A plethora of options – Credit NIOSH
# 8665
An infection control topic was raised on twitter last night by Dr. Ian Mackay that has ramifications for a lot of bearded men, myself included; how to get a good N95 respirator fit? As we’ve discussed previously (see Survival Of The Fit-tested), while N95 respirators can provide excellent protection, that falls apart if a proper seal isn’t maintained.
My personal attack plan involves a pair of scissors, a razor, and no small amount of regret.
But in many societies beards are more than just a fashion choice, they have deep social and religious meaning, making their removal a far more difficult decision. Despite the difficulty (some might say, impossibility) of maintaining a decent seal, we’ve seen more than a few bearded health care workers (HCWs) attempting to wear N95 respirators in Saudi Arabia.
One can’t help but wonder how much of a role ill-fitting N95 respirators (or worse, the use of surgical masks, and no eye protection) has played in the nosocomial spread of the MERS virus in the Middle East.
In the United States OSHA regulates worker safety, and that agency’s respiratory protection standard, 1910.134, requires workers to be clean shaven when wearing an N95 respirator. Facial hair, including some sideburns, can effectively destroy a respirator’s seal.
The experts in protective equipment for HCWs are the folks at the National Personal Protective Technology Laboratory (NPPTL) which is part of The National Institute for Occupational Safety and Health (NIOSH), have put together a FAQ on respirator use, which addresses the issue of beards.
What do you do with employees who have facial hair? (What if the beard or mustache is small enough that it is contained inside the respirator?)
Tight-fitting respirators require the wearer’s face to be clean shaven where the respirator’s seal comes in contact with the skin. If the facial hair does not extend far enough to interfere with the device’s seal in any way, or interfere with the function of the exhalation valve, the wearer may wear it with the approval of the respiratory protection administrator.
Loose-fitting respirators, such as Powered Air-Purifying Respirators (PAPRs) with loose-fitting hoods, do not form a tight seal with the face and, therefore, do not require the wearer to have a clean shaven face. Loose-fitting respirators (i.e. respirators with loose-fitting hoods or helmets) are the only type of respirators that may be worn with facial hair and do not require fit testing.
In response to a question posed on the NIOSH Science blog N95 Respirators and Surgical Masks by Lisa Brosseau, ScD, and Roland Berry Ann, we learn that the tolerance for beard stubble is pretty low:
For men working in healthcare or EMS with long shift length sometimes exceeding 12 hours how do you suggest ensuring adequate mask to face interface for an appropriate seal or do you suggest a PAPR.
Paragraphs (g)(1)(i) and (g)(1)(ii) in OSHA’s 29 CFR 1910.134 are intended to ensure that facial hair is prevented from interfering with the facepiece seal or valve function. We are unaware of any interpretive OSHA compliance or NIOSH policies defining a time duration between shaves or length of “stubble” or beard growth that would be prohibited. Although the growth and beard density varies among individuals, generally, a one-day’s growth of facial hair is deemed acceptable to avoid interfering with the facepiece’s ability to seal to the wearer’s face.
While far more expensive, the alternative to wearing a disposable N95 mask is to wear a battery powered PAPR (Powered Air Purifying Respirator). These may be full face, or hooded designs.
Credit CDC – NIOSH
Being a powered respirator, they are easier to work in and breath with for long periods of time, and it are preferred protection when performing AGPs (aerosol generating procedures) over the N95 respirator.
This from the Minnesota Department of Health:
Choosing a PAPR
A PAPR may be selected for use if:
The N95 respirator choice(s) does not fit.
Employee has facial hair or facial deformity that would interfere with mask-to-face seal.
The N95 respirator choice(s) are unavailable.
Desired for high-risk aerosol-generating procedures.
PAPRs can be used by persons who are medically certified, but who cannot wear
N95 -disposable respirators (e.g. persons with facial hair).see also>> Respirator Selection: Public Health Respiratory Protection Program Template
What is a PAPR?
The equipment is battery operated, consists of a half or full facepiece, breathing tube, battery-operated blower, and particulate filters (HEPA only).
A PAPR uses a blower to pass contaminated air through a HEPA filter, which removes the contaminant and supplies purified air to a facepiece.
A PAPR is not a true positive-pressure device because it can be over-breathed when inhaling.
A face shield may also be used in conjunction with a half-mask PAPR respirator for protection against body fluids.
While generally considered superior protection over N95 respirators, PAPRs have a high initial cost which ranges from several hundred to several thousands of dollars. PAPRs can also be hot , heavy, and for some users – claustrophobic to wear. Their battery packs require recharging – usually after 8 hours of operation - and PAPRs require replacement filters.
Although PAPRs are a potential solution for the bearded HCWs, their cost and availability in most healthcare settings are likely to be major obstacles to everyday use.
The CDC’s Updated Guidance on MERS Infection Control.
Standard, contact, and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection, based on CDC's case definition for patient under investigation. Note that additional infection prevention precautions or considerations may be needed if a MERS-CoV patient has other conditions or illnesses that warrant specific measures (e.g., tuberculosis, Clostridium difficile, multi-drug resistant organisms).
Though these recommendations focus on the hospital setting, the recommendations for personal protective equipment (PPE), source control (i.e., placing a facemask on potentially infected patients when outside of an airborne infection isolation room), and environmental infection control measures are applicable to any healthcare setting.
(Continue . . . )
For more on appropriate respiratory protection for HCWs dealing with MERS patients, you may wish to revisit last weeks CIDRAP Commentary: Protecting HCWs From MERS-CoV.
And a couple of more MERS infection control blogs that may be of interest:
MERS: Are Two Surgical Masks Better Than One?
Voting On MERS Transmission: Do The Eyes Have It?
UPDATED: Added a short Youtube video from Kimberly-Clark on Fit testing N95 masks.
