June 7, 2013 Version

1



### Framework for Setting the NIOSH PPT Program Action Plan for Healthcare Worke r Personal 1



### Protective Equipment : 2013

- 2018 2



### Background 3

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

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

pathogens. Keeping the ~ 1 8 million HCWs providing patient ca re healthy is an important component of 6

pandemic planning . Among the various non

- pharmaceutical intervention strategies available to reduce 7

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

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

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

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

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

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

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

used by HCWs during a pandemic

. 15

The process to develop the initial action plan ( 1 ) and its updates ( 2

- 4 ) has been driven by inputs from three 16

primary sources. One source of inputs is from a series of reports ( 5

- 8 ) from the Institute of Medicine 17

(IOM) of the National Academies , beginning in 200 8. A second major source of inputs comes from the 18

outputs and outcomes from completed and on

- going research and intervention activities

. The third 19

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

- 13 ) 20

The action plan and its updates provide both a near

- term and a long

- term strategy for NIOSH’s influenza 21

pandemic activities . The action plan s have also serve d to assist other government agencies in their 22

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

action plan for 2013

- 2018. This following framework will serve four initial purposes: 24

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

action plan ; 26

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

recommendations and activities ; 28

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

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

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

taken by NIOSH and the NIOSH PPT program to address the r ecommendations

. 32



### Identifying Proposed Recommendations and Activities 33

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

action plan were based on the 2008 IOM report ( 5 ) , while version 4 of the action pla n ( 4 ) incorporated the 35

recommendations from the 2009 IOM letter report

. ( 6 ) The most recent 2011 IOM report ( 7 ) identified 12 36June 7, 2013 Version

2

recommendations in four major areas: (1) transmission of influenza and the use of PPE in preventing 37

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

and (4) PPE policy, standards, and certification

. Bec ause of the thoroughness of this report ( 7 ) and our 39

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

use the se 12 IOM recommendations as the starting framework for this proposed revision

. 41

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

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

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

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

testing the results in real

- work settings ”. 46

47

Figure 1

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

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

- 2. 49

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

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

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

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

identified by DHHS ( 14

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

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

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

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

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

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

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

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

activities, and action steps within the program. 62

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

there are another 10 sub

- activity items below two of the activities related to recommendation #3). 64

Appendix 2 is a cross

- walk of the recommendations from the 2011 IOM report ( 7 ) , the DHHS H1N1 65

improvement plan ( 15 ) , and NORA HCSA se ctor goals

. ( 16 ) The data in Appendix 2 show good overlap 66June 7, 2013 Version

3

among the three sources, suggesting that the 20 11 IOM report is a valid source for identifying proposed 67

recommendations and activities. 68



### Comparing the Current NIOSH PPT Program and Proposed Recommendations 69

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

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

phase of the process

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

avai lable

. ( 19

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

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

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

summarizes the recommendations in which there is current activity within NIOSH

. Given the priority of 76

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

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

other government agencie s. E ven within the areas where NIOSH was considered to play a more 79

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

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

contributions to a CDC transmission workshop report

. ( 23 ) 82

83

Figure 2

. Mapping current NIOSH r esearch p rojects to the 12 proposed r ecommendations 84



### Proposed Priori tization Strategy 85

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

expect that NIOSH has the resources and expertise to tackle all of the m simultaneously. Furthermore, 87June 7, 2013 Version

4

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

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

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

For this action plan

, we propose to use improving HCW PPE compliance as the overarching goal for 91

prioritization

. O bservational studies of HCW compliance with proper PPE use practices and procedures 92

indicate that adherence is often quite low. ( 7 ) Surveys of workers (i.e., self

- reporting) have come to 93

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

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

during the entire period of exposure )

. The reasons for non

- compliance and barriers t o proper PPE use 96

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

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

- compliance, 98

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

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

. The 100

rationale for prioritizing activities that can be used to improve HCW PPE compliance is three

- fold. 101

 The re is a strong relationship between compliance and protection. ( 24

, 25 ) The ef fects of poor 102

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

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

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

described by the American Industrial Hygiene Association res piratory protection committee ( 26 )

, 106

is based upon t ime

- weighted averages of a constant exposure. In this figure, the l ines represent 107

three different types of hypothetic al respirators including a filtering facepiece respirator (FFR)

, 108

hooded powered air purifying respirator (PAPR)

, and full facepiece air purifying elastomeric

, 109

providing different levels of workplace protect ion factors (WPF)

. This model suggests that 110

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

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

examples can be given for other types of PPE. 113June 7, 2013 Version

5 114

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

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

50). T

e = Exposure duration, T

w = Time Worn, T

nw = Time Not Worn, WPF = Workplace Protection Factor. Source: 117

adapted from multiple sources. ( 24

- 26 ) 118

119

 No single solution exists that will address all of the reasons for non

- compliance and barriers to 120

proper use. A multi

- pronged or “bundled” strategy is needed to increase comp liance during 121

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

‒ Changing the organizational safety culture; 123

‒ Creating improved educational modalities and methods of information dissemination 124

such as the use of so cial media and new technologies like mobile

- phone apps); 125

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

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

infection control precautions for respiratory path ogens; 128

‒ PPE clinical effectiveness studies; 129

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

‒ Better fitting / more comfortable PPE. 131

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

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

compliance. For example, studies ( 27

- 29 ) have found that hand hygiene compliance rates 134

improved significantly when educational campai gns were bundled with wide spread distribution 135

of alcohol

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

new technology, alcohol

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

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

- disciplinary 138

nature of interventional research, focusing on compliance will encourage collaborations among 139June 7, 2013 Version

6

NIOSH intramural and extramural researchers and draw interest from new partners (e.g., end

140

users, hospitals, etc.). These synergistic interactions will enhance the current HCW PPE research 141

program. 142

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

“ To prevent work

- related injury, illness, and death by advancing the state of knowledge and 144

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

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

the workplace. As noted the NO RA HCSA sector goals ( 16 ) , promoting a “culture of safety” and 147

appropriate use of PPE are important. 148



### Pro cess for Obtaining Stakeholder Input 149

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

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

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

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

and 154

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

recommendations 156

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

Timeframe Milestone

April

– June 2013 Form internal NIOSH PPT p rogram 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 Prog ram 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 in itial 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



### Disclaimer 159

This information is distributed solely for the purpose o f pre

- dissemination peer review under applicable 160

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

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

agency determination or policy. 163June 7, 2013 Version

7



### Appendix 1. Proposed Recommendations and Activities 164

1. Develop Standardized Terms and Definitions 165

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

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

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

transmission. 169

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

Transmission 171

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

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

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

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

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

exposed to aerosols of influenza within these environments. 177

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

inferences regarding the re lative contributions of different transmission modes in varying 179

environmental/community contexts. 180

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

e nvironmental levels (air sampling and surface swabs) of contami nation , s erological studies of exposure 182

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

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

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

the infected patients. 186

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

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

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

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

disease outbreak, including conducting studies to a ssess promising respirator decontamination 191

methods

, their impact on protection

, and their effectiveness using either influenza virus or a 192

suitable surrogate. 193

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

and new technologies (e.g., antiviral

- coated respirators) to minimize self

- inoculation from handling 195

contaminated PPE. 196

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

comfort and tolerabil ity among heal thcare personnel and i dentify alterations in respirator design 198

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

and tolerability. 200

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

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

d etermine how u sing typical instruments impact protection, and to identify /mitigate possible 203

integration issues. 204

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

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

in typical healthcare

- specific PPE ensembles and to identify/ mitigate possible issues

. 207June 7, 2013 Version

8 3.1.7. Develop technologies and test methods to support new air

- purifying respirator s that specifically 208

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

tolerability. 210

3.1.8. Develop technologies a nd test methods to support a new low

- noise, lightweight PAPR and a face 211

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

3.2. Conduct studies to improve and evaluate the effectiveness of non

- facial PPE (e.g., gloves, gowns) in 213

preventing th e transmission of influenza or other viral respiratory diseases. 214

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

usability of non

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

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

components

. 218

3.2.2. Conduct studies to quantify the role of non

- facial PPE on droplet spray and direct

- contact (fomite) 219

transmission. 220

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

4.1. Conduct s tudies to investigate the effectiveness of goggles, face masks

, and face shields in preventing 222

aerosol transmission of viral respiratory diseases. 223

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

shields in preventing droplet

- spray and direct

- contact transmission of viral respiratory diseases. 225

5. Improve Fit

- Test Methods and Evaluate User Seal Checks 226

5.1. Perform research leading to the develop ment and adoption of novel, simpler fit

- test methods

. 227

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

facepiece respirators. 229

6. Explore Healthcare Safety Culture and Work Organization 230

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

factors on PPE compliance in healthcare settings. 232

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

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

reduce unnece ssary PPE donning and doffing). 235

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

are relevant to the use of PPE

, identifying and evaluating strategies to mitigate organizational barriers 237

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

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

Compliance 240

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

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

other related outcomes across the range of healthcare settings. 243

7.2. C onduct observational studies of PPE usage by healthcare personnel in different types of work settings

. 244

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

that go beyond simple knowledge

- based training. 246

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

healthcare settings

. 248

7.5. Examine long

- term practice change and safety culture implementation related to educational 249

interventions

. 250

7.6. Develop strategies to i mprov e use and understanding of PPE by home and community healthcare 251

personnel 252June 7, 2013 Version

9

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

interaction of worker, task, and environmental factors 254

7.8. Conduct a lessons

- learned summit o n PPE use by healthcare personnel during the 2009 H1N1 255

experience. 256

8. Develop and Certify PAPRs for Healthcare Personnel 257

8.1. Conduct s tudies to evaluate and develop certification requirements for a low noise, loose

- fitting PAPR for 258

healthcare personnel. 259

9. Move Forward on Better Fitting Respirators 260

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

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

fit

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

exist. 264

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

10.1. Conduct and evaluate c ase studies o n the implementation of 2009 H1N1 PPE related policies , includ ing 266

whether stockpiling of respirators should be continued and

, if so

, develop requirements, taking into 267

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

system for allocation and distribution

. 269

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

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

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

. 272

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

reusable equipment. 274

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

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

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

ample supply of respirators during a respiratory disease outbreak. 278

10.7. Develop and/or revise relevant respirator reuse /extende d use guidelines and policies

. 279

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

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

novel viral respi ratory infection. 282

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

11.1. Support the development of v oluntary consensus standards and independent third

- party testing and 284

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

of transmission of viral respiratory diseases. 286

12. Establish PPE Regulations for Healthcare Personnel 287

12.1. Promote and support the development of voluntary consensus standards for non

- respirator y PPE (e.g., 288

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

12.2. Support the development of aerosol

- transmissible diseases standard s that would include prevention of 290

the transmission of influenza and othe r viral respiratory diseases. 291

292

293

294

295June 7, 2013 Version

10



### Appendix 2. Cross

- walk of Recommendations 296

2011 IOM recommendation HHS recommendation s 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, a nd 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
require ments 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

fr equency 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 theJune 7, 2013 Version

11 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 Popula tions: Systems Research (T3) to Policy/Regulatory Research (T4)

8. Develop and Certify Powered Air

Purifying 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

- of

service life and other protection

informat ion.

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, inclu ding 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

eme rging 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:

* note s : IG = Intermediate goal. AOG = Activity/Output Goal. For brevity, only the highest level goal is 297
identified. There are several more specific sub

- level Activity/Output goals associated with each 298

Intermediate Goal. 299

300June 7, 2013 Version

12



### References 301

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

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

- 129/129

- 022208

- 303
Draft_doc.pdf , 2008). 304

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

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

- 129/0129

- 081908

- 306
RevisedDraft_doc.pdf , 2008). 307

3 NIOSH: "Personal Protective Equipment (PPE) for Hea lthcare Workers (HCW) Action Plan to 308
address Actions for the next 5 years." [Online] Available at 309 http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH

- 129/0129

- 032709

- RevisedDraft_doc.pdf , 2009). 310

4 NIOSH: "Personal Protective Equipment (PPE) for Healthcare Workers (HCW) Action Plan to 311
address Actions for the next 5 years." [Online] Available at 312 http://www.cdc.gov/niosh/docket/archive/pdfs/NIOSH

- 129/0129

- 010710

- ReportDraft4_doc.pdf , 2010). 313

5 Goldfrank, L.R., and C.T. Liverman: Preparing for an influenza pandemic: Personal protective 314
equipment for healthcare Workers : National Academies Press, 2008. 315

6 Shine, K.I., B. Rogers, and L.R. Goldfrank: Novel H1N1 Influenza and Respiratory Protection for 316

Health Care Workers. New England Journal of Medicine 361(19): 1823

- 1825 (2009). 317

7 Larson, E.L., and C.T. Liverman: Preventing Transmission of Pandemic Influenza and Other Viral 318
Respiratory Diseases: Personal Protective Equipment for Healthcare Workers: Update 2010 : National 319

Academies Press, 2011. 320

8 Clever, L.H., M.B. Rogers, A.M. Schultz, and T. Catharyn: Occupational Health Nurses and 321

Respiratory Protection: Improving Education and Training: Letter Report : National Academies Press, 322

2011. 323

9 NIOSH: "Personal Protective Technology Program Stakeholders Meeting, March 3, 2009." 324

[Online] Available at http://www.cdc.gov/niosh/npptl/resources/pressrel/letters/lttr

- 030309.html

, 325
2009). 326

10 NIOSH: "Personal Protective Technology Program Sta keholder Meeting, March 2

- 3, 2010." 327

[Online] Available at http://www.cdc.gov/niosh/npptl/resources/pressrel/letters/lttr

- 03022010.html

, 328
2010). 329

11 NIOSH: "NIOSH N PPTL PPT Program Stakeholders Meeting, March 29, 2011." [Online] Available 330

at 331 http://www.cdc.gov/niosh/npptl/resources/certpgmspt/meetin gs/03292011/PresentationsPosters0329 332

2011.html , 2011). 333

12 NIOSH: "NIOSH NPPTL PPT Program Stakeholder Meeting and Workshop, March 20

- 21, 2012." 334

[Online] Available at 335 http://www.cdc.gov/niosh/npptl/resources/certpgmspt/meetings/03202012/PresentationsPosters0320 336

2012.html , 2012). 337

13 NIOSH: "NIOSH Personal Protective Technology Program Healthcare Stakeholder Meeting." 338

[Online] Available at 339 http://www.cdc.gov/niosh/npptl/resources/certpgmspt/meetings/06182013/HealthcareInvitationLttr06 340

182013.html , 2013). 341

14 DHHS: "An HHS R etrospective on the 2009 H1N1 Influenza Pandemic to Advance All Hazards 342
Preparedness." [Online] Available at http://www.phe.gov/Preparedness/mcm/h1n1

- 343

re trospective/Documents/h1n1

- retrospective.pdf , 2012). 344

15 DHHS: "2009 H1N1 Influenza Improvement Plan." [Online] Available at 345 http://www.phe.gov/Pr eparedness/mcm/h1n1

- retrospective/Documents/2009

- h1n1

- 346
improvementplan.pdf , 2012). 347June 7, 2013 Version

13

16 NIOSH: "National Occupational Research Agenda (NORA) For Occupational Safety And Health 348
Research And Practice In The U.S. Healthcare And Social Assistance (HCSA) Sector." [Online] Available at 349 http://www.cdc.gov/niosh/nora/comment/agendas/hlthcaresocassist/pdfs/HlthcareSocAssistFeb2013.p 350

df , 2013). 351

17 NIOSH: "Imp lementation of the National Academies’ Program Recommendations: NIOSH 352
Personal Protective Technology (PPT) Program." [Online] Available at 353 http://www.cdc.gov/niosh/nas/pdfs/PPT%20Program%20Response%20to%20NA%20Rec_BSC%20Repor 354
t_Final_101411update101911.pdf , 2011). 355

18 NIOSH: "Review of Progress Implementation Report for NIOSH Personal Protective Technology 356
Program." [Online] Ava ilable at 357 http://www.cdc.gov/niosh/nas/pdfs/PPT%20Program%20Progress%20Score%20Sheet%20With%20Scor 358
es%20Final.pdf , 2012). 359

19 NIOSH: "NIOSH Activities: Respiratory Protection Research." [Online] Available at 360 http://www.cdc.gov/niosh/topics/flu/respiratory.html , 2013). 361

20 NIOSH: "NIOSH Activities: Influenza Transmission Resea rch." [Online] Available at 362 http://www.cdc.gov/niosh/topics/flu/transmission.html , 2013). 363

21 NIOSH: "Personal Protective Technologies Activities: NIOSH Research Projects." [Online] 364

Avail able at http://www.cdc.gov/niosh/programs/ppt/projects.html , 2012). 365

22 NIH: "Research Portfolio Online Reporting Tools (RePORT)." [Online] Available at 366 http://projectreporter.nih.gov/reporter.cfm , 2013). 367

23 CDC: "Meeting Summary of the Workshop "Approaches to Better Understand Human Influenza 368

Transmission." [Online] Available at 369 http://www.cdc.gov/influenzatransmissionworkshop2010/pdf/Influenza_Transmission_Workshop_Sum 370
mary_508.pdf , 2010). 371

24 Gosch, M., R. Shaffer, A. Eagan, R. Roberge, V. Davey, and L. Radonovich: B95: A new 372
respirator for health care personnel. American Journal of Infection Control (xxx): e1

- e7 (2013). 373

25 Janssen, L., H. Ettinger, S. Graham, R. Shaffer, and Z. Zhuang: The Use of Respirators to Reduce 374

Inhalation of Airborne Biological Agents. Journal of Occupational and Environmental Hygiene (just

375
accepted)(2013). 376

26 AIHA, R.P.C.: Respirator Performance Terminology. Letter to the Editor. Am. Ind. Hyg. Assoc. J 377
63: 132 (2002). 378

27 Gould, D., and N. Drey: Types of i nterventions used to improve hand hygiene compliance and 379
prevent healthcare associated infection. Journal of Infection Prevention 14(3): 88

- 93 (2013). 380

28 Hugonnet, S., T.V. Perneger, and D. Pittet: Alcohol

- based handrub improves compliance with 381

hand hygien e in intensive care units. Archives of Internal Medicine 162(9): 1037 (2002). 382

29 Kampf, G.: The six golden rules to improve compliance in hand hygiene. Journal of hospital 383
infection 56(2): 3

- 5 (2004). 384

30 Shaffer, R., D. Novak, and J. Krah: Improving Respir ator Use and Compliance in Healthcare

– An 385
Invitation. In NIOSH Science Blog ( http://blogs.cdc.gov/niosh

- science

- blog/2013/05/resp

- hc

- mtg/)

, 386
NIOSH (ed.), 2013. 387

388