test in the 

previous year. The most common places where respondents 

received their last tuberculosis skin test were an FOH clinic (50%) 

and a personal physician’s office (27%). Twenty (4%) respondents 

reported receiving their last tuberculosis skin test at their 

workplace. The most common reasons cited by respondents who 

did not have a tuberculosis skin test in the previous year for not 

having one were, “I did not think I needed a tuberculosis skin test” 

(48%), “I have not been told that I need to get tested” (46%), “I 

have not felt sick” (21%), and “I do not know where to get tested” 

(12%). (Respondents could cite more than one reason.) Six percent 

of respondents reported previously testing positive or having a 

history of latent or active tuberculosis.

A total of 273 (28%) DRO respondents and 178 (16%) OI 

respondents reported having had a tuberculosis skin test in the 

previous year. Of the total respondents who reported having 

face-to-face contact with immigrants, 378 (23%) reported having 

had a tuberculosis skin test in the previous year. Job titles with 

the highest percentage of respondents reporting having had a 

tuberculosis skin test in the previous year were IEA (38%), DRO 

Results

 (continued)
Page 16 Health Hazard Evaluation Report 2009-0184-3126

Results

 (continued) supervisor (26%), administrative personnel (18%), special agent or 

other OI employee (18%), and DO (17%). Of the 35 respondents 

from the “other” category for job title, 34% reported having had a 

tuberculosis skin test in the previous year.

A total of 997 (45%) respondents reported having received the 

seasonal influenza vaccine between October 1, 2008, and March 

31, 2009. The most common places where respondents received 

this seasonal influenza vaccine were at an FOH clinic (37%), at 

their personal physician’s office (34%), and at a pharmacy or 

store (8%). Fifty-four (5%) respondents reported receiving their 

seasonal influenza vaccine at their workplace. The most common 

reasons cited by the 1,215 respondents who did not have a seasonal 

influenza vaccine during the above period were “I didn’t think 

I needed the flu vaccine” (42%), “I did not think the influenza 

vaccine would keep me from getting the flu” (23%), “other” reason 

(15%), “It was inconvenient for me to get vaccinated” (11%), “The 

influenza vaccine causes the flu or makes me sick” (10%), and “the 

influenza vaccine is not safe (8%). (Respondents could cite more 

than one reason.) “Other” reasons included “I did not want it” and 

“I never get it.”

Designated Safety Officer

Of the 111 designated safety officers throughout the agency, 70 

completed the survey for a response rate of 63%. They represented 

3% of the total survey respondents. Of these 70 safety officers, 

33 (47%) were from OI, 32 (46%) were from DRO, 4 (6%) were 

from the Office of Intelligence, and 1 (1%) was from the Office of 

the Principal Legal Advisor. Of the 69 respondents who answered 

the subsequent questions, 30 (43%) reported having a written 

respiratory protection program at their workplace, 17 (25%) 

reported not having one, and 22 (32%) reported not knowing. 

Sixteen (50%) DRO safety officers and 18 (56%) OI safety officers 

reported either not having a written respiratory protection program 

or not knowing they had one. Excluding those respondents who 

worked in “other” workplaces not listed in the survey, the two most 

common workplaces of the safety officers that reported either not 

having a written respiratory protection program or not knowing 

whether they had one were SAC or RAC office (n = 13) and DRO 

field office or suboffice (n = 12). These two workplaces are the 

most common workplaces in the agency.
Health Hazard Evaluation Report 2009-0184-3126 Page 17

Most of the 30 responding safety officers who reported having a 

written respiratory protection program reported that their written 

program addressed all of the areas listed in the OSHA Respiratory 

Protection standard [29 CFR 1910.134]. Between 90% and 97% of 

responding safety officers reported that their workplace’s written 

respiratory protection program addressed most of the individual 

areas listed in the standard. However, fewer reported that their 

workplace’s program addressed medical evaluations of employees 

for respirator use (83%); cleaning, disinfecting, storing, inspecting, 

repairing, and discarding respirators (73%); and evaluating the 

effectiveness of the program (70%).

Of the 69 designated safety officers, 23 (33%) reported they 

were the respiratory protection program administrator at their 

workplace. Nine of these 23 safety officers reported overseeing 

these programs without having received specific respirator training. 

Of the 13 who did receive training, the most common sources 

of training reported were on-the-job training (n = 6), a multi-day 

respirator use training course (n = 5), and a one-day respirator use 

training course (n = 3).

Seven (10%) of the 69 designated safety officers reported they 

were involved in the selection of respirators for employees at their 

workplace. Of 69 safety officers, 68 reported that some type of 

mask or respiratory protection was available at their workplace. 

These safety officers reported availability of surgical masks (29%), 

dust masks (26%), N95 filtering respirators (96%), and full 

facepiece elastomeric air purifying respirators (3%). Half-mask 

elastomeric air purifying respirators and PAPRs were not reported 

to be available at their workplace. One safety officer answered 

“I don’t know” to the question about what type of respiratory 

protection was available at his or her workplace.

Fit Testers

A total of 245 (11%) of 2,160 respondents reported having been 

trained to become a respirator fit tester, 150 in the previous year and 

95 more than 1 year earlier. The agency reported that 319 employees 

were trained as fit testers during the fit-testing campaign of 2009, 

giving a response rate of 47% among fit testers. The median number 

of employees fit tested by the 119 responding fit testers from May 

2009 to survey administration was 20 employees (range: 0–400 

employees).

Results

 (continued)
Page 18 Health Hazard Evaluation Report 2009-0184-3126

Results

 (continued) Twenty-three fit testers who trained in the previous year and 91 

fit testers who trained more than 1 year earlier did not answer the 

subsequent question of who trained them. Of the 131 fit testers 

who did answer subsequent questions, most (74%) reported being 

trained by another agency employee, while 24 (18%) reported being 

trained by FPS HazMat Technicians fit testers.

In addition, between 94 and106 fit testers did not answer 

subsequent questions regarding their comfort level with their 

expertise. Of those who did answer these questions, 109 (72%) 

expressed agreement that they feel comfortable conducting a 

qualitative respirator fit test on an employee, 105 (72%) expressed 

agreement that they feel comfortable giving instructions to fit-test 

subjects during the fit-testing session, and 79 (54%) expressed 

agreement that they feel comfortable answering technical 

questions about respirator effectiveness. Ninety-seven (70%) fit 

testers expressed agreement that the fit tests that they conduct 

are accurate, while 87 (62%) fit testers expressed agreement that 

the training session they attended adequately prepared them to 

conduct fit tests.

While the response rate to our survey was suboptimal, our results 

yield useful information regarding employee exposures to airborne 

infectious agents and respiratory protection at the agency. Most 

(75%) employees who responded to the survey, particularly 

those from DRO and OI, reported having face-to-face contact 

with immigrants in their current job, which places them at risk 

for exposure to airborne infectious agents. Almost two thirds 

of respondents believe they are at risk of acquiring a respiratory 

infection due to their job, and almost one third responded that 

they frequently worry about this risk. In addition, the percentages 

of respondents who reported having face-to-face contact with 

persons with known infections were 18% for tuberculosis in 

the previous year and 17% for pH1N1 between April 2009 and 

the survey administration. This level of contact indicates that 

a comprehensive program to protect employees from airborne 

infectious diseases hazards is appropriate. The respirator fit-testing 

process appears to be comprehensive, as most (75%) responding 

employees completed all of the required steps of the respirator 

fit-testing process and were successfully fitted. However, some gaps 

existed particularly in the areas of medical clearance and respirator 

Discussion
Health Hazard Evaluation Report 2009-0184-3126 Page 19

Discussion

 (continued) training. Our findings suggest that verifying documentation of 

medical clearance did not always occur prior to fit testing. In 

addition, our findings indicate that the training that was supposed 

to have been included in the fit-testing session occasionally either did 

not occur or was suboptimal. 

The rate of medical clearance to wear a respirator for those 

undergoing evaluation was high at 98%. The online respirator 

medical evaluation questionnaire administered through FOH 

is comprehensive and contains all of the questions found in the 

OSHA Respirator Medical Evaluation Questionnaire, Appendix C, 

to the OSHA Respiratory Protection standard [29 CFR 1910.134]. 

This questionnaire is used for medical evaluation and to identify 

persons who require additional examination. A study of Department 

of Energy workers found that a similar medical evaluation 

questionnaire demonstrated a sensitivity of 100% for the detection 

of workers requiring work restrictions [Pappas et al. 1999]. This study 

supports the use of a self-administered questionnaire for medical 

clearance in certain settings such as a large federal agency. 

The rate of a successful fit test for those undergoing fit testing was 

high at 97%. The most common reasons cited by respondents for 

not being successfully fitted for a respirator were “I could not get a 

tight seal of the respirator on my face” and “the correct size respirator 

for my face was not available.” These reasons suggest that a larger 

selection of N95 respirators than the three 3M models might need 

to be available. The next most common reason cited by respondents 

for not being successfully fitted was “I have facial hair.” This finding, 

coupled with our observation that some employees with facial hair 

between the face and the respirator sealing surface were being fit 

tested, suggests that fit testers need to improve compliance with the 

OSHA Respiratory Protection standard [29 CFR 1910.134] and deny 

a fit test to those employees with facial hair. 

The agency’s tuberculosis exposure control plan states that “all 

employees with potential exposure to detainees or others with active 

tuberculosis will be provided N95 facemasks or HEPA respirators. 

Employees must wear the facemasks in high hazard settings where 

administrative and engineering controls are not likely to provide 

adequate protection. High hazard settings include close contact with 

a suspected active case of tuberculosis and entering a tuberculosis 

isolation room when it is occupied by an individual with a known or 

suspected active case of tuberculosis.” 
Page 20 Health Hazard Evaluation Report 2009-0184-3126

The term “facemask” should be replaced with “respirator” in 

this plan to prevent confusion with surgical face masks, which 

are not appropriate protection from exposure to tuberculosis. 

Furthermore, the term “HEPA respirator” is an outdated term and 

should also be avoided. Instead, the level of protection and the 

level of filtration should be noted (e.g., PAPR with high-efficiency 

filters).

Though most respondents reported having access to N95 filtering 

facepiece respirators, respirator usage by respondents for contact 

with persons with known tuberculosis was low at 17%. This 

indicates that employee training should emphasize the indications 

for respirator use, which include close contact with persons with 

active tuberculosis.

We found low compliance with tuberculosis screening agencywide. 

The agency’s tuberculosis exposure control plan states that all 

employees “who are at risk for exposure to tuberculosis” are 

included in the tuberculosis surveillance and screening program. 

Clarification on how a determination of an employee’s risk for 

exposure to tuberculosis is made is necessary. The plan requires 

baseline PPD testing during all preplacement examinations. The 

employee can provide written documentation of the results of 

a test performed within 6 months of the date of preplacement 

testing. The plan states that “baseline testing will be followed, 

at least annually, by PPD testing and risk assessment.” However, 

almost half of responding employees were not aware of the 

recommendation that they undergo at least annual tuberculosis 

screening.

Use of respirators or facemasks was not recommended by CDC 

for workers in nonhealthcare occupational settings for general 

work activities during the pH1N1 pandemic [CDC 2009]. CDC’s 

“Prevention Strategies for Seasonal Influenza in Healthcare 

Settings” currently recommends use of facemasks (not N95 

respirators) by workers for most forms of contact with persons 

with confirmed or suspected influenza in healthcare settings 

[CDC 2010b]. In addition, CDC’s “Interim Guidance for the Use 

of Masks to Control Influenza Transmission” does not currently 

recommend the use of facemasks or respirators for individuals in 

community settings who are not ill [CDC 2010a].

Less than half of the responding safety officers reported having a 

written respiratory protection program at their workplace, despite 

Discussion

 (continued)
Health Hazard Evaluation Report 2009-0184-3126 Page 21

Discussion

 (continued) the availability of an agencywide written program. It is possible that 

a written respiratory protection program may actually have been 

in existence at their workplace and the safety officer may not have 

known this. Nevertheless, safety officers should be knowledgeable 

about this program. These results are comparable to a survey 

conducted by the Bureau of Labor Statistics, U.S. Department of 

Labor, which found that only 35% of private industry workplaces 

that required respirator use had established a written respiratory 

protection program adopted by management [BLS and NIOSH 

2003].

Most responding safety officers reported having a written 

respiratory protection program and reported it had all of the 

required components of the OSHA Respiratory Protection 

standard [29 CFR 1910.134]. Only one third of safety officers 

reported they were the respiratory protection program 

administrator at their workplace, and fewer reported they were 

involved in the selection of appropriate respirators for employees at 

their workplace. These findings demonstrate that the role of safety 

officers in the respiratory protection program should be clarified 

and strengthened.

Most (72%) fit testers felt comfortable conducting a qualitative 

respirator fit test and giving instructions to fit-test subjects during the 

fit-testing session. Nevertheless, we observed that improvements can 

be made when giving instructions on proper donning of the respirator 

and conducting a seal check. Also, fewer (62%) fit testers thought 

that the training session adequately prepared them to conduct fit 

testing and fewer (54%) felt comfortable answering technical questions 

about respirators. These findings are consistent with our observation 

that some fit testers did not appear to have a solid understanding 

of the filtering efficiency of respirators during the fit-testing session. 

Though the slide presentation that served as training for fit testers 

given by FPS was thorough, more details on filtering efficiency and the 

technical capabilities of respirators could be added.

Our evaluation was subject to some limitations. We observed 

only 1 day of fit testing; thus, these observations may not be 

representative of all fit-testing sessions and all fit testers across the 

agency. Also, while we reviewed the slide presentation that served 

as training for fit testers, we did not observe an actual training 

session. The response rate to our survey was 11% despite two e-mail 

reminders from employer and union representatives. We believe 

several factors may have contributed to the low response rate. First, 
Page 22 Health Hazard Evaluation Report 2009-0184-3126

at the Office of the Chief Information Officers’ directive, we did 

not have direct contact with all employees and rather relied on this 

office to disseminate the invitation and survey for us. Employees 

may have been uncomfortable responding to a survey sent out 

by management despite being told it was confidential. Second, 

although we intended to invite all agency employees to participate 

in the survey, the e-mail invitation specifically encouraged 

participation among employees who had participated in the recent 

respirator fit-testing program. Third, though employees were 

instructed not to reply to the e-mail from the agency’s broadcast 

and to send their completed surveys to our dedicated e-mail 

address, it is possible we did not receive all completed surveys due 

to incorrect return. Fourth, the agency disseminated our survey on 

January 14, 2010, 2 days after the earthquake in Haiti. Employees 

from many agency programs were involved in this response. 

Finally, we were unable to verify the number of employees who 

actually received this e-mail, so our response rate may be an 

underestimation.

The response rate to our survey is lower than those seen in other 

electronic surveys (mean response rates between 19% and 40%), 

but lower rates are seen in larger surveys, workplace surveys, and 

surveys not offering incentives [Jones and Pitt 1999; Cook et al. 

2000; Sheehan 2001; Manfreda and Vehovar 2002; Kaplowitz 

et al. 2004; Shih and Fan 2008]. Nevertheless, our relatively 

low response rate raises the possibility that our results are not 

representative of all agency employees, especially employees from 

the management and leadership offices. An additional limitation 

of this evaluation was that the survey administration period was 

in January and February 2010. Because the respirator fit-testing 

campaign ended in September 2009, this may have limited 

respondents’ ability to recall certain information about the process 

and may have affected our results.

Discussion

 (continued)
Health Hazard Evaluation Report 2009-0184-3126 Page 23

Most responding agency employees, particularly those from DRO 

and OI, reported having face-to-face contact with immigrants in 

their current job, which places them at risk for potential exposure 

to airborne infectious agents. The quality of the observed respirator 

fit-testing procedures was good, and most responding employees 

completed all of the required steps of the respirator fit testing 

process. However, some gaps with respect to medical clearance and 

respirator training existed. We also found that written respiratory 

protection programs were lacking in some workplaces and that 

employee compliance with respirator usage and that annual 

tuberculosis screening was low.

Conclusions

Recommendations

A comprehensive infection control program, with attention to 

airborne infectious agents, is necessary at agency workplaces 

where employees have the potential for contact with immigrants. 

The program should include all of the following: education of 

employees, hand hygiene, respiratory hygiene and cough etiquette, 

procedures for the screening and management of immigrants 

with fever and respiratory symptoms, exclusion of ill employees 

from work, influenza vaccination, annual tuberculosis screening 

of employees, and a written respiratory protection program for 

employees. Although respirator use was the focus of our evaluation, 

use of respirators and other PPE ranks lowest in the hierarchy 

of controls and is a last line of defense for employees against 

hazards that cannot otherwise be eliminated or controlled. Careful 

attention to elimination of potential exposures, engineering 

controls, and administrative controls will reduce the need to rely 

on PPE, including respirators.

On the basis of our findings, we recommend the actions listed 

below to create a more healthful workplace. We encourage the 

agency to use a labor-management health and safety committee 

or working group to discuss the recommendations in this report 

and develop an action plan. Those involved in the work can best 

set priorities and assess the feasibility of our recommendations for 

the specific situation at the agency. While these recommendations 

focus on the areas covered in our evaluation, we note that they 

only address some of the elements necessary for a comprehensive 

infection control program.
Page 24 Health Hazard Evaluation Report 2009-0184-3126

Recommendations for Management

1. Develop and maintain a written respiratory protection program 

for all agency workplaces to protect employees against airborne 

infectious agents and other respiratory hazards. Clearly define 

which employees are covered under the respiratory protection 

program and which employees should wear respirators and the 

circumstances under which respirators should be worn. Include 

all areas listed in the OSHA Respiratory Protection standard [29 

CFR 1910.134] in the program, especially cleaning, disinfecting, 

storing, inspecting, repairing, and discarding respirators; and 

evaluating the effectiveness of the program.

2. Clarify the roles and responsibilities of the designated local 

safety officers within the respiratory protection program.

3. Offer a larger selection of N95 filtering facepiece respirators 

during the fit-testing campaign to correctly fit employees. For 

example, elastomeric respirators may an appropriate alternative 

to N95 filtering facepiece respirators. Also, loose-fitting PAPRs 

may be considered for employees with facial hair.

4. When respirator use is required, continue to require and 

arrange medical clearance as defined in the OSHA Respiratory 

Protection standard [29 CFR 1910.134] prior to fit testing. 

A written recommendation of whether or not the employee 

is medically able to use the respirator and any limitations on 

respirator use should be provided to the appropriate supervisors 

and the program administrator. It also might be helpful for 

agencywide records to be kept in a central location. Confidential 

medical information should not be shared with employee 

supervisors, the program administrator, or management.

5. Require and arrange annual respirator training as defined in 

the OSHA Respiratory Protection standard [29 CFR 1910.134]. 

Improve training to include specific indications for respirator 

use especially when employees come into contact with persons 

with active tuberculosis. Consider offering a training session 

separate from the fit-testing procedures.

Recommendations

 (continued)
Health Hazard Evaluation Report 2009-0184-3126 Page 25

6. Require and arrange fit testing annually, or when a different 

respirator facepiece (size, style, model, or make) is used, or when 

a change in an employee’s physical condition occurs that could 

affect respirator fit [29 CFR 1910.134]. Schedule additional 

sessions to accommodate employees who are unable to attend 

scheduled dates and times because of leave or job assignments.

7. Provide a mirror during fit-testing procedures to assist the subject 

in evaluating the fit and positioning of the respirator [29 CFR 

1910.134].

8. Develop and maintain clear written procedures for the use of 

respirators. Inform employees of these procedures. Define when 

voluntary use of respirators is permitted. Follow the OSHA 

Respiratory Protection standard [29 CFR 1910.134] regarding 

voluntary use including providing Appendix D of the OSHA 

respiratory protection standard [29 CFR 1910.134] to employees.

9. Conduct annual evaluations of the workplace to ensure that the 

written respiratory protection program is properly implemented, 

and consult employees to ensure that they are using the 

respirators properly [29 CFR 1910.134].

10. Improve training provided to fit testers to include information 

regarding filtering efficiency and the technical capabilities of 

respirators.

11. Define which employees are at risk for exposure to tuberculosis. 

Inform these employees that routine tuberculosis screening is 

recommended and that this screening should occur at least 

annually. Make employees aware that FOH offers tuberculosis 

screening at no cost to the employee.

12. Recommend the influenza vaccine to all employees annually. 

Make employees aware that FOH offers influenza vaccination at 

no cost to the employee. Explore the feasibility of offering the 

influenza vaccination to employees at the workplace.

Recommendations

 (continued)
Page 26 Health Hazard Evaluation Report 2009-0184-3126

Recommendations for Fit Testers

1. Verify medical clearance of subjects prior to performing a fit test.

2. Deny a fit test to those subjects with facial hair that comes 

between the sealing surface of the respirator and the face [29 

CFR 1910.134].

3. During the fit test, include specific instructions on proper 

donning and doffing of the respirator, following manufacturer 

instructions. If the test subject is not familiar with using a 

particular respirator, direct the test subject to don the mask 

several times and to adjust the straps each time to become adept 

at setting proper tension on the strap [29 CFR 1910.134].

4. Instruct fit test subjects on the appropriate way to perform a face 

seal check and ensure that these instructions conform to those 

of the respirator manufacturer.

Recommendations for Employees

1. Get fit tested if you are required to wear a respirator.

2. Follow workplace guidelines on use of respirators including the 

corresponding guidelines on facial hair.

3. Review manufacturer instructions for donning and doffing a 

respirator.

4. Perform a face seal check prior to each use of a respirator.

5. Report any change in medical status that may affect your ability 

to safely wear respiratory protection to your supervisor.

6. Undergo annual screening for tuberculosis.

7. Get the seasonal influenza vaccine every year.

Recommendations

 (continued)
Health Hazard Evaluation Report 2009-0184-3126 Page 27

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Beck-Sagué C, Dooley SW, Hutton MD, Otten J, Breeden A, 

Crawford JT, Pitchenik AE, Woodley C, Cauthen G, Jarvis WR 

[1992]. Hospital outbreak of multidrug-resistant Mycobacterium 

tuberculosis infections. Factors in transmission to staff and HIVinfected patients. JAMA 268(10):1280–1286.

Blachere FM, Lindsley WG, Pearce TA, Anderson SE, Fisher 

M, Khakoo R, Meade BJ, Lander O, Davis S, Thewlis RE, Celik 

I, Chen BT, Beezhold DH [2009]. Measurement of airborne 

influenza virus in a hospital emergency department. Clin Infect 

Dis 48(15):438–440.

Bloch AB, Orenstein WA, Ewing WM, Spain WH, Mallison GF, 

Herrmann KL, Hinman AR [1985]. Measles outbreak in a pediatric 

practice: airborne transmission in an office setting. Pediatrics 

75(4):676–83.

BLS, NIOSH [2003]. Respirator usage in private sector firms, 

2001. U.S. Department of Labor, Bureau of Labor Statistics/U.S. 

Department of Health and Human Services, Centers for Disease 

Control and Prevention, National Institute for Occupational Safety 

and Health. [http://www.cdc.gov/niosh/docs/respsurv/]. Date 

accessed: March 2011.

Bridges CB, Kuehnert MJ, Hall CB [2003]. Transmission of 

influenza: implications for control in health care settings. Clin 

Infect Dis 37(8):1094–1101.

CDC [2005]. Guidelines for preventing the transmission of 

Mycobacterium tuberculosis in health-care settings, 2005. MMWR 

Recomm Rep 54(17):1–141.

CDC [2006]. Prevention and control of tuberculosis in correctional 

and detention facilities: recommendations from CDC. MMWR 

55(RR-9):1–48.
Page 28 Health Hazard Evaluation Report 2009-0184-3126

CDC [2009]. Interim recommendations for facemask and 

respirator use to reduce 2009 influenza A (H1N1) virus 

transmission. [http://www.cdc.gov/h1n1flu/masks.htm]. Date 

accessed: March 2011.

CDC [2010a]. Interim guidance for the use of masks to control 

influenza transmission. [http://www.cdc.gov/flu/professionals/

infectioncontrol/maskguidance.htm]. Date accessed: March 2011.

CDC [2010b]. Prevention strategies for seasonal influenza in 

healthcare settings. [http://www.cdc.gov/flu/professionals/

infectioncontrol/healthcaresettings.htm]. Date accessed: March 

2011.

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response rates in Web- or Internet-based surveys. Educ Psychol 

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JB, Celik IB, Chen BT, Beezhold DH [2010a]. Distribution of 

airborne influenza virus and respiratory syncytial virus in an urgent 

care medical clinic. Clin Infect Dis 50(5):693–698.

References

 (continued)
Health Hazard Evaluation Report 2009-0184-3126 Page 29

Lindsley WG, Blachere FM, Thewlis RE, Vishnu A, Davis KA, 

Cao G, Palmer JE, Clark KE, Fisher MA, Khakoo R, Beezhold 

DH [2010b]. Measurements of airborne influenza virus in aerosol 

particles from human coughs. PLoS One 5(11):e15100.

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influencing response rates in Web surveys. University of 

Copenhagen, Denmark: The International Conference on 

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References

 (continued)
Page 30 Health Hazard Evaluation Report 2009-0184-3126

Appendix A: Airborne Infectious Agents 

Tuberculosis

Tuberculosis, a disease caused by the bacteria Mycobacterium tuberculosis, is spread from person to person 

through the air. Tuberculosis usually infects the lungs, but it can also infect other body parts such as the 

brain, kidneys, or spine. The symptoms of active tuberculosis disease in any body part include feeling 

sick or weak, weight loss, fever, and night sweats. The symptoms of tuberculosis disease of the lungs also 

include coughing, chest pain, and coughing up blood.

Tuberculosis bacteria are released into the air when a person with tuberculosis disease of the lungs or 

throat coughs, sneezes, or speaks. These bacteria can stay in the air for several hours, depending on the 

environment. Persons who breathe in the air containing these tuberculosis bacteria can become infected; 

this is called latent tuberculosis infection.

Persons with latent tuberculosis infection have tuberculosis bacteria in their bodies, but they are not ill 

because the bacteria are not active. These persons do not have symptoms of tuberculosis disease, and they 

cannot spread the germs to others. They may develop tuberculosis disease in the future but can be treated 

to prevent this from happening. Persons with tuberculosis disease are sick from active tuberculosis bacteria 

that are multiplying and destroying tissue in their body. They usually have symptoms of tuberculosis 

disease and are capable of spreading tuberculosis bacteria to others.

It is estimated that one third of the world’s population has latent tuberculosis infection, and approximately 

5%–10% of those infected will develop active tuberculosis disease within their lifetimes [Styblo 1980; 

Dye et al. 1999; Jasmer et al. 2002; Stewart et al. 2003]. More than 37 million foreign-born persons are 

currently living in the United States [DHS 2008]. Many of the undocumented immigrants processed by 

the federal immigration and customs agency annually come from countries with a high prevalence of 

tuberculosis.

In 2009, foreign-born persons accounted for 60% of all tuberculosis cases in the United States [CDC 

2010a]. The tuberculosis case rate for foreign-born persons is more than 10 times as high as the case rate 

for U.S.-born persons (18.6 vs. 1.7 cases per 100,000 persons) [CDC 2010a]. In 2009, four countries 

accounted for more than half of the tuberculosis cases in foreign-born persons: Mexico, the Philippines, 

India, and Vietnam [CDC 2010a]. Among all foreign-born populations, tuberculosis rates are highest in 

the first 2 years after U.S. entry (75 vs. 16 cases per 100,000 persons) [Cain et al. 2008]. It has been shown 

that undocumented foreign-born persons had a longer duration of symptoms before medical evaluation 

for tuberculosis when compared to U.S.-born persons and documented foreign-born persons [Achkar 

et al. 2008]. The tuberculosis case rate among people in the custody of the federal immigrations and 

customs agency was found to be 12.5 per 100,000 persons in 2005, with patients from Mexico, Honduras, 

Guatemala, and El Salvador accounting for 84.4% of the cases [Schneider and Lobato 2007].

It has been shown that 20%–30% of tuberculosis patient case contacts will be found to have latent 

tuberculosis infection and that approximately 5% of individuals with recently acquired latent tuberculosis 

infection will develop active tuberculosis disease within 2 years [Iseman 2000; CDC 2005a]. These data, in 
Health Hazard Evaluation Report 2009-0184-3126 Page 31

conjunction with the higher rates demonstrated among foreign-born persons, suggest that individuals who 

come into contact with these recent entrants, including immigration officers and agents, are at risk for 

acquiring tuberculosis.

In 1996, OSHA issued revised enforcement guidelines concerning occupational tuberculosis exposure 

[OSHA 1996]. The workplaces covered in those guidelines are those where the CDC has identified 

workers as having an elevated incidence of tuberculosis infection. These include healthcare settings, 

correctional institutions, homeless shelters, drug treatment centers, and long-term care facilities for 

the elderly. At these facilities, the OSHA guidelines require a protocol for the early identification 

of individuals with active tuberculosis; skin-test surveillance for employees; medical evaluation and 

management of employees with positive skin tests or symptoms of active tuberculosis; placement of 

individuals with confirmed or suspected tuberculosis in isolation rooms; performing high risk procedures 

in areas with negative pressure and appropriate exhausts; and training and information for employees 

about tuberculosis transmission, signs and symptoms of disease, medical surveillance and follow-up 

therapy, and proper use of controls [OSHA 1996].

The OSHA guidelines are based on the 1994 CDC guidelines for preventing tuberculosis transmission in 

healthcare facilities, which were subsequently updated in 2005 [CDC 2005b]. This document discusses, in 

detail, the importance of administrative and engineering controls, PPE, early identification and screening, 

risk assessment, a written tuberculosis control program, skin testing programs, and employee education. 

The 2006 CDC guidelines for preventing tuberculosis transmission in correctional and detention facilities 

also recommend a comprehensive program consisting of administrative, environmental, and personal 

respiratory protection controls [CDC 2006].

Environmental controls should be implemented when the risk for tuberculosis transmission persists 

despite efforts to screen and treat inmates/detainees. Environmental controls are used to remove or 

inactivate Mycobacterium tuberculosis in areas in which the organism could be transmitted. Additional 

information on the types of environmental controls used in correctional and detention facilities 

can be found in the 2006 CDC guidelines [CDC 2006]. This document provides ventilation design 

considerations and air exhaust/cleaning methods for airborne infection isolation rooms and local and 

general exhaust ventilation systems in areas intended to contain persons with diagnosed or undiagnosed 

infectious tuberculosis. Individuals known or suspected of having tuberculosis disease should be placed 

in an airborne infection isolation room or cell [CDC 2005b; CDC 2006]. Facilities without an on-site 

airborne infection isolation room should have a written plan for referring detainees with suspected or 

confirmed tuberculosis to a facility that is equipped to isolate, evaluate, and treat tuberculosis patients 

[CDC 2006].

One important administrative component of tuberculosis control in correctional and detention facilities 

involves routinely screening employees and inmates/detainees for latent tuberculosis infection, using the 

TST or an interferon-gamma release assay, and administering isoniazid treatment to those individuals 

testing positive. Two-step TST testing is necessary for those employees who have not undergone a TST in 

more than a year to account for the boosting effect [ATS and CDC 2000, ATS et al. 2000]. The agency 

Appendix A: Airborne Infectious Agents (continued)
Page 32 Health Hazard Evaluation Report 2009-0184-3126

tuberculosis exposure control plan states that TST testing should be conducted at least annually on 

employees “at risk of exposure to tuberculosis.” Upon admission to the agency’s custody, detainees are 

expected to be screened for tuberculosis disease in accordance with agency detention standards. Suspected 

tuberculosis patients are further evaluated and started or continued on treatment for tuberculosis disease 

if medically indicated.

Respiratory protection is used when administrative and environmental controls alone have not reduced 

the risk for infection with Mycobacterium tuberculosis to an acceptable level. For example, protection is 

warranted for inmates and facility staff when they enter airborne infection isolation rooms or transport 

infectious inmates. Respirators should be selected from those approved by CDC/NIOSH under the 

provisions outlined in 60 Fed. Reg. 30355 (1995) [CFR, 2010]. Decisions regarding which respirator is 

appropriate for a particular situation and setting should be made on the basis of a risk assessment of the 

likelihood for tuberculosis transmission. For correctional and detention facilities, a NIOSH-approved N95 

air-purifying respirator will provide adequate respiratory protection in most situations that require the use 

of respirators [CDC 2006].

Influenza

Influenza, commonly known as the flu, is a contagious respiratory illness caused by influenza viruses. 

Influenza viruses are thought to be spread mainly by droplets made when people with influenza cough, sneeze, 

or talk. Less often, a person might also get influenza by touching a surface or object that has influenza virus 

on it and then touching their own mouth, eyes, or nose [Wright and Webster 2001]. Evidence for airborne 

transmission of influenza also exists [Bridges et al. 2003; Blachere et al. 2009; Lindsley et al. 2010a,b].

Influenza can cause mild to severe illness and at times can lead to death. Symptoms of influenza include fever, 

chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, and fatigue, vomiting, and 

diarrhea [Nicholson 1992]. Complications of influenza include bacterial pneumonia, ear infections, sinus 

infections, dehydration, and worsening of chronic medical conditions [CDC 2010c]. Individuals at higher risk 

for developing influenza-related complications include children younger than 5 years old (especially children 

younger than 2 years old), adults 65 years of age and older, pregnant women, and people with chronic medical 

conditions (including asthma, chronic lung disease, neurological conditions, heart disease, blood, endocrine, 

kidney, liver, and metabolic disorders, weakened immune system due to HIV, cancer, or medication, morbid 

obesity) [CDC 2010c]. An annual average of approximately 36,000 deaths and 226,000 hospitalizations has 

been associated with influenza epidemics [Thompson et al. 2003; Thompson et al. 2004].

The 2009 pandemic influenza A (H1N1) (pH1N1) virus, also referred to as “swine flu,” was first detected in 

humans in the United States in April 2009. On June 11, 2009, the World Health Organization signaled that a 

pandemic of pH1N1 was underway. CDC estimated that, between April 2009 and April 2010, 43–89 million 

cases of pH1N1, 195,000–403,000 pH1N1-related hospitalizations, and 8,870–18,300 pH1N1-related deaths 

occurred [CDC 2010e].

Appendix A: Airborne Infectious Agents (continued)
Health Hazard Evaluation Report 2009-0184-3126 Page 33

Spread of the pH1N1 virus is thought to occur in the same way that seasonal influenza spreads [CDC 

2009a]. The symptoms of pH1N1 infection include fever, cough, sore throat, runny or stuffy nose, body 

aches, headache, chills, and fatigue. Some patients have vomiting and diarrhea, while some patients have 

respiratory symptoms without a fever. Illness with the pH1N1 virus has ranged from mild to severe. While 

most people who have been sick have recovered without needing medical treatment, hospitalizations and 

deaths from infection with this virus have occurred. Many people who have been hospitalized with this 

pH1N1 virus have had one or more medical conditions previously recognized as placing people at “high 

risk” of serious seasonal influenza-related complications, including pregnancy, diabetes, heart disease, 

asthma, and kidney disease [CDC 2009a]. In contrast to seasonal influenza, nearly 90% of deaths occurred 

among people younger than 65 years of age [CDC 2010c].

A comprehensive influenza infection control program should include all of the following: education of 

employees, influenza vaccination, hand hygiene, respiratory hygiene and cough etiquette, procedures 

for the screening and management of detainees with fever and respiratory symptoms, and the exclusion 

of ill employees. Use of N95 respirators or facemasks was not recommended by CDC for workers in 

nonhealthcare occupational settings for general work activities during the pH1N1 pandemic [CDC 2009c]. 

CDC’s “Prevention Strategies for Seasonal Influenza in Healthcare Settings” currently recommends use 

of facemasks (not N95 respirators) by workers for most forms of contact with persons with confirmed or 

suspected influenza in healthcare settings [CDC 2010d]. In addition, CDC’s “Interim Guidance for the 

Use of Masks to Control Influenza Transmission” does not currently recommend the use of face masks or 

respirators for individuals in community settings who are not ill [CDC 2010b].

Measles

Measles is a highly transmissible infectious disease caused by the rubeola virus. It causes fever, cough, 

runny nose, and a maculopapular (red, bumpy) rash. Transmission primarily occurs from person to person 

via large respiratory droplets. However, airborne transmission via aerosolized droplet nuclei has been 

documented in closed areas for up to 2 hours after a person with measles occupied the area [Bloch et al. 

1985]. Measles is highly communicable and may be transmitted from 4 days before to 4 days after rash 

onset.

Measles is still a common and often fatal disease in developing countries. The World Health Organization 

estimated that there were more than 20 million cases and 242,000 deaths from measles in 2006 [CDC 

2009b]. The disease is less common in the United States since the first measles vaccine was licensed for 

use in 1963. Most measles cases in the United States now are imported from other countries or linked to 

imported cases. Most imported cases originate in Asia and Europe and occur among U.S. citizens traveling 

abroad and persons visiting the United States from other countries [CDC 2009b]. Measles vaccination 

remains the best method of prevention. The MMR vaccine for measles, mumps, and rubella is indicated 

for all children 12 months of age and older and susceptible adolescents and adults without documented 

evidence of immunity [CDC 2009b].

Appendix A: Airborne Infectious Agents (continued)
Page 34 Health Hazard Evaluation Report 2009-0184-3126

Chicken Pox

Varicella or chicken pox is an acute infectious disease caused by the varicella zoster virus. It is characterized 

by fever, malaise, and a generalized, itchy, blistering then crusting rash. Recovery from primary varicella 

infection usually results in lifetime immunity. Transmission occurs from person to person from infected 

respiratory tract secretions, inhalation of airborne droplets, or by direct contact or inhalation of aerosols 

from skin lesions [CDC 2009b]. Varicella is highly contagious. It can be transmitted 1 to 2 days before 

rash onset through the first 4 to 5 days or until lesions have formed crusts [CDC 2009b].

In the prevaccine era, varicella was endemic in the United States, and virtually all persons acquired 

varicella by adulthood. Since the varicella vaccine was first licensed for use in the United States in March 

1995, the number of cases has significantly decreased [Seward et al. 2002].

In correctional and detention facilities, inmates with varicella should be isolated from other inmates and 

susceptible personnel until lesions crust. Inmates with varicella or disseminated herpes zoster should be 

transferred to a community hospital, if medically indicated. Otherwise, they should be housed either in 

the institution’s airborne infection isolation room or in a single cell with a door that closes restricted. All 

staff or inmates entering the cell of an inmate with contagious chickenpox or disseminated herpes zoster 

should wear at least an N95 filtering facepiece respirator or higher. They should wear gloves when any 

direct contact with the inmate is anticipated [BOP 2009].

References

Achkar JM, Sherpa T, Cohen HW, Holzman RS [2008]. Differences in clinical presentation among 

persons with pulmonary tuberculosis: a comparison of documented and undocumented foreign-born 

versus U.S.-born persons. Clin Infect Dis 47(10):1277–1283.

ATS (American Thoracic Society), CDC [2000]. Targeted tuberculin testing and treatment of latent 

tuberculosis infection. Am J Respir Crit Care Med 161(4):S221–247.

ATS, CDC, IDSA (Infectious Diseases Society of America) [2000]. Diagnostic standards and classification 

of tuberculosis in adults and children. Am J Respir Crit Care Med 161(4):1376–1395.

Blachere FM, Lindsley WG, Pearce TA, Anderson SE, Fisher M, Khakoo R, Meade BJ, Lander O, Davis 

S, Thewlis RE, Celik I, Chen BT, Beezhold DH [2009]. Measurement of airborne influenza virus in a 

hospital emergency department. Clin Infect Dis 48(15):438–440.

Bloch AB, Orenstein WA, Ewing WM, Spain WH, Mallison GF, Herrmann KL, Hinman AR [1985]. 

Measles outbreak in a pediatric practice: airborne transmission in an office setting. Pediatrics 75(4):676–

683.

Appendix A: Airborne Infectious Agents (continued)
Health Hazard Evaluation Report 2009-0184-3126 Page 35

Bridges CB, Kuehnert MJ, Hall CB [2003]. Transmission of influenza: implications for control in health 

care settings. Clin Infect Dis 37(8):1094–1101.

Federal Bureau of Prisons (BOP) [2009]. Management of varicella zoster virus infections. Federal Bureau of 

Prisons Clinical Practice Guideline – January 2009. [http://www.bop.gov/news/PDFs/varicella.pdf]. Date 

accessed: March 2011.

Cain KP, Benoit SR, Winston CA, MacKenzie WR [2008]. Tuberculosis among foreign-born persons in 

the United States. JAMA 300(4):405–412.

CDC [2005a]. Guidelines for the investigation of contacts of persons with infectious tuberculosis: 

recommendations from the National Tuberculosis Controllers Association and CDC. MMWR 54(RR15):1–47.

CDC [2005b]. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care 

settings. MMWR 54(RR-17): 1–147.

CDC [2006]. Prevention and control of tuberculosis in correctional and detention facilities: 

recommendations from CDC. MMWR 55(RR-9):1–48.

CDC [2009a]. 2009 H1N1 flu (“Swine Flu”) and you. [http://www.cdc.gov/H1N1flu/qa.htm]. Date 

accessed: March 2011.

CDC [2009b]. Epidemiology and prevention of vaccine-preventable diseases. Atkinson W, Wolfe S, 

Hamborsky J, McIntyre L, eds. 11th ed. Washington DC: Public Health Foundation.

CDC [2009c]. Interim recommendations for facemask and respirator use to reduce 2009 influenza A 

(H1N1) virus transmission. [http://www.cdc.gov/h1n1flu/masks.htm]. Date accessed: March 2011.

CDC [2010a]. Decrease in reported tuberculosis cases – United States, 2009. MMWR 59(RR-10):289–294.

CDC [2010b]. Interim guidance for the use of masks to control influenza transmission. [http://www.cdc.

gov/flu/professionals/infectioncontrol/maskguidance.htm]. Date accessed: March 2011.

CDC [2010c]. Key facts about influenza (flu) & flu vaccine. [http://www.cdc.gov/flu/keyfacts.htm]. Date 

accessed: March 2011.

CDC [2010d]. Prevention strategies for seasonal influenza in healthcare settings. [http://www.cdc.gov/flu/

professionals/infectioncontrol/healthcaresettings.htm]. Date accessed: March 2011.

Appendix A: Airborne Infectious Agents (continued)
Page 36 Health Hazard Evaluation Report 2009-0184-3126

CDC [2010e]. Updated CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the 

United States, April 2009 – April 10, 2010 [http://www.cdc.gov/h1n1flu/estimates_2009_h1n1.htm]. 

Date accessed: March 2011.

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Federal Register.

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Jasmer RM, Nahid P, Hopwell PC [2002]. Clinical practice. Latent tuberculosis infection. N Engl J Med 

347(23):1860–1866.

Lindsley WG, Blachere FM, Davis KA, Pearce TA, Fisher MA, Khakoo R, Davis SM, Rogers ME, Thewlis 

RE, Posada JA, Redrow JB, Celik IB, Chen BT, Beezhold DH [2010a]. Distribution of airborne influenza 

virus and respiratory syncytial virus in an urgent care medical clinic. Clin Infect Dis 50(5):693–698.

Lindsley WG, Blachere FM, Thewlis RE, Vishnu A, Davis KA, Cao G, Palmer JE, Clark KE, Fisher MA, 

Khakoo R, Beezhold DH [2010b]. Measurements of airborne influenza virus in aerosol particles from 

human coughs. PLoS One 5(11):e15100.

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Health Hazard Evaluation Report 2009-0184-3126 Page 37

Styblo K [1980]. Recent advances in epidemiological research in tuberculosis. Adv Tuberc Res 20:1–63.

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Appendix A: Airborne Infectious Agents (continued)
Page 38 Health Hazard Evaluation Report 2009-0184-3126

Appendix B: Respirators

An estimated 5 million workers are required to wear respirators at least some of the time while performing their 

job in 1.3 million workplaces throughout the United States [OSHA 2010]. A respirator is a personal protective 

device that is worn on the face, covers at least the nose and mouth, and is designed to protect the wearer from 

the inhalation of hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. 

Respirators should only be used as a “last line of defense” in the hierarchy of controls when engineering 

and administrative controls are not feasible or are being put in place. The overall effectiveness of respiratory 

protection is affected by (1) the level of respiratory protection selected (i.e., the assigned protection factor), 

(2) the fitting characteristics of the respirator model, (3) the care taken in donning the respirator, and (4) the 

effectiveness of the respiratory protection program, including fit testing and worker training.

Respirators are categorized into two principal types: air-purifying and air-supplied. Air-purifying respirators 

remove contaminants from the ambient air. Respirators of this type include particulate respirators, which filter 

out airborne particles and “gas masks,” which filter out chemicals and gases. The classification of particulate 

respirators can be further subdivided into particulate filtering facepiece respirators, elastomeric respirators, and 

PAPRs.

Particulate filtering facepiece respirators are sometimes referred to as disposable respirators because the entire 

respirator is discarded when it becomes unsuitable for further use because of considerations of hygiene, excessive 

resistance, or physical damage (Figure B1). Ten classes of NIOSH-approved particulate filtering respirators are 

available at this time. The minimal level of filtration approved by NIOSH is 95%. The N, R, and P designations 

refer to the filter’s oil resistance as described in Table B1.

Elastomeric respirators are sometimes referred to as reusable respirators because the facepiece is cleaned 

and reused, but the filter cartridges are discarded and replaced when they become unsuitable for further 

use. An example of a half-mask elastomeric respirator can be seen in Figure B2.

Table B1. NIOSH-approved particulate filtering facepiece respirators and their filtering efficiencies

Filter Class Description

N95, N99, N100 Filters at least 95%, 99%, 99.97% of airborne 

particles. Not resistant to oil.

R95, R99, R100 Filters at least 95%, 99%, 99.97% of airborne 

particles. Somewhat resistant to oil.

P95, P99, P100 Filters at least 95%, 99%, 99.97% of airborne 

particles. Strongly resistant to oil.

HE (High Efficiency Particulate Air) Filters at least 99.97% of airborne particles. For use 

on PAPRs only. PAPRs use only HE filters.
Health Hazard Evaluation Report 2009-0184-3126 Page 39

Figure B1. A preformed filtering facepiece 

respirator in which the facepiece is comprised 

of the filter material.

Figure B2. A half-mask elastomeric respirator 

comprised of a molded facepiece to which 

replaceable filtering cartridges are attached.

Appendix B: Respirators (continued)

Figure B3. Various types of PAPRs. A 

loose-fitting PAPR is shown on the left. 

Two examples of tight-fitting PAPRs are 

shown in the middle and on the right.

Figure B4. An SCBA containing the 

respirator and air supply.

PAPRs have a battery-powered blower that moves the air flow through the filters. PAPRs can either be 

tight-fitting or loose-fitting. Tight-fitting facepieces form a seal with the wearer’s face and must be fit tested 

to be sure that there is no leakage into the face mask. Loose-fitting facepieces cover all or part of the head 

without sealing directly onto the face. Examples of tight-fitting and loose-fitting PAPRs can be seen in 

Figure B3.

Air-supplied respirators provide air from a source other than the surrounding atmosphere. Air-supplied 

respirators are classified according to the method by which air is supplied and the way in which the 

air supply is regulated. These methods include SCBA, which include their own air supply, and airline 

respirators, which use compressed air from a remote source. A photograph of an SCBA is shown in Figure 

B4. Air-supplied respirators generally offer a higher level of protection than air-purifying respirators. 

Typically, workers exposed to high levels of contaminants, oxygen deficient or flammable atmospheres, or 

emergency conditions, are assigned to wear these respirators [Szeinuk et al. 2000].
Page 40 Health Hazard Evaluation Report 2009-0184-3126

NIOSH is responsible for classifying and certifying respirators for general and specific uses [NIOSH 1991]. 

NIOSH approval includes respirator components such as facepiece, strap, harnesses, filters, chemical 

cartridges, regulators, air hoses, and connectors. All respirators used to protect workers must be NIOSHapproved or otherwise accepted by OSHA. All NIOSH-approved respirators have an approval number. 

With few exceptions, the NIOSH approval number is not on the respirator itself, but on a separate 

NIOSH approval label that is found on or within the packaging. An example of this type of NIOSH label 

is shown in Figure B5. Figure B6 shows typical markings on approved filtering facepiece respirators. The 

markings shown in red are present on all NIOSH-approved filtering facepiece respirators, although they 

may appear either on the face, on the exhalation valve (if one exists) or on the head straps. The markings 

shown in black may or may not be on the respirator at all. The model or part number marked on the 

respirator will also appear on the approval label.

Figure B5. Example of the NIOSH respirator approval label.
Health Hazard Evaluation Report 2009-0184-3126 Page 41

Appendix B: Respirators (continued)

Figure B6. Example of typical markings on approved filtering facepiece respirators.

References

NIOSH [1991]. NIOSH Certified Equipment List. U.S. Department of Health Human Services, Centers 

for Disease Control and Prevention, National Institute for Occupational Safety and Health (Cincinnati, 

Ohio). Washington, DC: US Government Printing Office; 91–105.

OSHA [2010]. Respiratory Protection. [http://www.osha.gov/SLTC/respiratoryprotection/index.html]. 

Date accessed: March 2011.

Szeinuk J, Beckett WS, Clark N, Hailoo WL [2000]. Medical evaluations for respirator use. Am J Ind Med 

37(1):142–157.
Page 42 Health Hazard Evaluation Report 2009-0184-3126

Acknowledgments and

 Availability of Report

The Hazard Evaluations and Technical Assistance Branch (HETAB) 

of the National Institute for Occupational Safety and Health 

(NIOSH) conducts field investigations of possible health hazards 

in the workplace. These investigations are conducted under the 

authority of Section 20(a)(6) of the Occupational Safety and Health 

Act of 1970, 29 U.S.C. 669(a)(6) which authorizes the Secretary of 

Health and Human Services, following a written request from any 

employer or authorized representative of employees, to determine 

whether any substance normally found in the place of employment 

has potentially toxic effects in such concentrations as used or found. 

HETAB also provides, upon request, technical and consultative 

assistance to federal, state, and local agencies; labor; industry; and 

other groups or individuals to control occupational health hazards 

and to prevent related trauma and disease.

The findings and conclusions in this report are those of the authors 

and do not necessarily represent the views of NIOSH. Mention 

of any company or product does not constitute endorsement by 

NIOSH. In addition, citations to websites external to NIOSH 

do not constitute NIOSH endorsement of the sponsoring 

organizations or their programs or products. Furthermore, NIOSH 

is not responsible for the content of these websites. All Web 

addresses referenced in this document were accessible as of the 

publication date.

This report was prepared by Marie A. de Perio, R. Todd Niemeier, 

Bradley S. King, and Charles A. Mueller of HETAB, Division of 

Surveillance, Hazard Evaluations and Field Studies. Information 

technology support was provided by Scott Mason. Data 

management support was provided by Faith Armstrong. Health 

communication assistance was provided by Stefanie Evans. Editorial 

assistance was provided by Ellen Galloway. Desktop publishing was 

performed by Greg W. Hartle.

Copies of this report have been sent to employee and management 

representatives at the federal immigration and customs agency 

and the Occupational Safety and Health Administration National 

Office. This report is not copyrighted and may be freely reproduced. 

The report may be viewed and printed at http://www.cdc.gov/

niosh/hhe/. Copies may be purchased from the National Technical 

Information Service at 5825 Port Royal Road, Springfield, Virginia 

22161.
Health Hazard Evaluation Report 2009-0184-3126 Page 43
Below is a recommended citation for this report:

NIOSH 2011. Health hazard evaluation report: evaluation of respiratory protection 

practices for employees at federal immigration and customs agency workplaces – 

nationwide. By de Perio MA, Niemeier RT, King BS, Mueller CA. Cincinnati, OH: 

U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, NIOSH HETA

No. 2009-0184-3126.

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occupational safety and health topics, contact NIOSH at:

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or visit the NIOSH web site at: www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to 

NIOSH eNews by visiting www.cdc.gov/niosh/eNews.

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