a position statement and practical guide to the use of particulate filtering facepiece CORD-Papers-2022-06-02 (Version 1)

Title: A position statement and practical guide to the use of particulate filtering facepiece respirators (N95 FFP2 or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2
Abstract: SUMMARY: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 m that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators (respirators; e.g. N95 masks) are more effective than surgical masks against bio-aerosols many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA) however surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19 with respirators reserved for so-called aerosol-generating procedures. In contrast SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB) which is also transmitted via aerosol. In health facilities in SA distinguishing between TB and COVID-19 is challenging without examination and investigation both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death. RECOMMENDATIONS: Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of zero harm aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly we recommend: 1. the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections; 2. the use of respirators that meet national and international manufacturing standards; 3. evaluation of all respirators at the least by qualitative fit testing; and 4. the use of respirators as part of a package of care in line with international IPC recommendations. We recognise that this will be challenging not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.
Published: 2021-10-22
Journal: Afr J Thorac Crit Care Med
DOI: 10.7196/ajtccm.2021.v27i4.173
DOI_URL: http://doi.org/10.7196/ajtccm.2021.v27i4.173
Author Name: Dheda K
Author link: https://covid19-data.nist.gov/pid/rest/local/author/dheda_k
Author Name: Charalambous S
Author link: https://covid19-data.nist.gov/pid/rest/local/author/charalambous_s
Author Name: Karat A S
Author link: https://covid19-data.nist.gov/pid/rest/local/author/karat_a_s
Author Name: von Delft A
Author link: https://covid19-data.nist.gov/pid/rest/local/author/von_delft_a
Author Name: Lalloo U G
Author link: https://covid19-data.nist.gov/pid/rest/local/author/lalloo_u_g
Author Name: van Zyl Smit R
Author link: https://covid19-data.nist.gov/pid/rest/local/author/van_zyl_smit_r
Author Name: Perumal R
Author link: https://covid19-data.nist.gov/pid/rest/local/author/perumal_r
Author Name: Allwood B W
Author link: https://covid19-data.nist.gov/pid/rest/local/author/allwood_b_w
Author Name: Esmail A
Author link: https://covid19-data.nist.gov/pid/rest/local/author/esmail_a
Author Name: Wong M L
Author link: https://covid19-data.nist.gov/pid/rest/local/author/wong_m_l
Author Name: Duse A G
Author link: https://covid19-data.nist.gov/pid/rest/local/author/duse_a_g
Author Name: Richards G
Author link: https://covid19-data.nist.gov/pid/rest/local/author/richards_g
Author Name: Feldman C
Author link: https://covid19-data.nist.gov/pid/rest/local/author/feldman_c
Author Name: Mer M
Author link: https://covid19-data.nist.gov/pid/rest/local/author/mer_m
Author Name: Nyamande K
Author link: https://covid19-data.nist.gov/pid/rest/local/author/nyamande_k
Author Name: Lalla U
Author link: https://covid19-data.nist.gov/pid/rest/local/author/lalla_u
Author Name: Koegelenberg C F N
Author link: https://covid19-data.nist.gov/pid/rest/local/author/koegelenberg_c_f_n
Author Name: Venter F
Author link: https://covid19-data.nist.gov/pid/rest/local/author/venter_f
Author Name: Dawood H
Author link: https://covid19-data.nist.gov/pid/rest/local/author/dawood_h
Author Name: Adams S
Author link: https://covid19-data.nist.gov/pid/rest/local/author/adams_s
Author Name: Ntusi N A B
Author link: https://covid19-data.nist.gov/pid/rest/local/author/ntusi_n_a_b
Author Name: van der Westhuizen H M
Author link: https://covid19-data.nist.gov/pid/rest/local/author/van_der_westhuizen_h_m
Author Name: Moosa M Y S
Author link: https://covid19-data.nist.gov/pid/rest/local/author/moosa_m_y_s
Author Name: Martinson N A
Author link: https://covid19-data.nist.gov/pid/rest/local/author/martinson_n_a
Author Name: Moultrie H
Author link: https://covid19-data.nist.gov/pid/rest/local/author/moultrie_h
Author Name: Nel J
Author link: https://covid19-data.nist.gov/pid/rest/local/author/nel_j
Author Name: Hausler H
Author link: https://covid19-data.nist.gov/pid/rest/local/author/hausler_h
Author Name: Preiser W
Author link: https://covid19-data.nist.gov/pid/rest/local/author/preiser_w
Author Name: Lasersohn L
Author link: https://covid19-data.nist.gov/pid/rest/local/author/lasersohn_l
Author Name: Zar H J
Author link: https://covid19-data.nist.gov/pid/rest/local/author/zar_h_j
Author Name: Churchyard G J
Author link: https://covid19-data.nist.gov/pid/rest/local/author/churchyard_g_j
sha: 130f29d3addd0c0ecccc650cd080b09315426c35
license: cc-by
license_url: https://creativecommons.org/licenses/by/4.0/
source_x: Medline; PMC; WHO
source_x_url: https://www.medline.com/https://www.ncbi.nlm.nih.gov/pubmed/https://www.who.int/
pubmed_id: 34734176
pubmed_id_url: https://www.ncbi.nlm.nih.gov/pubmed/34734176
pmcid: PMC8545268
pmcid_url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8545268
url: https://doi.org/10.7196/ajtccm.2021.v27i4.173 https://www.ncbi.nlm.nih.gov/pubmed/34734176/
has_full_text: TRUE
Keywords Extracted from Text Content: FRSMs IPC airway AGP hydrogen peroxide sodium chloride people CE inhaled LRTIs latex particles Mtb HWs varicella microbiologically-proven bodies b. frontline ducts Fit Test Apparatus FT-10 (3M AGPs PPE KwaZulu-Natal SARS-CoV-2 children oxygen COVID-19 facial nasopharynx measles virus PHC spaces coronavirus disease 2019 patient line SAHPRA droplets PFP acute LRTI [17] tobacco skin SA patients pulmonary Person-to-person mucous membranes eyes lungs KN95 LRTI RPE measles Fit-tested particulate FFP individuals Mtb. FDA [27] [28] [29] FFP3 alveoli body eye high-TB-burden SARS-CoV-2 [2 persons droplet SA COVID-19 FFP2
Extracted Text Content in Record: First 5000 Characters:HWs in high tuberculosis (TB) burden countries are already at high risk of TB infection and disease. [8] [9] [10] [11] Despite significant progress, TB incidence in South Africa (SA) remains high at over 600 per 100 000 population (around 360 000 new cases per year), and it has consistently been the country's leading cause of death, responsible for ~60 000 deaths every year. [12] Management of a respiratory pandemic is more complex in high TB burden countries such as SA. In addition to previous or current TB, individuals seeking care often have a history of one or more of HIV, tobacco smoking, biomass fuel exposure, outdoor air pollution, or exposure to mine dust containing silica, which considerably expands the differential diagnosis in those presenting with respiratory symptoms. [13] [14] [15] [16] Presentations and risk factors can be difficult to differentiate without additional time and investigation, both of which can increase the likelihood and duration of HW exposure to infectious individuals. Current or previous TB may also place people at increased risk of developing COVID-19, [17] and having COVID-19 may increase the risk of TB, though reliable data are not yet available. International guidelines recommend that HWs should be wearing N95 or equivalent particulate filtering facepiece respirators ('respirators') for routine care of individuals with possible TB or COVID-19, although World Health Organization [WHO] COVID-19 guidelines are not entirely consistent. [18, 19] At the time of writing, however, SA COVID-19 guidelines state that this level of protection is needed only for 'aerosol-generating' procedures (AGPs), such as intubation and bronchoscopy. [19] [20] [21] Recent studies suggest that coughing -common in both TB and COVID-19 pneumonitis -may produce as much (or more) aerosol than some AGPs. [22] [23] [24] There is also strong evidence that, like Mycobacterium tuberculosis (Mtb), [2, 25] SARS-CoV-2 is also transmitted by aerosol. The data to support this are wide-ranging, and include outbreak investigations, [2] experiments showing virus viability in aerosols for up to 3 hours, [26] detection of viable virus in air samples from COVID-19 infected persons and animals, [27] [28] [29] and identification of SARS-CoV-2 in air filters and ducts. [30] In other studies, activities like speaking, shouting, and singing have been shown to produce substantial amounts of infectious aerosol, and the use of high-flow oxygen may also increase aerosol propagation. [31, 32] The definition of an AGP in SA guidelines is therefore overly restrictive [21] and there is a pressing need to ensure that HWs are adequately protected from both Mtb and SARS-CoV-2. In this position statement, we build the case for national policies to support more widespread and consistent use of respirators by HWs in high-TB-burden countries such as SA, both during the ongoing COVID-19 pandemic and beyond. We make specific recommendations for situations in which respirators should be worn by HWs in SA and discuss some of the additional efforts needed to sustain this policy. Effective implementation of infection prevention and control (IPC) in healthcare facilities is important to avoid 'institutional amplification' of epidemics, [33] [34] [35] to protect the people who attend and work there, and to preserve the health workforce -a critical issue at all times, and more so during a pandemic. TB in HWs is a persistent problem: numerous studies over 30 years have shown that HWs in high-TB-burden countries are more likely than the general population to develop both latent TB and active TB disease, largely because of occupational exposure. [8, 9, [36] [37] [38] [39] Many HWs may have underlying vulnerability to severe disease and require extra protection. [40, 41] In addition to the risk to HWs themselves, there are also risks of transmission to their families, vulnerable household members, and patients. The thousands of HWs who have developed and died from COVID-19 in the last 18 months clearly demonstrate both the risks faced by HWs and the insufficient priority given to HW safety. [7, [42] [43] [44] [45] HWs, like all other SA workers, have a right to a healthy and safe working environment. [46] HWs worldwide have paid a disproportionate price for governments' and health systems' lack of foresight, lack of preparation, and underinvestment in pandemic preparedness. [47] This has manifested, among other things, as inadequate or insufficient personal protective equipment (PPE) for frontline and other staff. [48, 49] Indeed, it was shown recently that none of the tested 'KN95' respirators evaluated in SA met stipulated safety standards for HW protection. [50] We echo calls by other authors for urgent research, funding, and prioritisation of IPC and HW protection [51] and for more comprehensive approaches to occupational health. [52, 53] Though we recognise that systemic changes will take time to enact, it is unacceptable that HWs remain at ri
Keywords Extracted from PMC Text: people SAHPRA IPC persons country.[60,61 acute LRTI eyes nuclei Delta epidemics,[33,35 consistent.[18,19 guidance.[20 hours,[26 restrictive[21 KN95 exposure.[62 high-TB-burden lungs bronchoscopy.[19–21 SA COVID-19 PPE AGPs protection.[50 patient line environment.[46 handwashing.[71,72 measles virus pathogen.[25 varicella ducts.[30 FFP2 coronavirus-2 patients.[59 droplet spread.[2 quality.[104,105] measles line 's alveoli individuals.[25 individuals safety.[7,42-45] propagation.[31,32 health.[52,53] sodium chloride.[80 SARS-CoV-2 62,70 COVID-19 children SARS-CoV-2 Mtb manufacturer.[99] high-TB-burden LRTIs pulmonary suggested,[8 inhaled.[78,79 COVID-19,[17 AGP Health (NDoH)[99 oxygen Fit-tested particulate FFP body facepiece FRSMs FFP3 SA legislation.[21,87 person.[25,66-69 patients Africans PHC inhaled principle[97 year.[12 mucous membranes IPC guidelines,[19,20 microbiologically-proven LRTI wearers airway SA))[50 HWs TB[57 pressure.[63,64 bodies tobacco skin nodes SARS-CoV-2[2,73-75] nasopharynx disease.[8–11
Extracted PMC Text Content in Record: First 5000 Characters:Almost 2.5 million South Africans have tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) since March 2020, and >90 000 have died in hospitals from COVID-19.[1] Although SARS-CoV-2 was initially thought to spread predominantly through droplet or direct contact, there is strong evidence that aerosol-based transmission is likely the dominant route of spread.[2] This is especially important in the light of the circulation (at the time of writing) of the Delta variant, which is more transmissible than the original virus or Beta variant.[3] Clinically distinguishing people with COVID-19 from those with other respiratory infections is impossible without testing. This is because many people infected with SARS-CoV-2 are asymptomatic (estimates of asymptomatic proportions vary widely from <20 to >90%),[4,5] and because many respiratory symptoms experienced are often nonspecific.[6] Frontline health workers (HWs) are highly exposed and at high risk of infection, as shown by the thousands who have been infected, developed illness, and died.[7] HWs in high tuberculosis (TB) burden countries are already at high risk of TB infection and disease.[8–11] Despite significant progress, TB incidence in South Africa (SA) remains high at over 600 per 100 000 population (around 360 000 new cases per year), and it has consistently been the country's leading cause of death, responsible for ~60 000 deaths every year.[12] Management of a respiratory pandemic is more complex in high TB burden countries such as SA. In addition to previous or current TB, individuals seeking care often have a history of one or more of HIV, tobacco smoking, biomass fuel exposure, outdoor air pollution, or exposure to mine dust containing silica, which considerably expands the differential diagnosis in those presenting with respiratory symptoms.[13,16] Presentations and risk factors can be difficult to differentiate without additional time and investigation, both of which can increase the likelihood and duration of HW exposure to infectious individuals. Current or previous TB may also place people at increased risk of developing COVID-19,[17] and having COVID-19 may increase the risk of TB, though reliable data are not yet available. International guidelines recommend that HWs should be wearing N95 or equivalent particulate filtering facepiece respirators ('respirators') for routine care of individuals with possible TB or COVID-19, although World Health Organization [WHO] COVID-19 guidelines are not entirely consistent.[18,19] At the time of writing, however, SA COVID-19 guidelines state that this level of protection is needed only for 'aerosol-generating' procedures (AGPs), such as intubation and bronchoscopy.[19–21] Recent studies suggest that coughing – common in both TB and COVID-19 pneumonitis – may produce as much (or more) aerosol than some AGPs.[22–24] There is also strong evidence that, like Mycobacterium tuberculosis (Mtb),[2,25] SARS-CoV-2 is also transmitted by aerosol. The data to support this are wide-ranging, and include outbreak investigations,[2] experiments showing virus viability in aerosols for up to 3 hours,[26] detection of viable virus in air samples from COVID-19 infected persons and animals,[27,29] and identification of SARS-CoV-2 in air filters and ducts.[30] In other studies, activities like speaking, shouting, and singing have been shown to produce substantial amounts of infectious aerosol, and the use of high-flow oxygen may also increase aerosol propagation.[31,32] The definition of an AGP in SA guidelines is therefore overly restrictive[21] and there is a pressing need to ensure that HWs are adequately protected from both Mtb and SARS-CoV-2. In this position statement, we build the case for national policies to support more widespread and consistent use of respirators by HWs in high-TB-burden countries such as SA, both during the ongoing COVID-19 pandemic and beyond. We make specific recommendations for situations in which respirators should be worn by HWs in SA and discuss some of the additional efforts needed to sustain this policy. Effective implementation of infection prevention and control (IPC) in healthcare facilities is important to avoid 'institutional amplification' of epidemics,[33,35] to protect the people who attend and work there, and to preserve the health workforce – a critical issue at all times, and more so during a pandemic. TB in HWs is a persistent problem: numerous studies over 30 years have shown that HWs in high-TB-burden countries are more likely than the general population to develop both latent TB and active TB disease, largely because of occupational exposure.[8,9,36-39] Many HWs may have underlying vulnerability to severe disease and require extra protection.[40,41] In addition to the risk to HWs themselves, there are also risks of transmission to their families, vulnerable household members, and patients. The thousands of HWs who have developed and died from
PDF JSON Files: document_parses/pdf_json/130f29d3addd0c0ecccc650cd080b09315426c35.json
PMC JSON Files: document_parses/pmc_json/PMC8545268.xml.json
G_ID: a_position_statement_and_practical_guide_to_the_use_of_particulate_filtering_facepiece