 Public health experts are issuing a new warning this morning about a highly contagious disease tuberculosis. There were more than 26,000 new cases of tuberculosis reported in the United States last year, nearly 4,000 here in New York City. What you are seeing is not from a developing country. It is not from decades ago. Tuberculosis, fueled by AIDS and immigration, is growing at such a rate that it cannot be ignored. This is the story of tuberculosis in the United States during the 1990s. A story that includes the emergence of multi-drug resistant strains, hospital outbreaks and the infection of many healthcare workers. A small number of workers even lost their lives to the disease. An epidemic is the word being used to describe the out-of-control outbreak of tuberculosis in many countries. Thanks to aggressive nationwide response, the occurrence of TB appears to be decreasing at this time, but the threat remains very significant for healthcare workers. Tuberculosis last peaked almost a century ago, but experts say it is not a re-emerging disease. It never really went away. And images like these remind us that this threat must be taken seriously. I'm Loretta Swit for the National Institute for Occupational Safety and Health. This program is intended to supplement the written NIOSH Guide for Respirator Program Administrators. The guide contains full details of NIOSH recommended procedures, as well as regulations set forth by OSHA, the Occupational Safety and Health Administration. What we're going to do here is provide an overview of each of your responsibilities as they are detailed in the guide so that you have a clear understanding of how to establish a respiratory protection program. It goes without saying that workers exposed to patients with infectious tuberculosis need to be protected from the disease. Because engineering controls like negative pressure isolation rooms may not control the TB hazard completely, the use of respirators is necessary. The OSHA Respiratory Protection Standard clearly states that a formal respiratory protection program must be in place at any facility where respirators are needed. There are many factors to consider when developing a program, but the administrator's guide divides this process into eight steps for you to follow. So now let's take a look at where to begin. Step one, conduct a TB risk assessment. Infection control measures should be based on careful assessment of the risk for TB transmission. A risk assessment must be performed for the entire facility as well as for specific areas. The primary goal of the assessment is to determine which employees must wear respirators and when they should be worn. Because the risk of transmission depends on many variables, it can vary greatly from one health care environment to another. A constellation of factors such as patient population, prevalence of TB in the community, and the effectiveness of existing TB control measures can impact risk levels. For example, the risk may be higher in an emergency room because patient care is initiated prior to diagnosis. If procedures that stimulate coughing routinely occur in these areas, the risk is compounded. Or consider this hospital waiting area. At first it may not seem like a place where you would have to assess the risk of TB transmission, but there could very well be factors present that increase the risk like high prevalence of TB in the community the hospital serves. Your initial assessment should take into account data from a variety of sources from within the facility, such as infection control and discharge records, and from the community at large. Follow-up assessments are required at least annually. The specific elements of a TB risk assessment are detailed in your administrator's guide. Once the assessment is complete, you will be ready for the next step. Select respirators. You should provide a variety of respirator models and sizes to all users. An adequate selection will ensure that workers can find a respirator with a comfortable and effective fit. Respirators that aren't comfortable will be less likely to be used as needed. Also, if respirators do not fit properly, they will not offer adequate protection. Of course, all respirators must be NIOSH certified. Respirators labeled N, R or P and that have a filter efficiency rating of at least 95% will provide adequate protection. For example, a respirator labeled N95 has an N-series filter with a 95% efficiency rating. The disposable particulate respirator is by far the most common type used in health care and is adequate for most situations. These respirators are lightweight, relatively easy to wear and do not require cleaning. They usually come in three sizes and can be obtained with or without an exhalation valve. If respiratory protection is needed in a sterile environment, disposable particulate respirators should be used, provided they are not equipped with an exhalation valve. Workers should never use a respirator with an exhalation valve in a sterile environment. An exhalation valve exhausts air breathed by the user and may contaminate the field. All disposable models can be used with a face shield in case protection against body fluids is needed. Workers should take care to ensure the shield does not interfere with the respirator's fit. Otherwise, the respirator may not provide needed protection. As you are probably aware, a typical surgical mask is not a respirator and does not adequately protect against TB. Because some disposable respirators resemble surgical masks, make sure that workers clearly understand the difference between them. Other particulate respirators use replaceable N, R or P filters. These filters are made of the same material as those found on disposable respirators that protect against TB. Half mask and full facepiece models are available. Full facepieces offer a better seal in addition to eye protection. The need for such protection will of course depend on the overall level of risk. Note that all respirators of this type have an exhalation valve as well and therefore cannot be used in sterile areas. The next type of respirator is the powered air purifying respirator or PAPR. These respirators use a motorized blower to pass contaminated air through a HEPA filter and are powered by a battery pack attached to the wearer. Purified air is then delivered to a half mask, full facepiece or hood. PAPRs are designed for higher risk situations where disposable or replaceable filter half mask respirators do not provide adequate protection. Your risk assessment will indicate when the use of PAPRs may be necessary. Note that some types of facial hair can interfere with the function of tight fitting respirators which compromises the protective seal. In such cases hooded PAPRs can be used. Like other respirators we've discussed, PAPRs are not suitable for use in sterile environments. The final type of respirator you may need to consider is the positive pressure supplied air respirator. Unlike more common respirators which filter environmental air, supplied air respirators deliver compressed air from a stationary source to a half mask or full facepiece. These respirators offer an advanced level of respiratory protection and should be used in special circumstances such as an autopsy where greatest protection is needed. Once you have selected respirators based on your risk assessment, it's time to put all aspects of the program in writing. You are required to establish standard operating procedures or SOPs governing the selection and use of respirators at your facility based on each user's need. A written SOP should describe a procedure so thoroughly that it cannot be misinterpreted. SOPs should contain all information necessary to maintain a successful respirator program. This information should be presented in an easy to follow manner such that it is useful to all individuals directly involved in the program. The following individuals should have a thorough understanding of your program's SOPs, you as the program administrator, those responsible for fitting respirators, respiratory protection trainers, and supervisors who oversee respirator use. Your administrator's guide contains a sample SOP that covers all required respirator program elements. You may also wish to contact respirator manufacturers for further guidance. Respirators can place certain physical stresses on wearers, especially the pulmonary and cardiac systems. However, because respirators used in healthcare are generally lightweight, such stresses are usually small and virtually all workers can safely wear respirators. Even so, current OSHA TB Respiratory Protection regulations state that workers should not be assigned tasks requiring respirators unless they have been determined to be physically able to wear them on the job. These regulations further state that a physician should establish the criteria for making this determination. The Centers for Disease Control and Prevention recommend using a health questionnaire as the first step in screening workers. If the results from the evaluation are essentially normal, the worker can be cleared for respirator use. If the results indicate a potential problem, further evaluations, such as a physical exam or a spirometry testing, should be performed. Your administrator's guide contains a sample medical questionnaire and medical clearance form. This marks the halfway point in developing a respirator program. By now you will have conducted a TB risk assessment and based on that assessment selected appropriate respirators for each area of your facility. You will have detailed all aspects of the program in writing and determined who may not wear respirators based on your medical screening. And now it's time to discuss the four remaining steps. Step 5 Provide Training Your administrator's guide will help you decide who should receive training, who should conduct it, and the topics to be covered. The training should convey all information necessary to facilitate proper use of the respirators you have selected. Workers must also receive annual retraining. It is important to present this information in such a way that workers are highly motivated to protect their health through proper respirator use. Workers will be more likely to adopt safe behaviors if the training focuses on both the risk of infection and the benefits of respiratory protection. One of the most popular approaches to encouraging safe behavior is the health belief model. Using this model, let's look at the four key beliefs that your training should instill in workers. First, workers must feel susceptible to the disease. Many individuals do not feel susceptible to TB because they have no firsthand experience with the disease and do not understand how it develops. Therefore, it is imperative that the training establish a clear cause and effect relationship between exposure and disease. Workers must understand how TB is transmitted and recognize situations that place them at risk for infection. If this threat is presented in concrete logical terms, workers will be more likely to believe that it is real and be compelled to take appropriate action. Workers must also believe the illness poses serious consequences to health and well-being. Rather than describing TB in abstract medical terms, your training program should realistically describe the impact of the disease on quality of life. Workers must be able to appreciate how TB can compromise family interaction, recreational activities, hobbies, and livelihood. You may wish to use case histories and testimonials from workers who have developed TB to illustrate these effects. Workers must believe that respirators can control the risk. They should understand that respirator use can effectively reduce the risk of exposure. To convey this information, the training should explain how respirators work and the importance of proper use and maintenance. Workers should be confident of their ability to wear respirators correctly. If workers understand the basic principles of respirator operation, they will be more likely to accept them and believe they are effective. And finally, workers must believe that the benefits of respirator use outweigh the barriers. Realistically speaking, wearing a respirator is a major inconvenience to most workers. But rather than ignoring this fact, your training program should emphasize that protecting one's health and well-being is well worth the effort. Any inconvenience associated with respirators must be viewed as a very small price to pay for the protection they provide. A successful training program will strive to foster all of these beliefs in respirator users. You may find it useful to obtain prepared educational materials for use in your program. NIOSH offers a TB Protection Guide for Workers, as well as a video. Information on obtaining these materials will be given at the end of this program. Step 6 Fit Test Respirators Workers must be fit tested before they are issued any type of tight-fitting respirator and each year thereafter. Fit testing is performed to determine which brand, model, and size of respirator fits the user adequately. A proper fit will prevent inward leakage of TB bacteria and ensure that the respirator performs as intended. You will need to decide whether to use qualitative or quantitative fit testing at your facility. In either case, testing must be performed by a qualified individual who is knowledgeable about testing procedures and instruments. Qualitative fit testing is limited to half-mask respirators. It relies on the wearer's subjective response to taste, odor, or irritation. In this example, the tester is releasing saccharine aerosol under the testing hood. If the subject can taste the substance, the fit of the respirator is not acceptable. However, if the wearer does not detect the saccharine, an acceptable fit has been achieved. Quantitative fit testing can be used for all respirators and utilizes special measurement equipment. This testing yields objective data that are used to determine fit quality. Again, you must ensure that the tester is able to calibrate and operate all testing instruments and interpret results correctly. Once an appropriate respirator has been selected, provide the user with a wallet-sized card containing his or her name, the date of the test, and the type, brand, model, and size of respirator. This information must also be kept in your program files. In addition to the initial fit test, wearers must check the seal of their respirators every time they put them on. User seal checks are necessary to ensure that a respirator has been put on correctly. Instructions for user seal checking are usually provided by the manufacturer and can also be found in your administrator's guide. Of course, complete details about user seal checking must be provided and reinforced during training. Only after all face-fitting procedures are complete can you issue respirators to your workers. Step 7 Maintain Respirators As part of your ongoing duties, you must periodically observe respirator users to ensure that respirators are properly maintained. A poorly maintained or malfunctioning respirator may actually be more dangerous than not wearing one at all. Workers should always follow the manufacturer's instructions when performing any type of respirator maintenance. For non-disposable respirators, it's a good idea to inspect the respirator every time it is disassembled for cleaning and sanitizing. If any defects are found, repair or replacement is imperative. Of course, the disposable respirators worn by most workers cannot be cleaned or sanitized. However, routine inspection is still necessary. Disposables must be discarded and replaced when they become worn or soiled. All respirators should be stored in an accessible place where they are protected from physical damage as well as moisture, heat and other contaminants. Step 8 Program Evaluation Once your respirator program is up and running, you should evaluate the program at least annually. This evaluation should be comprehensive, covering all aspects of the program. Your annual evaluation should consist of the following measures. Review the program using the checklist provided in your administrator's guide. Conduct a risk assessment to determine if the level of risk has changed. Review the medical surveillance of respirator users. Follow-up on any evidence of excessive exposure to hazards. General inspections of day-to-day operations will also help you determine if respirators are being worn and maintained correctly. This should include consulting respirator users in order to identify potential problems. Based on your evaluation, you may find it necessary to revise the program's written SOPs. And those are the eight steps to developing a successful respirator program. The more successful your program, the more attention you give to it, the more seriously you take your responsibility. The more these images will be history. As a program administrator, it is important for you to remain knowledgeable about respiratory protection. You may find it helpful to obtain educational materials from respirator manufacturers. Professional associations and journals also provide current and reliable information. Or you can visit other facilities to observe their programs. NIOSH also sponsors professional training courses at its education and research centers located throughout the country. And on behalf of NIOSH, I'd like to thank you for your commitment to the well-being of the health care community. I'm Areta Swit. Thank you for watching. To request copies of NIOSH Publication 96102 Protect Yourself Against Tuberculosis, or the video Respirators Your TB Defense, call 1-800-35-NIOSH. You may also call for information on courses at NIOSH Education and Research Centers. NIOSH can also be reached on the Internet at www.cdc.gov.niyosh.