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Although we only had a taste of in 2009 (due to the relatively mild nature of the pandemic H1N1 virus), one of the realities we’d face with any severe respiratory outbreak would be coping with a finite supply of disposable PPEs (Personal Protective Equipment) for Health Care Workers (HCWs), such as N95 masks, gloves, and gloves.
While much would depend upon the severity, infectiousness, and duration of a pandemic wave, at one time the HHS estimated the nation would need 30 billion masks (27 billion surgical, 5 Billion N95) to deal with a major pandemic (see Time Magazine A New Pandemic Fear: A Shortage of Surgical Masks).
Our Strategic National Stockpile reportedly contains well over 100 million N95 and surgical masks (see Caught With Our Masks Down), but the demand for PPEs during a serious pandemic would far exceed the available supply.
In May of 2008 - in OSHA's Proposed Guidance On Respirators And Facemasks, we looked at their preliminary estimates of mask use by hospital and EMS/First Responders in a single pandemic wave.
(Click to Enlarge) Source DRAFT Workplace Stockpiling of Respirators and Facemask for Pandemic Influenza
The numbers of HCW's that will be working during a pandemic are unknown, but according to the CDC, there are 18 million Health Care Workers in this country. It is probably safe to assume that many HCW's who now have limited contact with critically ill patients would be called upon to treat flu victims during an emergency.
If just 1/3rd of these health-care workers were to provide direct care during a pandemic, and each required 480 N95 masks, then we'd need nearly 3 billion masks. And of course there will be plenty of non-HCW related positions that would presumably involve potential virus exposure (police, firefighters, national guard, etc).
Whatever the actual demand for masks and respirators would end up being during a severe pandemic, it will very likely exceed the available supply.
In 2009 the Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics released draft ethical pandemic guidelines on the rationing of scarce resources, where they estimated their were only enough PPE’s in the state of Minnesota to last 3 weeks into a severe pandemic.
Strategies to maximize the existing supply of respirators during a pandemic emergency are of great importance, and this past week NIOSH (the National Institute For Occupational Safety & Health) released updated guidelines on two ways to do just that.
First stop, an overview from NIOSH, followed by excerpts from the actual guidance document.
PANDEMIC PLANNING
Options to Prolong Existing and Surge Capacity Supplies of Respirators during Infection with Novel Influenza A Viruses Associated with Severe Disease
This webpage provides options for prolonging existing and surge capacity supplies of respirators during an infectious disease outbreak or pandemic. These options are for use by professionals with responsibility to manage a healthcare institution’s respiratory protection program.
Supplies of NIOSH-certified and FDA-cleared Surgical N95 filtering facepiece respirators can become depleted during an influenza pandemic or wide-spread respiratory pathogen outbreak. When facing depleted inventories as a result of these types of events, healthcare facilities should consider a combination of approaches to conserve supplies of N95 respirators:
- Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls;
- Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators) where feasible;
- Implement practices allowing extended use and/or limited reuse of N95 respirators; and
- Prioritize the use of N95 respirators for those personnel at the highest risk of contracting or experiencing complications of infection.
Page last updated: March 14, 2014
The two primary strategies explored in the guidance document are `extended use’ and `reuse’ of disposable N95 respirators. These are defined as:
Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters.
Reuse1 refers to the practice of using the same N95 respirator for multiple encounters with patients but removing it ('doffing') after each encounter. The respirator is stored in between encounters to be put on again ('donned') prior to the next encounter with a patient.
Admittedly, neither is ideal, but extended use and/or reuse of respirators could help conserve and maximize the availability of finite supplies of PPEs. While both options are explored in depth, the guidance suggests:
Extended use is favored over reuse because it is expected to involve less touching of the respirator and therefore less risk of contact transmission.
It is important to note that these are not `one size fits all’ recommendations, with the guidance further advising:
The decision to implement these practices should be made on a case by case basis taking into account respiratory pathogen characteristics (e.g., routes of transmission, prevalence of disease in the region, infection attack rate, and severity of illness) and local conditions (e.g., number of disposable N95 respirators available, current respirator usage rate, success of other respirator conservation strategies, etc.).
Given the complexity of the issues, and the length of this guidance document, I've only excerpted the opening paragraphs. Follow the link below to read it in its entirety.
PANDEMIC PLANNING
Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings
Background
This document recommends practices for extended use and limited reuse of NIOSH-certified N95 filtering facepiece respirators (commonly called “N95 respirators”). The recommendations are intended for use by professionals who manage respiratory protection programs in healthcare institutions to protect health care workers from job-related risks of exposure to infectious respiratory illnesses.
Supplies of N95 respirators can become depleted during an influenza pandemic (1-3) or wide-spread outbreaks of other infectious respiratory illnesses.(4) Existing CDC guidelines recommend a combination of approaches to conserve supplies while safeguarding health care workers in such circumstances. These existing guidelines recommend that health care institutions:
- Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls;
- Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators) where feasible;
- Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable; and
- Prioritize the use of N95 respirators for those personnel at the highest risk of contracting or experiencing complications of infection.
This document focuses on one of the above strategies, the extended use and limited reuse of N95 respirators only; please consult the CDC or NIOSH website for guidance related to implementing the other recommended approaches for conserving supplies of N95 respirators.
There are also non-emergency situations (e.g., close contact with patients with tuberculosis) where N95 respirator reuse has been recommended in healthcare settings and is commonly practiced.(5-9) This document serves to supplement previous guidance on this topic.
(Continue . . . )
One of the great (but rarely voiced) concerns about a particularly severe pandemic is that when the personal protective equipment runs out, many HCWs will decide they are no longer willing to work without basic respiratory protection.
Even were they to agree to work without protection, the attrition rate from infection would likely reduce their numbers quickly, rendering any noble gesture on their part short-lived.
So any steps that can increase the useful life of existing PPEs, and give hospitals time to restock their supplies (which, admittedly, may be very difficult in a pandemic), are crucial if healthcare facilities are to remain operational.
For more on the thorny issues of HCWs working during a pandemic, you may wish to revisit:
Study: Willingness of Physicians To Work During A Severe Pandemic
Downton Abbey Rekindles An Old HCW Debate
UK Poll: Will HCW’s Work In A Pandemic?
[PDF - 4.7 MB]
or influenza-like illness, the emergency warning signs to seek urgent care, including but not limited to difficulty breathing, shortness of breath, or pain or pressure in the chest or abdomen, and the need to seek care aggressively if they have conditions that put them at higher risk of complications of influenza or if they have any concerns about their symptoms.