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1 Framework for Setting the NIOSH PPT Program Action Plan for Healthcare Worker Personal 

2 Protective Equipment: 2013-2018

3 Background

4 Following the severe acute respiratory syndrome (SARS) outbreak in 2003, increased attention was given 

5 to identifying the best ways to protect healthcare workers (HCWs) from emerging respiratory 

6 pathogens. Keeping the ~18 million HCWs providing patient care healthy is an important component of 

7 pandemic planning. Among the various non-pharmaceutical intervention strategies available to reduce 

8 pathogen transmission in occupational settings, the use of personal protective equipment (PPE) plays a 

9 critical role. PPE can be defined as equipment such as gowns, gloves, face shields, eyewear, respirators, 

10 and surgical masks worn to minimize exposure to a hazard. 

11 In 2006, the National Institute for Occupational Safety and Health’s (NIOSH) Personal Protective 

12 Technology (PPT) program began an initiative to develop and execute a comprehensive approach to 

13 HCW protection. This action plan was to include research and intervention, certification, standards 

14 development, and information dissemination program to improve the efficacy and effectiveness of PPE

15 used by HCWs during a pandemic. 

The process to develop the initial action plan(1) and its updates(2-4)16 has been driven by inputs from three 

primary sources. One source of inputs is from a series of reports(5-8)17 from the Institute of Medicine 

18 (IOM) of the National Academies, beginning in 2008. A second major source of inputs comes from the 

19 outputs and outcomes from completed and on-going research and intervention activities. The third 

major source is from the program’s stakeholders, including its annual stakeholder meetings.(9-13)20 

21 The action plan and its updates provide both a near-term and a long-term strategy for NIOSH’s influenza 

22 pandemic activities. The action plans have also served to assist other government agencies in their 

23 research agenda setting process. The NIOSH PPT program is preparing to again update the PPE for HCW 

24 action plan for 2013-2018. This following framework will serve four initial purposes: 

25 (1) Identifies proposed “recommendations” and “activities” to use in an updated PPE for HCW 

26 action plan; 

27 (2) Compares current NIOSH intramural and extramural program activities versus the proposed 

28 recommendations and activities; 

29 (3) Proposes an overarching strategy for NIOSH PPT program management to prioritize among 

30 competing recommendations, activities, and future action steps; and

31 (4) Outlines the process planned for seeking stakeholder input on what “action steps” should be 

32 taken by NIOSH and the NIOSH PPT program to address the recommendations. 

33 Identifying Proposed Recommendations and Activities

As discussed in the previous section, the first draft version(1)34 and the subsequent two revisions of the 

action plan were based on the 2008 IOM report(5), while version 4 of the action plan

(4)

35 incorporated the 

recommendations from the 2009 IOM letter report.

(6)

 The most recent 2011 IOM report(7)36 identified 12 
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37 recommendations in four major areas: (1) transmission of influenza and the use of PPE in preventing 

38 transmission, (2) designing and engineering PPE to be effective and wearable, (3) use of PPE by HCWs, 

and (4) PPE policy, standards, and certification. Because of the thoroughness of this report(7)39 and our 

40 historical practice of using IOM recommendations as the framework for the action plan, we decided to 

41 use these 12 IOM recommendations as the starting framework for this proposed revision. 

42 One advantage of using these recommendations is that they encompass the full spectrum of needed 

43 research, including basic and applied research through policy/regulatory science. Figure 1 outlines 

IOM’s conceptual approach to moving from research into practice.(7)44 As noted in the report, “this 

45 approach ensures that basic science initiatives are fully explored, while also addressing clinical needs and 

46 testing the results in real-work settings”. 

47

48 Figure 1. An integrated system moving research into practice, depicting the translation of research from basic science 

research (T1) through policy and regulatory research (T4). Source: IOM report(7)49 Page 26, Figure 1-2.

In addition to the 12 overarching recommendations, each chapter of the IOM report(7)50 identified 

51 additional findings and research needs which were usually a subset of a one or more of the 12 

52 recommendations. These findings and research needs serve as the basis for the proposed activity areas 

within each recommendation. While the 2011 IOM report(7)53 serves as the starting point, research needs 

identified by DHHS(14, 15)and NORA(16)54 have been incorporated to the extent possible. For example, IOM 

55 recommendation #10 that focused specifically on clarifying PPE guidelines for outbreaks serves as a 

natural location for incorporating several of the HHS improvement plan(15)56 recommendations related to 

57 PPE. In developing this framework document, we also reviewed the NIOSH PPT program’s Government 

Performance and Results Act (GPRA) goals(17)and the NIOSH Board of Scientific Counselors report(18)58 on 

59 the program’s progress toward those goals. The five GPRA goals are not targeted specifically toward 

60 HCW, but areas where a given HCW PPE research action step supports the broader PPT program GPRA 

61 goal can be identified within the actions steps to further ensure alignment of goals, recommendations, 

62 activities, and action steps within the program. 

63 Appendix 1 contains the 12 proposed overarching recommendations and 36 proposed activities (note: 

64 there are another 10 sub-activity items below two of the activities related to recommendation #3). 

Appendix 2 is a cross-walk of the recommendations from the 2011 IOM report(7)65 , the DHHS H1N1 

improvement plan(15), and NORA HCSA sector goals.

(16)

66 The data in Appendix 2 show good overlap 
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67 among the three sources, suggesting that the 2011 IOM report is a valid source for identifying proposed 

68 recommendations and activities.

69 Comparing the Current NIOSH PPT Program and Proposed Recommendations

70 The 12 proposed recommendations were compared to the existing NIOSH research portfolio to identify

71 areas of current NIOSH research and for possible gaps for developing specific action items in the next 

72 phase of the process. Short summaries of NIOSH intramural projects related to HCW PPE are 

available.

(19-21)

73 Internal resources (e.g., the NIOSH Project Planning and Management (NPPM) System) 

and an external grants database(22)74 were also used to identify relevant projects both within the 

75 intramural and extramural NIOSH PPT program portfolio and in related NIOSH program areas. Figure 2 

76 summarizes the recommendations in which there is current activity within NIOSH. Given the priority of 

77 these research areas within the NIOSH PPT program since 2006 and the HCSA sector, it is not surprising 

78 that NIOSH is involved in most of the areas, either in a leadership role or in supporting the efforts of 

79 other government agencies. Even within the areas where NIOSH was considered to play a more 

80 supportive role; there may be specific NIOSH research projects that support one of the activities. The 

81 only area in which there is no current activity can be considered completed with the NIOSH 

contributions to a CDC transmission workshop report.

(23)

82

83

84 Figure 2. Mapping current NIOSH research projects to the 12 proposed recommendations

85 Proposed Prioritization Strategy 

86 All of the proposed recommendations and activities (Appendix 1) are important, but it is not practical to 

87 expect that NIOSH has the resources and expertise to tackle all of them simultaneously. Furthermore, 

Cross Cutting 

Research

1. Develop 

standardized terms 

& definitions

2. Viral respiratory 

disease 

transmission

Safety to 

Efficacy 

(T1→ T2)

3. Improve & 

evaluate PPE 

effectiveness

4. Effectiveness of 

facemasks & 

faceshields as PPE

5. Improve fit test 

methods

Efficacy to 

Effectiveness 

(T2→ T3)

6. Safety culture

7. Strategies & 

interventions to 

improve PPE use

Effectiveness 

to Disease 

Reduction in 

Populations 

(T3→ T4)

8. PAPR standard

9. Better fitting 

respirators

10. Clarify PPE 

guidelines for 

outbreaks

11. Standards for 

facemasks & 

faceshields

12. PPE regulations 

for HCW

Current area 

of NIOSH 

research

Others leading, 

with NIOSH input No current activity

Key
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88 during times of increased budget scrutiny, NIOSH and other government agencies cannot fund all of the 

89 desirable research projects, but instead need to make difficult decisions. Prioritization tools will enable 

90 NIOSH and its stakeholders to implement the action plan in the most efficient way.

91 For this action plan, we propose to use improving HCW PPE compliance as the overarching goal for 

92 prioritization. Observational studies of HCW compliance with proper PPE use practices and procedures 

indicate that adherence is often quite low. (7)93 Surveys of workers (i.e., self-reporting) have come to 

94 similar conclusions. Like other interventions (e.g., hand washing, use of seat belts, etc.), a limitation of 

95 PPE is its reliance upon the wearer to perform the intervention correctly (e.g., wear their PPE at all times 

96 during the entire period of exposure). The reasons for non-compliance and barriers to proper PPE use 

among HCWs include both organizational and individual factors. The 2011(7)and 2008(5)97 IOM reports 

98 identified a number of potential factors, including lack of accountability for PPE non-compliance, 

99 workload issues, time constraints, risk perception, PPE effectiveness concerns, PPE availability, PPE 

100 comfort, PPE interference with patient care, and the inability to communicate while wearing PPE. The 

101 rationale for prioritizing activities that can be used to improve HCW PPE compliance is three-fold.

 There is a strong relationship between compliance and protection.(24, 25)102 The effects of poor 

103 compliance have been studied by the industrial hygiene community. For example, Figure 3 

104 illustrates the relationship between wear time (a critical component of compliance) and

105 effective protection factor (EPF) (i.e., actual exposure reduction). This relationship, first 

described by the American Industrial Hygiene Association respiratory protection committee(26)106 ,

107 is based upon time-weighted averages of a constant exposure. In this figure, the lines represent 

108 three different types of hypothetical respirators including a filtering facepiece respirator (FFR), 

109 hooded powered air purifying respirator (PAPR), and full facepiece air purifying elastomeric, 

110 providing different levels of workplace protection factors (WPF). This model suggests that 

111 compliance needs to be > 75% to see more than a 25% increase in EPF, even for a respirator

112 (e.g., full facepiece elastomeric) with superior ability to reduce exposure. Similar theoretical 

113 examples can be given for other types of PPE.
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114

115 Figure 3. Model depicting the relationship between EPF and Compliance. In this example, the 3 hypothetic 

116 respiratory types are FFR (WPF = 10), hooded PAPR (WPF = 25), and full facepiece air purifying elastomeric (WPF = 

117 50). Te = Exposure duration, Tw = Time Worn, Tnw = Time Not Worn, WPF = Workplace Protection Factor. Source: 

adapted from multiple sources.(24-26)118

119

120  No single solution exists that will address all of the reasons for non-compliance and barriers to 

121 proper use. A multi-pronged or “bundled” strategy is needed to increase compliance during 

122 both normal and emergency situations, which could include research and interventions such as: 

123 ‒ Changing the organizational safety culture;

124 ‒ Creating improved educational modalities and methods of information dissemination 

125 such as the use of social media and new technologies like mobile-phone apps);

126 ‒ Developing clear polices/recommendations based upon sound science; 

127 ‒ Better understanding of the modes of human to human transmission and recommended 

128 infection control precautions for respiratory pathogens; 

129 ‒ PPE clinical effectiveness studies;

130 ‒ Less burdensome fit test methods for tight fitting respirators; and

131 ‒ Better fitting / more comfortable PPE. 

132 While no single solution is likely to be successful by itself, studies of other public health 

133 interventions demonstrate how research (e.g., new technologies and innovations) can improve 

compliance. For example, studies(27-29)134 have found that hand hygiene compliance rates 

135 improved significantly when educational campaigns were bundled with wide spread distribution 

136 of alcohol-based hand rub bottles/dispensers. In these instances, the intervention involved a 

137 new technology, alcohol-based hand rub, which eliminated a known barrier to traditional hand 

138 washing by decreasing the time needed to perform the action. Because of the multi-disciplinary 

139 nature of interventional research, focusing on compliance will encourage collaborations among 
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140 NIOSH intramural and extramural researchers and draw interest from new partners (e.g., end141 users, hospitals, etc.). These synergistic interactions will enhance the current HCW PPE research 

142 program.

143  Focusing on improving HCW PPE compliance is consistent with the NIOSH PPT program mission 

144 “To prevent work-related injury, illness, and death by advancing the state of knowledge and 

145 application of PPT”. Proper use of PPE is an important application of PPT. Concentrating on 

146 HCWs and compliance in healthcare settings is consistent with the NIOSH focus on workers and 

the workplace. As noted the NORA HCSA sector goals(16)147 , promoting a “culture of safety” and 

148 appropriate use of PPE are important. 

149 Process for Obtaining Stakeholder Input

150 We plan to obtain stakeholder comments in three specific areas:

151 1. Our proposed use of the IOM recommendations as the basis for the 12 overarching 

152 recommendations and 36 activities in next revision of the action plan;

153 2. Our proposed use of improving HCW PPE compliance as the overarching goal for prioritization;

154 and

155 3. Specific actions that NIOSH and the NIOSH PPT program should take to address the proposed 

156 recommendations

157 The Table shows the timeframe and process for updating the NIOSH PPT program HCW PPE action plan.

Timeframe Milestone

April – June 2013 Form internal NIOSH PPT program Working Group

Publish NIOSH Science Blog(30)seeking comments on research needs to 

improve PPE compliance in healthcare

Discuss Framework document at the NIOSH PPT Program Healthcare 

Stakeholder Meeting(13)

July – September 2013 Publish Framework document on the NIOSH Docket

Publish Federal Register Notice seeking public comment

NIOSH PPT program Working Group drafts initial action plan

October – December 2014 NIOSH PPT program Working Group revises draft action plan 

Final action plan is published to the NIOSH docket and the NIOSH PPT 

program website

158

159 Disclaimer

160 This information is distributed solely for the purpose of pre-dissemination peer review under applicable 

161 information quality guidelines. It has not been formally disseminated by the National Institute for 

162 Occupational Safety and Health. It does not represent and should not be construed to represent any 

163 agency determination or policy.
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164 Appendix 1. Proposed Recommendations and Activities

165 1. Develop Standardized Terms and Definitions

166 1.1. Through a consensus process involving the industrial hygiene, infectious diseases, and healthcare 

167 communities, develop standardized terms, definitions, and appropriate classifications to describe 

168 transmission routes and aerodynamic diameter of particles associated with viral respiratory disease 

169 transmission. 

170 2. Develop and Implement a Comprehensive Research Strategy to Understand Viral Respiratory Disease 

171 Transmission

172 2.1. Animal studies (ferrets and guinea pigs) should be done to determine which interventions (e.g., increased 

173 air exchange, antimicrobial treated surfaces, and UV treatment of air) are likely to be the most effective.

174 2.2. Environmental studies (in multiple locations, e.g., schools, public transportation, healthcare facilities) 

175 should be done to assess the effect of UV light and humidity on influenza transmission and whether the 

176 identified influenza RNA in aerosol samplers are viable and reflect the extent to which individuals are 

177 exposed to aerosols of influenza within these environments. 

178 2.3. Statistical and mathematical models should be developed and evaluated for their utility in prediction and 

179 inferences regarding the relative contributions of different transmission modes in varying 

180 environmental/community contexts.

181 2.4. Clinical studies should be conducted to examine all possible modes of transmission, including 

182 environmental levels (air sampling and surface swabs) of contamination, serological studies of exposure 

183 to influenza virus in family members or roommates, and the size distribution of patients’ respiratory 

184 particles to which healthcare personnel are exposed and some measure of the intensity of the exposure 

185 to patients that might include distance from, time in contact with, and specific procedures performed on 

186 the infected patients.

187 3. Continue and Expand Research on PPE for Healthcare Personnel

188 3.1. Conduct studies to improve and evaluate the effectiveness of respirators for healthcare personnel in 

189 preventing the transmission of influenza or other viral respiratory diseases.

190 3.1.1. Assess impact of various strategies for reuse / extended use of respirators during a respiratory 

191 disease outbreak, including conducting studies to assess promising respirator decontamination 

192 methods, their impact on protection, and their effectiveness using either influenza virus or a 

193 suitable surrogate.

194 3.1.2. Develop and assess the efficacy and effectiveness of protocols (e.g., respirator donning and doffing) 

195 and new technologies (e.g., antiviral-coated respirators) to minimize self-inoculation from handling 

196 contaminated PPE.

197 3.1.3. Conduct research to examine the features of N95s, PAPRs, and elastomeric respirators that impact 

198 comfort and tolerability among healthcare personnel and identify alterations in respirator design 

199 and construction that show promise in improving problem features that adversely impact comfort 

200 and tolerability.

201 3.1.4. Assess respirator total inward leakage (TIL) of very small particles (< 100 nm).

202 3.1.5. Conduct workplace protection studies to assess protection during typical tasks over time, 

203 determine how using typical instruments impact protection, and to identify/mitigate possible 

204 integration issues.

205 3.1.6. Conduct human factors (field of view, visual acuity, communication) and operational performance 

206 studies on respirators to assess the ability of healthcare personnel to perform medical procedures 

207 in typical healthcare-specific PPE ensembles and to identify/mitigate possible issues.
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208 3.1.7. Develop technologies and test methods to support new air-purifying respirators that specifically 

209 address the needs of healthcare personnel, including new materials to improve fit, comfort, and 

210 tolerability. 

211 3.1.8. Develop technologies and test methods to support a new low-noise, lightweight PAPR and a face 

212 shield for healthcare personnel that are reusable and easy to clean. 

213 3.2. Conduct studies to improve and evaluate the effectiveness of non-facial PPE (e.g., gloves, gowns) in 

214 preventing the transmission of influenza or other viral respiratory diseases.

215 3.2.1. Conduct research to identify factors (duration of use, material properties) affecting the comfort and 

216 usability of non-facial PPE, and identify/implement changes having the potential to positively 

217 influence comfort, tolerability, or integration with other healthcare specific PPE ensemble 

218 components. 

219 3.2.2. Conduct studies to quantify the role of non-facial PPE on droplet spray and direct-contact (fomite) 

220 transmission. 

221 4. Examine the Effectiveness of Face Masks and Face Shields as PPE

222 4.1. Conduct studies to investigate the effectiveness of goggles, face masks, and face shields in preventing 

223 aerosol transmission of viral respiratory diseases.

224 4.2. Perform manned and unmanned studies to investigate the effectiveness of goggles, face masks, and face 

225 shields in preventing droplet-spray and direct-contact transmission of viral respiratory diseases.

226 5. Improve Fit-Test Methods and Evaluate User Seal Checks

227 5.1. Perform research leading to the development and adoption of novel, simpler fit-test methods.

228 5.2. Conduct research to improve and evaluate the effectiveness of performing user seal checks on filtering 

229 facepiece respirators.

230 6. Explore Healthcare Safety Culture and Work Organization

231 6.1. Conduct research to better understand the role of safety culture and other behavioral and organizational 

232 factors on PPE compliance in healthcare settings. 

233 6.2. Conduct human factors and ergonomics research relevant to the design and organization of healthcare 

234 work tasks to improve worker safety by reducing hazardous exposures and effectively using PPE (e.g., 

235 reduce unnecessary PPE donning and doffing).

236 6.3. Conduct studies to explore the links between patient safety and healthcare worker safety and health that 

237 are relevant to the use of PPE, identifying and evaluating strategies to mitigate organizational barriers 

238 that limit the proper use of PPE by healthcare personnel.

239 7. Identify and Disseminate Effective Leadership and Training Strategies and Other Interventions to Improve PPE 

240 Compliance

241 7.1. Support intervention effectiveness research to assess strategies, including innovative participatory 

242 approaches to training, for healthcare and supervisory staff at all levels to improve PPE compliance and 

243 other related outcomes across the range of healthcare settings.

244 7.2. Conduct observational studies of PPE usage by healthcare personnel in different types of work settings.

245 7.3. Develop, implement, and evaluate comprehensive leadership and training strategies and interventions 

246 that go beyond simple knowledge-based training.

247 7.4. Design training interventions specifically for supervisory and managerial personnel in different types of 

248 healthcare settings.

249 7.5. Examine long-term practice change and safety culture implementation related to educational 

250 interventions.

251 7.6. Develop strategies to improve use and understanding of PPE by home and community healthcare 

252 personnel
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253 7.7. Develop assessment tools and metrics that take a broader approach to PPE and acknowledge the 

254 interaction of worker, task, and environmental factors

255 7.8. Conduct a lessons-learned summit on PPE use by healthcare personnel during the 2009 H1N1 

256 experience.

257 8. Develop and Certify PAPRs for Healthcare Personnel

258 8.1. Conduct studies to evaluate and develop certification requirements for a low noise, loose-fitting PAPR for 

259 healthcare personnel.

260 9. Move Forward on Better Fitting Respirators

261 9.1. Continue rulemaking for TIL regulations that require respirators to meet fit criteria. 

262 9.2. To improve consumer and purchaser information on fit capabilities, establish a website to disseminate 

263 fit-test results for specific respirator models on an anthropometric (NIOSH) test panel, where such data 

264 exist.

265 10. Clarify PPE Guidelines for Outbreaks of Novel Viral Respiratory Infections

266 10.1. Conduct and evaluate case studies on the implementation of 2009 H1N1 PPE related policies, including 

267 whether stockpiling of respirators should be continued and, if so, develop requirements, taking into 

268 account the national need, domestic manufacturing surge capacity and sourcing of raw materials, and a 

269 system for allocation and distribution.

270 10.2. Conduct studies that compare theoretical models of estimating quantities of PPE for emergency 

271 preparedness with recent experience to inform future public health planning.

272 10.3. Develop and deploy systems to monitor safety, effectiveness, and shortages of PPE.

273 10.4. Conduct research into cost effectiveness issues relevant to PPE, including issues of disposable vs.

274 reusable equipment.

275 10.5. Perform prospective research efforts to examine the impact of public health guidance on PPE compliance 

276 by state, local, and health system policy; clinical practice; and costs.

277 10.6. Encourage respirator manufacturers to achieve both NIOSH certification and FDA clearance to ensure an 

278 ample supply of respirators during a respiratory disease outbreak.

279 10.7. Develop and/or revise relevant respirator reuse /extended use guidelines and policies.

280 10.8. Develop a coordinated process to make, announce, and revise consistent guidelines regarding the use of 

281 PPE to be worn by healthcare personnel during a verified, sustained national/international outbreak of a 

282 novel viral respiratory infection. 

283 11. Standards and Certification for Face Masks and Face Shields

284 11.1. Support the development of voluntary consensus standards and independent third-party testing and 

285 certification processes for face shields and face masks as PPE, with specific tests for assessing prevention 

286 of transmission of viral respiratory diseases.

287 12. Establish PPE Regulations for Healthcare Personnel

288 12.1. Promote and support the development of voluntary consensus standards for non-respiratory PPE (e.g., 

289 gowns, gloves, face shields, face masks) in the event of influenza and other viral respiratory diseases.

290 12.2. Support the development of aerosol-transmissible diseases standards that would include prevention of 

291 the transmission of influenza and other viral respiratory diseases.

292

293

294

295
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296 Appendix 2. Cross-walk of Recommendations

2011 IOM recommendation HHS recommendations NORA HCSA Goals*

Cross-Cutting Research

1. Develop Standardized Terms and 

Definitions

2. Develop and Implement a 

Comprehensive Research Strategy 

to Understand Viral Respiratory 

Disease Transmission

5.4.4. Conduct research to better 

understand influenza transmission, to 

clarify when surgical masks are 

sufficient, and when the use of N95 

respirators or other devices may be 

more appropriate

IG 5.1: Understanding mechanisms and 

routes – Investigators across a broad 

range of disciplines will conduct 

research to understand mechanisms 

and determinants of routes by which 

infectious diseases are transmitted in 

the healthcare and social assistance 

setting.

Safety to Efficacy: Basic Research (T1) to Clinical/Applied Research (T2)

3. Continue and Expand Research on 

PPE for Healthcare Personnel

5.4.4. Conduct research to better 

understand influenza transmission, to 

clarify when surgical masks are 

sufficient, and when the use of N95 

respirators or other devices may be 

more appropriate 

5.4.5 Innovate and strengthen RPD 

design, use, testing, and certification for 

both occupational and community 

settings for a wide population, including 

the pediatric population

5.4.6 Develop and/or revise relevant 

RPD use/reuse guidance and policies 

IG 5.10 Research and adopting best 

practices for PPE – With a range of 

partners in the public and private 

sectors, encourage an integrated effort 

to fully understand the unique 

requirements of healthcare and social 

assistance workers, and to develop 

innovative materials, technologies, and 

products that can meet their needs, as 

well as those of their patients.

AOG 5.9.4: Conduct research to 

improve the understanding of how 

human factors and behavioral issues 

related to the ease and effectiveness of 

PPE use for extended periods of time 

and during diverse work environments 

affect PPE use and compliance.

4. Examine the Effectiveness of Face 

Masks and Face Shields as PPE

AOG 5.10.3: Conduct research to 

document the protective differences 

between various types of PPE using 

methods that simulate real-life usage 

and assess all potential leakage paths.

5. Improve Fit-Test Methods and 

Evaluate User Seal Checks

AOG 5.10.6: Conduct research on the 

frequency of fit testing to assess the rate 

at which respirator fit changes as a 

function of time, to investigate the 

factors that affect such change, and to 

guide recommendations for frequency 

and type of fit testing. 

AOG 5.10.7: Conduct pre-use check 

research, investigating the efficacy of 

user seal checks on filtering facepiece 

respirators.

Efficacy to Effectiveness: Clinical/Applied Research (T2) to Systems Research (T3)

6. Explore Healthcare Safety Culture 

and Work Organization

IG 5.9: Research and adopting best 

practices for PPE – Healthcare and 

social assistance facilities will establish 

and promote a culture of safety where 

employer and employee commitment to 

worker safety in general, and the 
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appropriate use of PPE in particular, are 

strengthened.

7. Identify and Disseminate Effective 

Leadership and Training Strategies 

and Other Interventions to Improve 

PPE Use

AOG 5.9.1: Develop and disseminate 

training programs which emphasize the 

correct use (and disposal) of PPE during 

patient care across HCSA settings.

AOG 5.9.2: Conduct demonstration 

projects on PPE compliance and use.

AOG 5.9.3: Publish and disseminate 

broadly the results of these projects to 

ensure the proliferation of successful 

PPE strategies.

Effectiveness to Disease Reduction in Populations: Systems Research (T3) to Policy/Regulatory Research (T4)

8. Develop and Certify Powered AirPurifying Respirators (PAPRs) for 

Healthcare Personnel

9. Move Forward on Better Fitting 

Respirators

AOG 5.10.5: Conduct research to 

explore innovative application of new 

technologies, such as use of new 

materials to achieve better “out of the 

box” fit and reduce need for fit testing; or 

incorporating sensors into PPE to detect 

breaches and notify users of end-ofservice life and other protection 

information.

10. Clarify PPE Guidelines for 

Outbreaks of Novel Viral 

Respiratory Infections

5.4.1 Determine whether the stockpiling 

of respirators in the SNS should be 

continued and if so, develop 

requirements for stockpiling, taking into 

account national need, including 

domestic manufacturing surge 

capabilities and sourcing of raw 

materials, and a system for allocation 

and distribution 

5.4.2 Encourage RPD manufacturers to 

pursue both NIOSH certification and 

FDA clearance to ensure an ample 

supply of FDA-cleared N95 respirators 

are available for use in healthcare 

settings during a pandemic: 

5.4.3 Develop systems to monitor safety, 

effectiveness, and shortages of RPDs 

after deployment 

AOG 5.9.5: Develop surveillance of PPE 

usage to identify priorities, trends and 

emerging issues associated with the use 

of PPE in the workplace and use the 

information to establish a baseline on 

PPE usage, develop benchmarks and 

performance measures, sharpen the 

focus of research efforts and aid in the 

development of a more effective and

active dissemination program.

11. Standards and Certification for 

Face Masks and Face Shields

12. Establish PPE Regulations for 

Healthcare Personnel

5.4.2 Encourage RPD manufacturers to 

pursue both NIOSH certification and 

FDA clearance to ensure an ample 

supply of FDA-cleared N95 respirators 

are available for use in healthcare 

settings during a pandemic:

297 * notes: IG = Intermediate goal. AOG = Activity/Output Goal. For brevity, only the highest level goal is 

298 identified. There are several more specific sub-level Activity/Output goals associated with each 

299 Intermediate Goal.

300
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301 References

302 1 NIOSH: "Draft Personal Protective Equipment (PPE) for Healthcare Workers (HCW) Action Plan." 

303 [Online] Available at http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH-129/129-022208-

304 Draft_doc.pdf, 2008).

305 2 NIOSH: "Personal protective equipment (PPE) for healthcare workers (HCW) action plan." 

306 [Online] Available at http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH-129/0129-081908-

307 RevisedDraft_doc.pdf, 2008).

308 3 NIOSH: "Personal Protective Equipment (PPE) for Healthcare Workers (HCW) Action Plan to 

309 address Actions for the next 5 years." [Online] Available at 

310 http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH-129/0129-032709-RevisedDraft_doc.pdf, 2009).

311 4 NIOSH: "Personal Protective Equipment (PPE) for Healthcare Workers (HCW) Action Plan to 

312 address Actions for the next 5 years." [Online] Available at 

313 http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH-129/0129-010710-ReportDraft4_doc.pdf, 2010).

314 5 Goldfrank, L.R., and C.T. Liverman: Preparing for an influenza pandemic: Personal protective 

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