DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Institute for Occupational Safety and Health

Summary

Evidence from surveillance studies indicates gaps in hospitals’ respiratory 

protection programmatic operations 

and healthcare workers’ (HCWs) marginal compliance with respiratory protection recommended practices. Improper use of respiratory protective 

devices (RPDs) may expose HCWs to 

infectious respiratory illnesses. In this 

document, NIOSH addresses common 

myths related to respiratory protection 

and provides information to reinforce 

respiratory protection program administrator responsibilities and HCW 

knowledge concerning the proper use 

of these devices so that they can be prepared for the next public health emergency and best protect themselves in 

daily practice.

Preparedness through Daily Practice: 

The Myths of Respiratory Protection

in Healthcare

Description of 

Exposure

Background

The healthcare industry is among the 

fastest growing occupational sectors in 

the United States, with nearly 18 million workers [NIOSH 2012]. Because 

of the nature of their work, HCWs may 

be exposed to various infectious respiratory illnesses that are spread through 

airborne and droplet routes, such as 

Mycobacterium tuberculosis and seasonal influenza, respectively. During a 

public health emergency, HCWs have 

an increased risk of exposure [HHS 

2005]. They were among the most affected during the 2009 H1N1 pandemic. One study reported higher rates of 

influenza-related hospitalizations compared with workers in other industries [Luckhaupt et al. 2012]. Appropriate implementation of precautions 

against airborne and droplet transmission are critical to prevent the spread of 

aerosol transmissible diseases among 

HCWs who work directly with patients 

and others [Siegel et al. 2007]. However, only 20% of HCWs known to be infected by contagious patients reported 

using RPDs during all interactions with 

patients suspected of being infectious 

[Wise et al. 2011]. Addressing HCWs’ 

marginal use of RPDs might be a way 

to reduce their risk. Any staff member 

may be exposed if he or she works in areas near patients who are suspected of 

having a disease that requires precautions against airborne transmission. To 

minimize the risk of exposure, healthcare 

facilities should implement engineering and administrative controls, including airborne infection isolation rooms 

and employee vaccination programs. In 

some cases, the Centers for Disease 

Control and Prevention (CDC) recommends that HCWs wear RPDs, such 

as N95 filtering facepiece respirators 

(FFRs), also known as “N95s”, or powered air purifying respirators (PAPRs) if 

they must share the same airspace with 

a potentially infectious patient [Siegel 

et al. 2007] To read more on healthcare 

workplace pandemic influenza risk classification, please reference this Occupational Safety and Health Administration 

(OSHA) fact sheet.

To be effectively protected from infectious respiratory diseases that require 

Airborne Precautions, HCWs must 

properly use RPDs when needed. From 

past research, NIOSH has determined 

that many HCWs do not follow recommended practices; and in some cases, 

they do not use RPDs when they should 

[Beckman et al. 2013; Wise et al. 2011].

NIOSH Research—the 

Respirator Evaluation 

in Acute Care Hospitals 

(REACH II) Study

From 2011–2012, NIOSH worked 

with health departments and universities in six states located in five U.S. 

regions for the Respirator Evaluation 
in Acute Care Hospitals study (REACH II). The goal of 

REACH II was to determine whether HCWs were following 

recommended respiratory protection practices [Siegel et al. 

2007; CDC 2013]. In addition, NIOSH questioned whether acute care hospitals were implementing their respiratory protection programs in workplaces where respirator use 

is required by the OSHA respiratory protection standard 29 

CFR* 1910.134. More than 1,500 workers (i.e., hospital managers, unit managers, and HCWs) in 98 hospitals participated in the study. NIOSH found that many hospitals did have 

a written respiratory protection program but that hospital 

managers and HCWs were following these programs differently. REACH II results confirm past research, finding that 

many HCWs are not following recommended infection control guidelines and appear to be confused about when, what 

type, and how to properly care for, use, remove and dispose 

of RPDs [Peterson et al, 2015; Siegel et al. 2007]. To ensure 

their health is protected, respiratory protection program administrators must be knowledgeable and inform HCWs about 

the required elements of a respiratory protection program and 

recommended infection precaution practices before the next 

public health emergency occurs (See infographics of Key Requirements and Infection Control in Healthcare).

Pandemic Preparedness

Influenza pandemics vary widely in their severity and impact [Reed et al. 2013]. In addition, pandemics are unpredictable in terms of when and where they begin. Scientists 

have not established accurate methods for forecasting influenza pandemics, nor have they established methods for 

predicting the severity of a future pandemic [Chretien et al. 

2014]. When a pandemic occurs, most people will likely have 

little to no immunity to the novel virus causing the pandemic, and a vaccine will likely not be immediately available. The 

next pandemic could cause an estimated 314,000‒734,000 

hospitalizations in the United States alone [OSHA 2009]. 

In the last decade, several different types of infectious disease outbreaks have occurred. Therefore as part of emergency preparedness efforts, hospitals and other medical facilities 

should include planning for HCWs to properly use RPDs as 

part of response efforts. During the REACH II research process [Peterson et al. 2015], NIOSH discovered several common myths that require attention.

Myth: We are prepared for an 

influenza pandemic because 

there are stockpiles of N95s

Stockpiles of personal protective equipment (PPE), including RPDs, are maintained by some government bodies and 

*Code of Federal Regulations. See CFR in References.

healthcare facilities; however, a pandemic could easily 

consume these supplies. More than 75% of the N95s in the 

Federal Strategic National Stockpile were shipped out during 

the 2009 H1N1 pandemic [HHS 2012]. Despite the stockpiled supplies, some healthcare facilities reported shortages 

of RPDs and issues with the devices they received. In many 

cases, the RPDs received did not match the facility’s current inventory in terms of sizes and models; requiring many 

HCWs to be fit tested for the new devices [HHS 2012]. In addition, the Department of Health and Human Services recommends that healthcare facilities have a 6‒8 week supply of 

disposable N95s [HHS 2005]. Yet about 50% of hospitals report that they do not have an RPD stockpile [Rebmann et al. 

2013]. Overall, a number of healthcare facilities are not fully 

equipped for the next influenza pandemic or infectious disease outbreak and should further plan and prepare.

Myth: Respirators and surgical 

masks provide the same type and 

level of protection for the user

Respirators and surgical masks (i.e. facemasks) are intended for different functions and do not provide the same types 

or levels of protection. Surgical masks can be used as source 

control to protect patients from an HCW’s respiratory secretions as well as to protect HCWs from large-droplet splashes or sprays of bodily fluids from patients. Surgical masks are 

typically disposable, loose-fitting, and do not form a tight 

seal to the face (See Figure 1). They are also not designed to 

capture a large percentage of small particles, which means 

that they cannot prevent the wearer from breathing in airborne particles that may be transmitted by coughs, sneezes, 

or certain medical procedures (i.e. aerosol generating procedures). Because of these factors, HCWs using surgical masks 

will not be protected against exposure to airborne transmissible diseases [NIOSH 2009].

Respirators are designed to protect HCWs by providing a 

tight seal against the skin and filtering out a wide size range 

of airborne particles. However, the NIOSH certification 

process does not include testing for splash and spray protections. If an HCW needs both respiratory and splash and 

spray protection, then a surgical N95 respirator should be 

used [NIOSH 2013] (See Figure 2). Ideally, RPDs should be 

selected based on the type of infectious disease transmission 

precaution recommended by the CDC [Siegel et al. 2007]. In 

some cases, the task being performed on a patient with a suspected or confirmed infectious disease (i.e., aerosol-generating procedure or close contact) will affect the types of RPDs 

that are recommended (See Figure 3).

For more information about respiratory protection devices 

in healthcare settings, please see the OSHA/NIOSH Hospital 

Respiratory Protection Program Toolkit.
Figure 1. Loose-fitting surgical mask Figure 2. Tight-fitting N95 Filtering Facepiece Respirator 

(sealed against the skin)

Myth: All N95 respirators fit and 

protect the same

Although all N95 FFRs are designed to filter at least 95% of 

a wide size-range of particles, this protection depends on 

selecting the right respirator for the wearer. To be properly protected, the wearer must select a respirator that fits well 

to his or her face and minimizes the amount of air leakage 

into the facepiece [NIOSH 2009]. Because the fit of a respirator depends on certain factors, including facial characteristics, employers must provide a variety of respirator models 

and sizes for workers to try during the fit testing process. In 

addition, users and their RPP administrator should consider their purpose for wearing a respirator: do they only need 

respiratory protection? Or do they also need to be shielded from possible splashes and sprays? These factors must be 

considered during a HCWs first fit test, which is done before 

an employee is authorized to wear a respirator [The Joint 

Commission 2014].

According to OSHA regulations, before an employee is allowed to wear a respirator, he or she must be fit tested. Fit 

testing must be repeated on a yearly basis, when a different 

respirator must be used, or when there has been a change 

to the wearer’s facial structure such as in cases of extreme 

weight change or dental work. Results from REACH II indicate that many HCWs do not know the model and size respirator for which they have been fit tested, nor do they know 

how often fit testing should take place. If HCWs are unaware of this information, they may use a device for which 

they have not been fit tested, or not be fit tested frequently enough. During a pandemic, shortages of N95 FFRs are 

likely to occur, and workers may need to switch to a different model or size device. In this emergency situation, HCWs 

would need to be fit tested again with the new respirator (See 

Infographic of Fit Test Requirements).

Myth: A good fit is good enough

Selecting a respirator that fits properly is important, but 

HCWs will not be protected if they do not use the respirator 

correctly. During the REACH II study, researchers observed 

more than 300 HCWs as they donned (put on) and doffed 

(took off) a respirator. In many of the hospitals, HCWs used 

improper practices, including wrong strap placement, not 

performing a user seal check, improper removal (not using straps), and improper disposal of the device. Every respirator has its own user instructions from the manufacturer, 

which typically include information about proper donning 

and doffing techniques for the device. HCWs should be 

trained on a yearly basis to use their respirator and have access to these instructions so that they are aware of the proper procedures for their respirator. (Please see these general 

guidelines for proper donning and doffing procedures.)

Myth: Medical evaluations are 

only necessary before initial 

clearance for respirator use

Medical evaluations are necessary before initial clearance 

because respirators can affect a wearer’s physiological and 

psychological status. The evaluation process ensures that a 

worker’s health will be not be negatively affected by wearing 
an RPD. Before clearance, an employee fills out a medical 

questionnaire; and if any answer indicates a possible health 

issue, the employee will be referred for a follow-up examination.

OSHA also requires medical evaluations in other scenarios 

such as when the licensed medical provider deems it necessary; when a HCW reports medical symptoms that may interfere with their ability to safely use a respirator; when a supervisor feels that a worker needs to be re-evaluated; and 

when changes in the workplace may affect an employee’s ability to wear a respirator [29 CFR 1910.134]. Findings from the 

REACH II study [Peterson et al. 2015] indicate that both 

managers and HCWs are aware that medical evaluations need 

to be conducted prior to use, but many are unaware of the 

other scenarios in which evaluations may be necessary. More 

information about medical evaluations can be found on the 

NIOSH Medical Evaluation FAQs webpage.

Acknowledgments

This document was prepared by Jaclyn Krah, MA, Debra Novak, PhD, RN and Lindsay Stradtman, MPH, National Personal Protective Technology Laboratory, National Institute 

for Occupational Safety and Health.

We would like to thank Dr. Kristina Peterson from RTI International and the members of the REACH II evaluation group 

for their input and guidance with this document.

References

Beckman S, Materna B, Goldmacher S, Zipprich J, D’Alessandro M, 

Novak D, et al. [2013]. Evaluation of respiratory protection programs and practices in California hospitals during the 2009–2010 

H1N1 influenza pandemic. Am J Infect Control 41(11):1024–1031.

CDC [2013]. Prevention strategies for seasonal influenza in healthcare settings. Atlanta, GA: U.S. Department of Health and Human 

Figure 3. Recommended type of RPD for airborne and droplet precautions and seasonal influenza.

Close contact

Aerosol-generating 

procedure

N95 Filtering 

Facepiece Respirator 

(N95 FFR), equivalent 

or higher

N95 FFR, 

equivalent or higher

Close contact Surgical mask, 

equivalent or higher

Aerosol-generating 

procedure

See CDC 

recommendations for 

specific agent

Patient with suspected 

or confirmed infectious 

disease requiring 

droplet precautions

N95 FFR, equivalent 

or higher

Surgical mask, 

equivalent or higher

Close contact

Aerosol-generating 

procedure

Patient with 

suspected or 

confirmed 

seasonal influenza

Patient with suspected

or confirmed infectious 

disease requiring 

airborne precautions 
For More Information

To receive documents or other information about occupational safety and health topics, contact NIOSH at

Phone: 1-800-CDC-INFO (1-800-232-4636)

TTY: 1-888-232-6348 ■ E-mail: cdcinfo@cdc.gov

or visit the NIOSH website at www.cdc.gov/niosh.

For a monthly update on news at NIOSH, subscribe to 

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

Mention of any company or product does not constitute endorsement by NIOSH. In addition, citations to 

websites external to NIOSH do not constitute NIOSH 

endorsement of the sponsoring organizations or their 

programs or products. Furthermore, NIOSH is not responsible for the content of these websites.

This document is in the public domain and may be 

freely copied or reprinted. NIOSH encourages all 

readers of the Workplace Solutions to make them 

available to all interested employers and workers.

As part of the Centers for Disease Control and Prevention, 

NIOSH is the Federal agency responsible for conducting research and making recommendations to prevent work-related illnesses and injuries. All Workplace Solutions are based on 

research studies that show how worker exposures to hazardous agents or activities can be significantly reduced.

DHHS (NIOSH) Publication No. 2016–109

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Suggested Citation

NIOSH [2015]. Workplace solutions: preparedness through 

daily practice: the myths of respiratory protection in healthcare. 

By Krah J, Novak D, Stradtman L. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety 

and Health, DHHS (NIOSH) Publication No. 2016-109.