Prevalence of Respiratory Protective Devices in U.S. Healthcare Systems

Lindsay Stradtman, MPH, CPH

ASPPH/CDC Public Health Fellow

January 7, 2014

Disclaimers: This report was supported by Cooperative Agreement Number U36/CCU300430 from the

Centers for Disease Control and Prevention and the Association of Schools and Programs of Public 

Health. The findings and conclusions of this report do not necessarily represent the official views

of CDC or ASPPH. Mention of product names does not imply endorsement. 
2

Introduction

Several emerging infectious disease outbreaks in the past decade, including Severe Acute 

Respiratory Syndrome (SARS) in 2003 and Influenza A (H1N1) in 2009, have highlighted the need for 

an increased focus on influenza pandemic planning (1). Planning efforts have accelerated, especially for

those most at risk during a pandemic, such as healthcare workers (HCWs). According to the 

Occupational Safety and Health Administration (OSHA), HCWs are at very high or high exposure risk 

during an influenza pandemic (2). Recent findings suggest that HCWs not only have an increased risk of 

influenza but were among the most burdened during the H1N1 pandemic (3, 4). Engineering controls are 

the preferred method for protecting HCWs but may not be adequate or even possible during a pandemic 

(5-7). In addition, certain administrative controls, such as vaccination, may not be attainable in the 

beginning of the pandemic, as it usually takes 4-6 months to develop a vaccine targeting a novel type of 

influenza (5). Therefore, personal protective equipment (PPE), especially respiratory protective devices 

(RPDs), will likely serve as an important source of worker protection during a pandemic.

Due to the expected importance of RPD use among HCWs during a pandemic, the U.S. 

Department of Health and Human Services (HHS) recommends that healthcare facilities stockpile a 6-8 

week supply of disposable N95 filtering facepiece respirators (N95 FFRs) (8). However, it has been 

widely documented that this recommendation has been a challenge for many healthcare facilities. Noted 

barriers to stockpiling N95 FFRs include: lack of storage space, limited use within normal working 

parameters, possible expiration issues, and working against the typical “just-in-time” procurement and 

manufacturing model, which only allows for a limited number of on-hand supplies (9-12). This is 

problematic due to the sheer number of RPDs that will be needed during a pandemic (13). According to 

the Centers for Disease Control and Prevention (CDC), an estimated 90 million N95 FFRs would be 

needed to protect healthcare workers during a 42-day pandemic (14). The rapid increase in RPD usage

was even apparent during the 2009 H1N1 pandemic. For example, several hospitals in Vancouver, 

Canada experienced a 107% increase in N95 FFR use during the pandemic (15). PPE usage may also 

increase beyond pandemic recommendations due to HCW concerns about disease transmission (16).

Many HCWs also reported that N95 FFRs were not readily available at their healthcare facility during 

the H1N1 pandemic for various reasons, including inability of suppliers and manufacturers to meet 

demand (9, 17, 18). It should also be noted that there were also shortages of N95 FFR fit testing 

equipment (12, 19).
3

Regardless of the lessons learned during the H1N1 pandemic, healthcare facilities are still not

prepared for the next pandemic. The Center for Biosecurity of UPMC conducted a 2-year assessment of 

HHS’ Hospital Preparedness Program. It was concluded that the U.S. healthcare system is not prepared 

for a catastrophic health event, which is defined as, “any natural or manmade incident...that results in a 

number of ill or injured persons sufficient to overwhelm the capabilities of immediate local and regional 

emergency response and health care systems” (20). This lack of preparedness also applies to RPDs; for 

example, Rebmann et al. found that 50.7% of hospitals do not currently have a stockpile of N95 FFRs 

(21). These findings are worrisome considering recent reports suggest that HCWs would be less willing 

to work during a pandemic if adequate PPE was not available, including RPDs (7, 22-24). Furthermore, 

the lack of RPD stockpiles at healthcare facilities emphasizes the importance of the RPDs included in

the Strategic National Stockpile (SNS).

Strategic National Stockpile

The SNS is, “...the Federal cache of pharmaceuticals, vaccines, medical supplies, equipment, 

and other items established to augment local supplies of critical medical countermeasures that may be 

needed for a public health emergency or disaster” (25). The SNS is overseen by the HHS Public Health 

Emergency Medical Countermeasures Enterprise (PHEMCE), with the CDC managing medical 

countermeasure (MCM) procurement and maintenance, including RPDs (25). In April 2009, the U.S. 

Government concluded that the H1N1outbreak was a public health emergency. As a protective measure, 

the SNS deployed 25% of influenza control supplies, including 39 million RPDs (i.e. N95 FFRs and 

masks). In October 2009, an additional 59.5 million N95 FFRs were deployed from the SNS (26).

Overall, 75% of the SNS’ N95 FFRs were deployed during the pandemic (27).

As RPDs from the SNS were distributed to healthcare facilities, several notable issues occurred.

In many cases, the N95 FFRs received from the SNS did not match healthcare facilities’ current stock of 

models. Thus, there was a need to fit test HCWs for these new devices as well as conduct training, 

which was a time-consuming process (27-29). Another issue that occurred was that many of the SNS’ 

N95 FFRs were certified by the National Institute for Occupational Safety and Health (NIOSH) but not 

cleared by the U.S. Food and Drug Administration (FDA) (27). This had legal ramifications that will be 

further discussed. Because the SNS’ supply of N95 FFRs was drastically reduced during the H1N1 

pandemic, as well as the issues that occurred during the deployment of RPDs, the PHEMCE has tasked 

CDC with completing an assessment. More specifically, in FY14, CDC will assess the quantity and 
4

composition of the SNS’ RPDs, and determine if RPD stockpiling should even continue (30). During 

this assessment process, it has become apparent that there is a need for data on the types of RPDs 

currently being used in healthcare settings. An important factor in this assessment is the prevalence of 

NIOSH-certified and FDA-cleared RPDs in healthcare settings.

NIOSH-Certified and FDA-Cleared RPDs

In terms of RPDs, NIOSH’s responsibility is to certify a device’s level of respiratory protection, 

not its ability to prevent disease. In order for an RPD to be marketed as a device that prevents disease, it 

must be cleared and regulated by the FDA (31). FDA-cleared respirators, also known as Surgical N95s, 

must be NIOSH-approved and meet certain fluid and flammability protection standards (5, 6). However, 

Surgical N95s are not required to meet any specific standards in regards to the prevention of disease. 

Many of the current FDA requirements for Surgical N95s relate to their intended use during surgical 

procedures (6). Furthermore, FDA regulations are primarily aimed at manufacturers and how medical 

devices are sold. For instance, manufacturers are not permitted to market their product for a use that has 

not been approved by the FDA. Once a medical device is cleared, the FDA cannot regulate the ways in 

which it is used (32). Employers and employees using medical devices such as Surgical N95s, however, 

must follow OSHA regulations (6).

During a pandemic, OSHA recommends that healthcare facilities provide HCWs with NIOSHcertified respirators that are rated N95 or higher. However, OSHA also recommends that HCWs use 

Surgical N95s if respiratory and fluid protection are needed (5). As aforementioned, healthcare facilities

struggled to maintain an adequate supply of RPDs during the H1N1 pandemic (9, 17, 18). Both NIOSHapproved N95 FFRs and FDA-cleared Surgical N95s were in short supply. Additionally, many of the 

RPDs deployed from the SNS were not FDA-cleared. In order for the deployed NIOSH-approved N95 

FFRs to be used by HCWs for disease prevention purposes, the FDA issued an Emergency Use 

Authorization (EUA). During the H1N1 pandemic, EUAs were issued for 15 non-FDA cleared, NIOSHapproved N95 FFRs (6, 27, 29, 33). The Federal Food, Drug, and Cosmetic Act, which was amended by 

the Project BioShield Act of 2004, sanctions the use of EUAs, which allows for increased access to 

available MCMs during public health emergencies (25, 34). The FDA commissioner can sanction EUAs 

for either unapproved medical devices or unapproved uses of FDA-approved medical devices (34). It 

should be noted that, “An EUA is an authorization for certain uses of MCMs during specified 

emergencies and is not a form of product approval” (35). In June 2010, the EUA for N95 FFRs was 
5

terminated; thus returning to regulations that state non-FDA cleared RPDs cannot be used for the 

prevention of infectious diseases (33).

The issue of using FDA-cleared vs. non-FDA cleared RPDs in healthcare facilities has received

increased attention among industry officials. HCWs have voiced concern over the need for FDA-cleared 

RPDs in healthcare settings, bearing in mind the shortages faced during the H1N1 pandemic (36). 

Officials at the Institute of Medicine have also suggested that the fluid and flammability requirements 

for FDA-cleared RPDs are not necessary in most situations in order to protect HCWs from infectious 

diseases, such as influenza (6). In addition to disposable FFRs, other types of RPDs are being used in 

healthcare settings, such as powered air purifying respirators (PAPRs) and elastomeric half-facepiece

respirators (EHFRs). PAPRs and EHFRs are typically used by HCWs with facial hair and those that 

have problems fit testing with disposable FFRs (6, 10). Currently, only disposable FFRs are FDAcleared; accordingly, there are no FDA-cleared PAPRs or EHFRs. Moreover, there is very little data 

regarding the prevalence of FDA-cleared vs. non-FDA cleared RPDs in healthcare settings. To our 

knowledge, there has only been one study that has examined this issue. In 2011, infection control 

professionals and safety/employee health administrators were surveyed to determine if FDA-cleared 

Surgical N95s were used at their facilities. Twenty-four percent of infection control professionals and 

38% of safety/employee health administrators reported that their facilities were using at least one 

Surgical N95. More importantly, approximately 50% of each group did not know or were not sure if 

FDA-cleared RPDs were used in their facilities (36). There is also no available data on specific FDAcleared and non-FDA cleared RPD models used in healthcare settings. This data is imperative because it 

has implications for replenishment of the SNS as well as the need for EUAs during the next pandemic.

Needs & Goals

Thus, there is a need for the following in order to enhance influenza pandemic preparedness:

 Data on the prevalence of FDA-cleared Surgical N95s in healthcare settings, including 

specific models and the number of HCWs using these devices.

 Data on the prevalence of non-FDA cleared RPDs (i.e. EHFRs, PAPRs, and N95 FFRs) in 

healthcare settings, including specific models and the number of HCWs using these devices.
6

The goals of this report are to:

 Assess the prevalence of FDA-cleared and non-FDA cleared RPDs, including specific 

models, in healthcare settings.

 Provide data for working groups that are making recommendations and/or decisions 

involving RPD supplies and usage during an influenza pandemic.

Disposable N95 FFRs

A 2012 analysis of the North American RPD market indicates that disposable respirators account 

for 26.4% of the overall market. It should be noted that this analysis provides an overview of the entire 

RPD market and does not account for healthcare settings. Overall demand for disposable respirators has 

become stagnant, with 3M, Moldex, and Honeywell as the top manufacturers for these devices (37).

According to NIOSH, there are currently 69 different models of FDA-cleared Surgical N95 respirators 

being produced by approximately 23 manufacturers (38, 39). As aforementioned, there has only been 

one study to our knowledge that has assessed the prevalence of FDA-cleared RPDs in healthcare 

settings. Study findings suggest that many involved with healthcare respiratory protection programs do 

not know the prevalence of FDA-cleared RPDs in their facilities (36). 

In terms of non-FDA cleared, NIOSH-approved N95 FFRs, there are currently 314 different 

models being produced by approximately 36 manufacturers (38-40). Available data from the 

Association of State and Territorial Health Officials (ASTHO) suggests that state governments might be 

also be collecting data on the types of N95 FFRs used in healthcare settings. A 2010 ASTHO report 

indicated that at least one state health department had surveyed healthcare facilities to determine 

preferred types of N95 FFRs. Based on survey findings, the state health department then stockpiled 

preferred N95 FFR models for emergency purposes. The report does not indicate which types of N95 

FFRs were stockpiled; thus, it could not be determined whether the devices were FDA-cleared (12).

PAPRs

As aforementioned, PAPRs are a viable choice for HCWs that have facial hair, cannot be fit 

tested or wear a disposable FFR or EHFR (6). PAPRs may become an important option for respiratory 

protection during an influenza pandemic because they do not require fit testing. HCWs that normally do 

not need respiratory protection may need an RPD during a pandemic; and fit testing may not feasible 
7

(6). PAPRs also provide increased protection and are perceived by some individuals to be more 

comfortable than disposable FFRs (37, 41). PAPRs account for 10.9% of the overall RPD market in 

North America. There has been major growth in the market for loose-fitting head protection, including 

PAPRs. Moreover, the PAPR segment accounts for some of the highest revenue growth in the market.

The top PAPR manufacturers are: 3M, MSA, Bullard, Honeywell, and Scott Safety (37). There are 

currently 235 types of NIOSH-approved PAPRs, including those protecting against gases and vapors,

being produced by 18 manufacturers (39, 42).

In October 2013, the National Personal Protective Technology Laboratory (NPPTL) conducted a 

review of the various PAPR systems sold by top medical supply distributors. An initial list of top 

medical supply distributors was created based on several sources: NPPTL staff with expertise in 

healthcare, a 2012 Gartner report on the top 25 healthcare companies based on supply chain capabilities 

(43), and a contact at the Healthcare Industry Distributors Association. Fourteen distributors were 

identified based on the aforementioned information. Distributors were included if the needed 

information was readily available on the company’s website, or if the information was provided by a 

customer service representative. Accordingly, 11 distributors were included on the final list1. The review 

determined that 7 distributors were selling the following 8 PAPR systems as well as related items (i.e. 

replacement hoods and battery packs):

 3MTM Air-MateTM

 3MTM PowerflowTM Face-Mounted PAPR

 3MTM VersafloTM

 BullardTM EVATM

 BullardTM PA20TM (Discontinued)2

 BullardTM PA30TM (Discontinued)

 North® by Honeywell PAPR System, Universal, Li-Ion

 North® Compact AirTM PAPR

 

1

The 11 distributors reviewed were: Buffalo Hospital Supply, Cardinal Health, Henry Schein, McKesson, Medline, MMS 

Medical, Owens & Minor, Physicians Sales & Service, Puerto Rico Hospital Supply Inc., Seneca Medical, and Twin Med 

Medical.

2 According to Bullard’s website, the PA20TM and the PA30TM are discontinued.
8

EHFRs

Similarly to PAPRs, EHFRs can be used by HCWs that have trouble fit testing with disposable 

FFRs (10). EHFRs are also similar to N95 FFRs in that they provide approximately the same level of

protection (41). Non-disposables, which include EHFRs, account for 25% of the North American RPD 

market, and have some of the greatest revenue growth. In 2011, 307,000 EHFRs were sold in North 

America; and by 2016, that number is expected to increase to nearly 346,000. The top non-disposable 

manufacturers are: 3M, MSA, Honeywell, and Scott Safety (37). There are currently 2,000 types of 

EHFRs, including those protecting against gases and vapors, being produced by 10 manufacturers (39, 

42). The previously mentioned NPPTL review of top medical supply distributors determined that 6 

distributors were selling the following 14 types of EHFRs and related supplies:

 3MTM 6000 series half facepiece 

 3MTM 6500 Rugged Comfort series half facepiece

 3MTM 6500 Rugged Comfort series half facepiece with quick latch

 3MTM 7500 series half facepiece

 3MTM half facepiece reusable respirator drop down

 3MTM half facepiece reusable respirator assembly, P100 

 Aearo UnistarTM quarter-mask reusable respirator

 AO Safety® AO 5Star® air-purifying/airline respirator

 AO Safety® Flexi-Star® air-purifying half mask respirator

 Moldex 8000 series

 MSA Advantage® 200 LS half-mask respirator

 North® 5500 series

 North® 7700 series silicone respirator with half mask

 North Safety CFR-ITM Comfort Fit

It should also be noted that some of the aforementioned distributors also sell full-mask non-disposables. 

EHFRs have gained some popularity in healthcare settings as evidenced by the Veterans Health 

Administration’s (VHA) recent order for 65,000 EHFRs – the Honeywell Sperian® Survivair Blue 1 Hversion. Significantly, the VHA is the largest integrated healthcare system in the U.S. (44). 
9

NPPTL Study

Despite all the information gathered on the prevalence of RPDs in healthcare settings, there is no 

available data on the specific models of each type of RPD being used. NPPTL was tasked with 

conducting a survey in order to better understand the types of RPDs used in major U.S. healthcare 

systems. More specifically, the survey aimed to answer the following questions:

 Are healthcare systems using N95 FFRs, PAPRs or EHFRs?

 How many HCWs are using each of these devices?

 Which RPDs, including specific models, are most commonly used in healthcare settings?

 How many of these devices are non-FDA cleared?

Methods

An online, 10-question quantitative survey was created for pilot testing purposes. The survey 

was multiple choice and many of the answer options were informed from various sources: 

 A previous NPPTL-affiliated study regarding respiratory protection practices in healthcare 

settings (45).

 The aforementioned NPPTL review of the top medical supply distributors.

 The VHA’s recent EHFR order.

 N95 FFR models known to have been in the SNS during the H1N1 pandemic (33).

 NPPTL staff with expertise in RPD use in healthcare systems.

 Past studies that have examined RPDs (10, 46, 47).

The survey was first pilot tested for accuracy by 5 NPPTL staff members and approved by the NPPTL 

Director. Infection control and respiratory protection program administrators for top U.S. healthcare 

systems were then approached to participate in the survey. Healthcare systems were initially selected 

based on the following:

 The top 3 ranked hospital systems in each size category (e.g. small, medium, and large; based 

on total operating expenses) in the 2013 Truven Health Analytics Top 15 Health System 

study (48). 

 Six healthcare systems selected by the Joint Commission as having innovative respiratory 

protection programs.
10

 NPPTL staff contacts at highly ranked healthcare facilities.

Eighteen healthcare systems were initially approached with the aim of having 9 complete the 

survey. Acquiring correct contact information for many of the healthcare systems proved to be difficult; 

thus, only 11 healthcare systems were effectively reached and indicated willingness to participate in the 

survey. Willing participants were then e-mailed a link to the online survey, which was administered via 

Survey Monkey, and given 5 business days to complete the survey. Participants were also provided a 

worksheet to facilitate the gathering of necessary data for the survey. The worksheet was developed due 

to conversations with potential survey participants; several individuals stated that they would need to 

gather the information from different facilities in their healthcare system. 

Results

Overall, 9 healthcare systems completed the survey for a participation rate of 81.8%. Only those 

healthcare systems that indicated willingness to participate in the survey, and received a link to the 

online survey, were included in the participation rate calculation. Respondents’ respective healthcare 

systems were located in the following states: California, Colorado, Iowa, Nebraska, North Carolina, 

Oklahoma, and Virginia. The majority of respondents reported that employees in their healthcare 

systems had used N95 FFRs (88.9%) and PAPRs (77.8%) in the past year; only one respondent 

indicated that their healthcare system had used EHFRs. Of those reporting N95 FFR use, over half 

(62.5%) indicated that more than 500 employees had used this device in the last 12 months. For 

healthcare systems reporting EHFRs and PAPRs, the majority (100% and 85.7%, respectively) reported 

that approximately 100 or less employees had used these devices in the past year. The most common 

EHFR models reported were: 3MTM 6000 series (100%), 3MTM 7500 series (100%), and North® by 

Honeywell 7700 series Half Mask (100%). The most commonly reported PAPRs were: 3MTM AirMateTM (85.7%) and 3MTM Breathe EasyTM (28.6%). It should be noted that one healthcare facility 

indicated they were considering the 3MTM Versa FloTM, which would have made this particular model 

one of the most commonly reported at 28.6%. In terms of N95 FFRs, the most common models reported 

were: 3MTM 1860/1860S (75%) and 3MTM 1870 (62.5%).
11

Please list the state or states in which your healthcare system is located.

State n (%)

California 2 (22.2)

Colorado 1 (11.1)

Iowa 1 (11.1)

Nebraska 1 (11.1)

North Carolina 2 (22.2)

Oklahoma 1 (11.1)

Virginia 1 (11.1)

Have any of your employees used a _____ at least once in the past year?

Type of RPD Yes

n (%)

No

n (%)

EHFR 1 (11.1) 8 (88.9)

PAPR 7 (77.8) 2 (22.2)

N95 FFR 8 (88.9) 1 (11.1)

Approximately how many of your employees have used a _____ in the past year?

No. of Employees EHFRs

n (%)

PAPRs

n (%)

N95s

n (%)

< 10 0 (0.0) 1 (14.3) 0 (0.0)

11 – 100 1 (100) 6 (85.7) 0 (0.0)

101 – 500 0 (0.0) 0 (0.0) 3 (37.5)

> 500 0 (0.0) 0 (0.0) 5 (62.5)

What are the three most common types of elastomeric half-mask respirators used in your 

healthcare system? If not listed, please provide the name of the manufacturer and model number.

EHFR Model n (%)

3MTM 6000 series 1 (100)

3MTM 7500 series 1 (100)

Honeywell Sperian® Survivair® Blue 1 H-version 0 (0.0)

Honeywell Sperian® Survivair® Blue 1 S-series 0 (0.0)

North® by Honeywell 5500 series Half Mask 0 (0.0)

North® by Honeywell 7700 series Half Mask 1 (100)

Other (please specify) 0 (0.0)
12

What are the three most common types of PAPRs used in your healthcare system? If not listed, 

please provide the name of the manufacturer and model number.

PAPR Model n (%)

3MTM Air-MateTM 6 (85.7)

BullardTM EVATM 0 (0.0)

BullardTM PA20TM 0 (0.0)

BullardTM PA30TM 0 (0.0)

Syntech International MAXAIR 0 (0.0)

Other (please specify)

 3MTM YL71603

 3MTM Breathe EasyTM

 3MTM VersafloTM

 3MTM Breathe EasyTM

 Considering 3MTM Versa FloTM

3 (42.9)

What are the three most common types of N95s used in your healthcare system? If not listed, 

please provide the name of the manufacturer and model number.

N95 Model n (%)

3MTM 1860/1860S 6 (75.0)

3MTM 1870 5 (62.5)

3MTM 8210 0 (0.0)

3MTM 9210 1 (12.5)

Gerson® 1730 0 (0.0)

Kimberly-ClarkTM PFR95-170 (46727)/PFR95-174 (46827) 1 (12.5)

Moldex® 2200 series 1 (12.5)

Moldex® 3000 series 0 (0.0)

Other (please specify)

 3MTM VFlexTM 1805

 Kimberly-ClarkTM 62126

 Kimberly-ClarkTM 62355

 Moldex® 1500

 Safe Life® B130

 Safe Life® B150

 Tronex 500N95D

 Tronex 511N95D

4 (50.0)

 

3

3MTM YL7160 is a battery charger for 3MTM PAPR systems and is not an actual model.
13

As aforementioned, Surgical N95s are the only type of RPD that is currently FDA-cleared. 

Respondents indicated using the following 9 types of FDA-cleared surgical N95s: 

 3MTM 1860/1860S

 3MTM 1870

 3MTM VFlexTM 1805

 Kimberly-ClarkTM PFR95-170 (46727)/PFR95-174 (46827)

 Moldex® 1500

 Moldex® 2200 series

 Safe Life® B130

 Safe Life® B150

 Tronex 500N95D

As for non-FDA cleared RPDs, participants reported using the following 10 types of RPDs in their 

healthcare systems:

 EHFRs

 3MTM 6000 series

 3MTM 7500 series

 North® by Honeywell 7700 series Half Mask

 PAPRs

 3MTM Air-MateTM

 3MTM Breathe EasyTM

 3MTM Versa FloTM

 N95 FFRs

 3MTM 9210

 Kimberly-ClarkTM 62126

 Kimberly-ClarkTM 62355

 Tronex 511N95D

The 9 FDA-cleared devices account for 69.2% of the N95 FFRs used in healthcare systems included in 

our survey. Therefore, 30.8% of N95 FFRs used by respondents’ healthcare systems are not FDAcleared. Overall, 52.6% of all reported RPDs are not FDA-cleared.
14

Implications

Our findings suggest that N95 FFRs are still the most widely used RPD in healthcare settings. 

Even though a majority of N95 FFRs were FDA-cleared, other types of RPDs that are not FDA-cleared 

are becoming more prevalent in healthcare settings. For instance, nearly 80% of participants reported 

using PAPRs in their healthcare systems within the past year. Importantly, over half of RPDs used in 

healthcare systems included in our survey were non-FDA cleared devices. With many HCWs potentially 

using these devices each year, the increasing prevalence of non-FDA cleared RPDs could impact 

infection control efforts during the next pandemic. If this trend continues into the next pandemic, for 

example, it may necessitate an increase in EUAs for RPDs used in healthcare settings. Additionally, the 

increased prevalence of non-FDA cleared RPDs, especially PAPRs, could widen the discrepancies 

between the RPDs in the SNS and those used in healthcare systems.

This survey was only a pilot, and therefore, has several limitations. Because of its small sample 

size and nonprobability sampling method, the findings may not be generalizable to all U.S. healthcare 

systems. Additionally, non-response bias may be present due to several potential participants’ lack of 

response to survey invitations. Based on survey findings, as well as a review of the literature, it is 

apparent that future research regarding this issue is needed. Therefore, we recommend further 

investigation of the following:

 Because our survey was exploratory in nature, a larger study is needed in order to gather 

more accurate data on the types of RPDs currently used in U.S. healthcare systems. 

Currently, NPPTL plans to partner with the American Association of Occupational Health 

Nurses (AAOHN) in order to conduct a larger survey. NPPTL has decided to partner with 

AAOHN for the larger survey because the organization has known access to respiratory 

protection program managers at various U.S. healthcare facilities.

 Due to the discovery that state governments may be collecting data on the types of RPDs 

used in healthcare settings, we suggest further investigation into this issue. State governments 

play a key role in deployment of SNS supplies to healthcare facilities during a pandemic. 

Therefore, they have the potential to be a key resource on this issue, and may be 

knowledgeable about the types of RPDs healthcare facilities within their state are using.
15

References

1. Iskander J, Strikas RA, Gensheimer KF, Cox NJ, Redd SC. Pandemic influenza planning, United 

States, 1978-2008. Emerg Infect Dis. 2013 Jun;19(6):879-85. 

2. United States. Occupational Safety and Health Administration. Healthcare Workplaces 

Classified as Very High or High Exposure Risk for Pandemic Influenza: What to do to protect workers. 

Washington DC: U.S. Department of Labor; 2009.

3. Kuster SP, Shah PS, Coleman BL, Lam PP, Tong A, Wormsbecker A, et al. Incidence of 

influenza in healthy adults and healthcare workers: a systematic review and meta-analysis. PloS One. 

2011;6(10):e26239. 

4. Luckhaupt SE, Sweeney MH, Funk R, Calvert GM, Nowell M, D'Mello T, et al. Influenzaassociated hospitalizations by industry, 2009-10 influenza season, United States. Emerg Infect Dis. 2012 

Apr;18(4):556-62. 

5. United States. Occupational Safety and Health Administration. Pandemic Influenza Preparedness 

and Response Guidance for Healthcare Workers and Healthcare Employers. OSHA 3328-05R. 

Washington DC: U.S. Department of Labor; 2009.

6. Institute of Medicine. Preventing transmission of pandemic influenza and other viral respiratory 

diseases: Personal protective equipment for healthcare personnel.Washington DC: The National 

Academies Press; 2011.

7. Institute of Medicine. Respiratory Protection for Healthcare Workers in the Workplace Against 

Novel H1N1 Influenza A: A Letter Report. Washington DC: The National Academies Press; 2009.

8. United States. Department of Health and Human Services. HHS Pandemic Influenza Plan. 

Washington DC: Department of Health and Human Services; 2005.

9. Bunyan D, Ritchie L, Jenkins D, Coia JE. Respiratory and facial protection: a critical review of 

recent literature. J Hosp Infect. 2013 Nov;85(3):165-9. 

10. Workers’ Compensation Board of B.C. Assessment and Determination of Practical 

Considerations for Widescale Utilization of Elastometric Half-facepiece Respirators during a Pandemic 

or Outbreak Situation. British Columbia: Worker’s Compensation Board of B.C.; 2013.

11. Center for Biosecurity of UPMC. Hospitals Rising to the Challenge: The First Five Years of the 

U.S. Hospital Preparedness Program and Priorities Going Forward. Baltimore: Center for Biosecurity of 

UPMC; 2009.

12. Association of State and Territorial Health Officials. Assessing Policy Barriers to Effective 

Public Health Response in the H1N1 Influenza Pandemic. Arlington: Association of State and Territorial 

Health Officials; 2010.

13. Hashikura M, Kizu J. Stockpile of personal protective equipment in hospital settings: 

preparedness for influenza pandemics. Am J Infect Control. 2009 Nov;37(9):703-7. 

14. Institute of Medicine. Reusability of Facemasks During an Influenza Pandemic: Facing the Flu. 

Washington DC: The National Academies Press; 2006.

15. Murray M, Grant J, Bryce E, Chilton P, Forrester L. Facial protective equipment, personnel, and 

pandemics: impact of the pandemic (H1N1) 2009 virus on personnel and use of facial protective 

equipment. Infect Control Hosp Epidemiol. 2010 Oct;31(10):1011-6. 

16. Phin NF, Rylands AJ, Allan J, Edwards C, Enstone JE, Nguyen-Van-Tam JS. Personal protective 

equipment in an influenza pandemic: a UK simulation exercise. J Hosp Infect. 2009 Jan;71(1):15-21.

17. Beckman S, Materna B, Goldmacher S, Zipprich J, D'Alessandro M, Novak D, et al. Evaluation 

of respiratory protection programs and practices in California hospitals during the 2009-2010 H1N1 

influenza pandemic. Am J Infect Control. 2013 Nov;41(11):1024-31. 
16

18. Lautenbach E, Saint S, Henderson DK, Harris AD. Initial response of health care institutions to 

emergence of H1N1 influenza: experiences, obstacles, and perceived future needs. Clin Infect Dis. 2010 

Feb;50(4):523-7. 

19. Institute of Medicine. The Domestic and International Impacts of the 2009-H1N1 Influenza A 

Pandemic: Global Challenges, Global Solutions: Workshop Summary. Washington DC: The National 

Acadamies Press; 2010.

20. Center for Biosecurity of UPMC. The Next Challenge in Healthcare Preparedness: Catastrophic 

Health Events. Baltimore: Center for Biosecurity of UPMC; 2010.

21. Rebmann T, Wang J, Swick Z, Reddick D, delRosario JL, Jr. Business continuity and pandemic 

preparedness: US health care versus non-health care agencies. Am J Infect Control. 2013 Apr;41(4):e27-

33. 

22. Dezzani Martin S, Brown LM, Reid WM. Predictors of Nurses' Intentions to Work During the 

2009 Influenza A (H1N1) Pandemic. Am J Nurs. 2013 Dec;113(12):24-31.

23. Devnani M. Factors associated with the willingness of health care personnel to work during an 

influenza public health emergency: an integrative review. Prehosp Disaster Med. 2012 Dec;27(6):551-

66. 

24. Martin SD. Nurses' ability and willingness to work during pandemic flu. J Nurs Manag. 2011

Jan;19(1):98-108. 

25. United States. Department of Health and Human Services. 2012 Public Health Emergency 

Medical Countermeasures Enterprise (PHEMCE) Strategy. Washington DC: Department of Health and 

Human Services; 2012.

26. United States. Centers for Disease Control and Prevention. The 2009 H1N1 Pandemic: Summary 

Highlights, April 2009-April 2010.Atlanta: Centers for Disease Control and Prevention; 2010.

27. United States. Department of Health and Human Services. 2009 H1N1 Influenza Improvement 

Plan. Washington DC: Department of Health and Human Services; 2012.

28. United States. Department of Health and Human Services. An HHS Retrospective on the 2009 

H1N1 Influenza Pandemic to Advance All Hazards Preparedness. Washington DC: Department of 

Health and Human Services; 2012.

29. Institute of Medicine. Medical Countermeasures Dispensing: Emergency Use Authorization and 

the Postal Model: Workshop Summary. Washington DC: The National Academies Press, 2010.

30. United States. Department of Health and Human Services Services. Public Health Emergency 

Medical Countermeasures Enterprise (PHEMCE) Implementation Plan. Washington DC: Department of 

Health and Human Services; 2012.

31. United States. Food and Drug Administration. Medical Devices: FDA's Role in Regulating PPE. 

Silver Spring: Department of Health and Human Services; 2013. 

32. Courtney B, McDowell H, Sadove E. Recent Developments in FDA’s Emergency Authority for 

Medical Countermeasures. Presented for the Public Health Law Webinar Series. 2012. 

http://www.fda.gov/downloads/EmergencyPreparedness/MedicalCountermeasures/UCM296344.pdf.

33. United States. Food and Drug Administration. Summary Fact Sheet for Disposable Respirators 

for Use During the Swine Flu Emergency. Silver Spring: Department of Health and Human Services; 

2013.

34. United States. Food and Drug Administration. Regulatory Information: Emergency Use 

Authorization of Medical Products. Silver Spring: Department of Health and Human Services; 2007.

35. Courtney B, Sherman S, Penn M. Federal legal preparedness tools for facilitating medical 

countermeasure use during public health emergencies. J Law Med Ethics. 2013 Mar;41 Suppl 1:22-7. 
17

36. Figueroa M. Respiratory Protection Programs and Healthcare Professionals: Compliance, 

Knowledge, and Perceptions. PhD thesis. University of Medicine and Dentistry of New Jersey; 2013.

37. Frost & Sullivan. Strategic Analysis of the North American Respiratory Protection Market: The 

Search for a New Growth Pipeline. San Antonio: Frost & Sullivan; 2012.

38. National Personal Protective Technology Laboratory [Internet]. Pittsburgh: National Institute for 

Occupational Safety and Health; 2013 [cited 2013 Dec 18]. Available from: 

http://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource3healthcare.html#e.

39. Shaffer R. FW: SurgN95_InventoryList.xlsx [Internet]. Message to: Lindsay Stradtman. 2013 

Dec 3.

40. National Personal Protective Technology Laboratory [Internet]. Pittsburgh: National Institute for 

Occupational Safety and Health; 2013 [cited 2013 Dec 18]. Available from: 

http://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html.

41. United States. Occupational Safety and Health Administration. Assigned Protection Factors for 

the Revised Respiratory Protection Standard. OSHA 3352-02. Washington DC: U.S. Department of 

Labor; 2009.

42. National Personal Protective Technology Laboratory [Internet]. Pittsburgh: National Institute for 

Occupational Safety and Health; 2013 [cited 2013 Dec 18]. Available from: 

http://www2a.cdc.gov/drds/cel/cel_form_code.asp.

43. Gartner, Inc. The Healthcare Supply Chain Top 25 for 2012. Stamford: Gartner, Inc; 2012.

44. Sperian Respiratory Protection USA Awarded a 65,000 Reusable Respirator Order by the 

Veterans Health Administration. PR Newswire [Internet]. 2013 Jul 12 [cited 2013 Nov 5]. Available 

from: http://www.prnewswire.com/news-releases/sperian-respiratory-protection-usa-awarded-a-65000-

reusable-respirator-order-by-the-veterans-health-administration-98274354.html.

45. Peterson K. Adherence to Respiratory Protection Guidelines by Healthcare Workers and 

Hospitals: REACH II Evaluation. Presented for the NIOSH Personal Protective Technology Program 

Healthcare Stakeholder Meeting. 2013. 

http://www.archive.org/download/NioshPersonalProtectiveTechnologyProgramHealthcareStakeholderM

eeting/PresentPetersonREACH2.pdf.

46. Radonovich LJ, Jr., Yanke R, Cheng J, Bender B. Diminished speech intelligibility associated 

with certain types of respirators worn by healthcare workers. J Occup Environ Hyg. 2010 Jan;7(1):63-

70. 

47. Tompkins BM, Kerchberger JP. Special article: personal protective equipment for care of 

pandemic influenza patients: a training workshop for the powered air purifying respirator. Anesth Analg.

2010 Oct;111(4):933-45. PubMed PMID: 20810676. Epub 2010/09/03. eng.

48. Truven Health Analytics. 15 Top Health Systems Study. Ann Arbor: Truven Health Analytics; 

2013.