Tb Protection

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TB TB Respiratory Protection Program Respiratory Protection Program

In Health Care Facilities In Health Care Facilities

Administrator's Guide Administrator's Guide

U.S. DEPARTMENT OF HEALTH AN D H UMAN SERVICESPu blic H ealth Service

Centers for Disease Control and PreventionNational Institute for Occup ational Safety an d H ealth

Sep tember 1999


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D D i i s c l a s c l a i i m e r m er Mention of any company name or p rodu ct d oes not constitute

end orsement by th e National Institute for Occup ational Safety and H ealth.

Copies of this and other N IOSH d ocumen ts are available from

Na tional Institute for Occup ational Safety an d H ealthPu blications Dissemination

4676 Colum bia Parkw ay

Cincinn ati, OH 45226-1998

1-800-35-NIOSH (1-800-356-4674)Fax number : (513) 533-8573

To receive other information abou toccup ational safety and health p roblems, call

1-800-35-NIOSH (1-800-356-4674), orvisit the NIOSH Web site at:

ww w.cdc.gov/ niosh

DHHS (NIOSH) Publication No. 99-143


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F F o o r r e ew w o or d r d The use of respirator s in the health care setting is a relatively new bu t im-por tan t s tep forward in the e ffor t s to prevent the t ransmiss ion of

tuber culosis (TB). Air pu rifying respirator s provid e a barr ier to preventheal th care workers from inhal ing M ycobacteriu m tuberculosis. The level of pr otection a respirator p rovid es is d eterm ined b y the efficiency of the fil-ter mater ial and how well the facepiece f i ts or seals to the heal th carew orker s face. A num ber of s tud ies have show n that surgical masks w illnot pr ovid e ade qu ate protection in filtering out the TB organism. Ad dition-al ly, surgical masks are not respirators and therefore, are not NIOSHcertified and do not satisfy OSHA r equirements for respiratory protection.The prop er use of respirators rep resents a significant improv ement in em-ployee protect ion against TB. N IOSH real izes that the u se of respiratorsinvolves a num ber of new an d p erhap s confusing pr act ices for the heal thcare commu nity. This man ua l is designed to serve as a pr actical guid e forthose individu als responsible for ini t ia t ing an d ru nning a TB respiratorypr otection p rogram in health care facilities.

Other areas of the hospi tal may also require the use of respirators but theprogram and respirators used may be different. If such a program exists inyour facility and has an experienced p rogram adm inistrator, it w ould be ef-fective to ad minister the TB respirator p rogram un d er the existing prog ram

and u se existing facilities for fit-testing, cleaning, m ainten ance, storage, etc.

This docum ent is not d esigned to provid e information on vent i la t ion sys-tems, negative pressure isolation room s, and risk assessment m ethodologies,w hich should be includ ed in a total TB pr event ion progr am. The TB res-p i r a to r p rog ram desc r ibed i n t h i s documen t does no t supp lan t t herespirator p rotection pr ogram necessary for other regulated h azard s (e.g.,formaldeh yd e or e thylene oxid e) that m ay be found in heal th care facil i-ties.

Sincerely yours,

Linda Rosenstock, M.D., M.P.H.Director


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T T a a b l e b l e o f C o n t e n t o f C o n t e n t s s

Disclaimer

Foreword

Abbreviations

Acknowledgments

Introduction

Respiratory Protection Program Elements For H ealth Care WorkersExposed To Tub erculosis

Respiratory Program Ad ministrationGeneralN IOSH Recomm end ed Steps for Impr oving the Know ledge and

Skills of the Program Adm inistratorDuties

Step 1 Cond uct a TB Risk Assessment

Step 2 Select Resp irators

Respirator Selection for Protection Against TB

IntroductionTypes of Respira tors for Protection Against TB

A. Disposable Particulate RespiratorsB. Replaceable Particulate RespiratorsC. PAPRsD. Positive-Pressure Sup plied-Air Respirators

Step 3 Write Stand ard Op erating Procedu resSample SOP

Step 4 Med ically Screen All Users

iv

v

ix

x

1

1

22

23

4

5

5

5778910

1112

18


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Step 5 Provide Training

Respirator Training Progr amIntroduction

Who Shou ld Receive Respira tor TrainingWho Should Condu ct this TrainingWhat Should th e Training Includ eOSHA Training Requ iremen ts Un der 29 CFR 1910.139

Tips For TrainingEstablish Specific Training ObjectivesMake the Objectives Measurable and ObservableMake the O bjectives Know n to the TraineeActively Involve the Trainee in th e TrainingAllow Time for Ad justm entProvide Feedback Provide Refresher Training

Tips For Redu cing Resistance and Prom oting Safety Behav iorsSafety Managemen tSupervisory PracticesAd ditional Respon sibilities of the Sup ervisorEnvironmental and Organizational Sup ports

Step 6 User Seal Check, Fit-Test, and Issue Respirators

Respira tor Face Fitting Procedu resFit-Testing Procedu resUser seal checking Procedures

Step 7 Insp ect, Clean, Main tain, and Store Respirators

Routine Respirator InspectionIntroductionInspection Before and After Each U seInspection Du ring Cleaning

19

191919191920

2121212121222222

2223232424

26

262627

28

28282830


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Cleaning, Repa iring, and Storing Respirator s Used For Protection Against TBIntroductionCleaning

A. DisassemblyB. Cleanin g and San itizin gC. Cleaning and San itiz ing Solu tionsD. Loose-Fitting PAPRS

RepairStorage

Sample SOP

Step 8 Evaluate the Program

Respirator Program EvaluationAnn ual EvaluationAd ditional Evaluation

References

Appendix A 1910.139 Respirat ory Protection for M. tu berculosis

Appendix B OSHA Instru ction CPL 2.106 (TB Enforcemen t)

Appendix C 1910.1020 Access to Emp loyee Exposu re an d M ed ical Record s

Appendix D Nam es and Ad dresses of Respirator Manu facturers and Distributors

Appendix E Respiratory Protection Checklist

Appendix F CDC Gu idelines (Pages 4-6)

Appendix G Memorand um for OSHA Regional Adm inistrators

Appendix H Ap pen d ix A to 1910.134: Fit Testing Pr ocedu re

30303031313131313233

36

363636

37

38

45

62

76

82

90

93

97


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ACGIH American Conference of Governmental Industrial Hygienists

AFB Acid-fast bacilli

AIHA American Industrial Hygiene Association

ANSI American National Standards Institute

APF Assigned Protection Factor

ATS American Thoracic Society

cc Cubic centimeter(s)

CDC Centers for Disease Control and Prevention

CFR Code of Federal R egulations

CNC Condensation nuclei counter

CNP Controlled negative pressure

DHHS Department of Health and Human Services

FF Fit-factor

g Gram(s)

HCWs Health Care Workers

HEPA filter High-efficiency particulate air filter

h r Hour(s)

in . Inch(es)

L Liter(s)

L/ min Liter(s) per minute M. tuberculosis Mycobacterium tuberculosis

mg Milligram(s)

min Minute(s)

ml Milliliter(s)

NIOSH National Institute for Occupational Safety and Health

OSHA Occupational Safety and Health Administration

QLFT Qualitative fit-testing

QNFT Quantitative fit-testingPAPR Powered air-purifying respirator

PEL Permissible exposure limit

PPD Purified protein derivative

RPA Respirator Program Administrator

sec Second (s)

SOPs Standard operating procedures

TB Tuberculosis

USP United States Pharmacopeia

m Micrometer

AAbbreviations bbreviations


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AAcknowledgments cknowledgments

This d ocum ent w as develop ed by N an cy Bolling er, Jeff Bryan t, Walter

Ruch, Jerry Flesch, Edward Petsonk, Thomas Hodous, Brian Day, TeriPalermo, Michael Colligan, Linda Martin, and Robert Mullan.Technical review and assistance were p rovided by Larry Reed , Roland

Berry Ann, and Larry Murp hy. Kim Clough , Brian Day, and DorothyTan-Wilhelm produ ced the poster. We than k Ann e H amilton andChris Ellison for editing and Kim Clough for the cover design,

ph otography, and formatt ing of the d ocum ent.

Cover p hotograp hs courtesy of MSA, Alpha Pro Tech, and N IOSH .

NIOSH thanks the many reviewers who helped in completing thisdocument, particularly the following agencies and their representa-

tives:

CDC H osp ital Infections Pro gram , Elizabeth Bolyard

CDC D ivision of TB Elimina tion, Patr icia Simon e

CDC N ational Cen ter for Infections Disease, Walter Bond

OSHA Demetra Collia and John Steelnack

Ruby Memorial Hospital Staff


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I I n t r o d u c t i o n n t r o d u c t i o n

Written Stand ard Operating Procedu res (SOPs)describing the selection and use of respirators

mu st be developed . Information and guidanceneeded for the proper selection, use, and care of these devices mu st be includ ed.

Respirator selection must be based on thehazard to wh ich the w orker is exposed. Moreprotective respirators may be needed for cer-tain h igh-risk procedures [CDC 1994, p. 99].

The respirator user must be trained in thecorrect use of the respirator as well as itslimitations. This training mu st include instruc-tions for wearing and ad justing the respiratorand for checking the fit.

Respirators must be regularly cleaned anddisinfected. Disposable respirators (cannot beused by m ore than one person) must be dis-carded if they are soiled or physically d am-aged (e.g., creased or torn). If the rep laceablefilter respirator is used by more than oneperson (that is, not assigned to one personpermanently), it must be cleaned and disin-fected after each use.

Respirators must be stored in a convenient,clean, sanitary location. They must be stored sothey are protected from dust, harm ful chemi-cals, sunlight, moisture, and excessive heat orcold.

Respirators that are used routinely must beinspected during cleaning, and damaged ordeteriorated p arts must be replaced.

Approp riate surveillance must be maintained

for work area conditions and the degree of worker exposu re or stress. Any changes fromthe last evaluation must be identified andevaluated.

A regular inspection and evaluation (e.g.,yearly) must be condu cted to determine thecontinued effectiveness of the program.

A determination must be made that a worker

Re sp i r at o r y Pr o t e c t i o nRe sp i r at o r y P r o t e ct i o nPr o g r a m El e m e n t s Fo r H e a l t hPr o g r a m El e m e n t s Fo r H e a l t h

C ar e Wo r k e r s Ex p o s e d ToC a r e Wo r k e r s Ex p o s ed T oTu b e r c u l o s i sTu b e r c u l o s i s

From 1985 to 1992, the incidence of turberculosis (TB)in the general U.S. popu lation increased ap proxi-mately 14 percent, reversing a 30-year d ownwardtrend. In 1993, 25,313 new cases of TB were reportedin the U.S. [CDC 1994]. Associated w ith this resu r-gence were hosp ital outbreaks of TB, and the emer-gence of mu ltiple-dru g-resistant TB. In response tothese public health threats, extensive efforts weretaken across the nation to improve TB-prevention andTB-control programs. As a result of these measu res,since 1992, there has been a consistent decline in thenumber and incidence of TB (i.e., 7.4 cases per 100,000population and 19,855 total cases in 1997) and adecline in m ultiple-drug-resistant TB [CDC 1998b].The public health and the occup ational risks of TBthus appear to be once again decreasing, but theyremain very significant.

* Code of Federal Regulations. See CFR in references.+ [29 CFR 1910.139] was formerly codified at [29 CFR 1910.134].

Health care workers exposed to patients with infec-tious TB requ ire protection from that d isease. Be-cause the u se of engineering controls (such as isola-tion rooms and ventilation) may not completelycontrol the TB hazard, respiratory protection isneeded.

When respirators are used, the Occup ational Safetyand Health Administration (OSHA) standard forrespiratory p rotection for M. tuberculosis [29 CFR*

1910.139]+

mu st be followed . OSHA has stated thatit will promu lgate a separate stand ard for TB; butun til then, the u se of respirators for TB exposureswill be enforced under the original respiratoryprotection program prescribed by OSHA in 29 CFR1910.139 (see Appendix A). This program requiresthe following:


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NIOSH Recommended NIOSH Recommended Steps for S teps fo r Impro v ing the Knowledge Imp ro ving t he Knowl edge and and Skills Skills o f t he Progr am A dminist r ato r o f t he Progr am A dminist r ato r

Become comp letely familiar w ith and u n-de r s t and t h e OSHA re sp ir a to r s t anda rd .Also unders tand s tandards , in te rpre ta -t ion le t ters , and f ie ld manuals whichprovide in te rpre ta t ion and inspec t ionmeth ods u sed by OSHA inspec tors (seeAp pen dix B).

Attend a respirator course given by com-mercial vend ors and N IOSH Edu cat ionalResource Center s.

Obtain ma terials from resp irator man ufac-tu rers . These includ e VCR tap es, s l ideshow s, pu blications, etc.

Read and u nde r s t and t he N IOSH Guide to In du st rial Respiratory Protection [Bollingerand Schutz 1987], the A merican N ationalStandard for Respiratory Protection [ANSIZ88.2-1992], the A merican In du st rial Hy-giene Association Respiratory Protection

M anual [AIHA 1993], and the Centers for Disease Control and Prevention (CDC) Guide-lines for Preventing the Transmission of My-cobacterium tuberculosis in Health-CareFacilities [CDC 1994].

Read respirator ar t ic les in the A merican In du st rial Hygien e A ssociation Journ al, A p- plied Occupational and En viron mental Hy-giene , an d oth er jou rn als. The Internet mayalso be a source of inform ation.

Read books on resp i ra tory pro tec t ionava i lab le f rom The Am er ican Ind us t r ia lHy giene Association (AIHA), The Am eri-can Conference of Governmenta l Indu s-trial Hygienists (ACGIH ), and others.

Visit insta llations (health care an d oth ers)that hav e ongoing respiratory pr otect ionprograms.

For a respirator p rogram to be p roperly estab-l ished and e ffect ive on a cont inu ing b as i s ,w ritten SOPs mu st be established. One person(the p rogram ad ministrator) must be in chargeof the program and be given the authority andresponsibi l i ty to manage al l aspects of theprogram . The adm inistrator must have suff i-

c ien t know ledge (ob ta ined by t ra in ing orexperience) to develop and implement a respi-ratory protect ion program . Preferably, he orshe shou ld have a backg round in i nd us t r i a lhygiene, safety, heal th care, or engineering.The program adm inist ra tor should repor t tothe h ighest official possible (man ager of th esafe ty depar tment , superv isor of nurses ,worker heal th manager, infect ion controlma nag er, etc.) and shou ld be given sufficient

t ime to adm iniste r the resp i ra tor p rogram inadd ition to any other du ties assigned.

G e n e r a l G e n e r a l

RespiratorRespir ato r Pro gramProgram AdministrationAdministrat ion

NOTE: Each of these requirements will be addressed inmore detail throughout this document.

is physically able to safely do the work w hileusing the respiratory protection equipment.The physician must determine what health andphysical conditions are pertinent. Therespirator user's medical status should be

reviewed periodically (e.g., annually).

Respirators must be selected from thoseapp roved by the National Institute for Occupa-tional Safety and Health (NIOSH) under theprovisions of 42 CFR 84 or 30 CFR 11 (high-efficiency particulate air [HEPA] filter only).

If a health care facility uses respirators forworker p rotection against other regulated haz-ard s (e.g., formaldehyde, ethylene oxide, etc.),

then a respirator program must be imple-mented for these hazards that incorporate allthe requ irements of OSHA standard 1910.134.


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Remember: Every thi ng concerning the respira-tor program must be written.

N95 Disposable Respirator N95 Disposable Respirator N95 Disposable Respirator N95 Disposable Respirator N95 Disposable Respirator Photo courtesy of Geiss.Photo courtesy of Geiss.Photo courtesy of Geiss.Photo courtesy of Geiss.Photo courtesy of Geiss.

Dut ies Dut ies Dut ies Dut ies Dut ies

The administr ator must be responsible for theenti re program and ensure that the program isw ri tt en, revi ewed, and impl emented. The ad-ministrator should:

Develop a wri tt en policy statement show-ing that the employer is responsible forproviding a safe and healt hfu l workp lace.For example: The management of this fa-cility is responsible for providing a safew orkplace for i ts w orkers and for supply-ing respirators and any other materialsnecessary to provide such an environ-

ment.Develop a policy detailing the workers' re-sponsibility to follow all written policies andthe consequences of not following them. Forexample, the workers are responsible forfollowing all procedures and w ritten policiesdeveloped by the program manager; work-ers violating these policies may need to beretrained and provided with positive feed-back to improve adherence to the policies.

Provid e a wri tt en program showing re-sponsibility, accountability, and author-it y f or conducti ng the program and i ndi -cate the person delegated to conductparts of the program.

Review the TB risk assessment regularlyto determine whether conditions havechanged. CDC recommends that th isreview be conducted at least yearly inminimal-, very low-, and low-risk cat-egori es; every 6-12 months for intermedi-ate-risk categories; and every 3 monthsin high-r isk categories [CDC 1994, pp. 8-23].

Determine what types and brands of respi -rators to pur chase.

Designate an area or areas staffed to main-tain, issue, and fit-test respiratory protec-tive equipment.

Develop admi nistrati ve procedures for thepurchase of approved respirators and forinventory control of spare parts, if needed.

Ensure that only N IOSH-cert i fi ed respi ra-tor s are pur chased and used.

Determine what records need to be kept,where to keep them, and how long to keepthem. Consider the type of records thatneed to be maintained to demonstratecompl iance wi th OSHA standards and tosatisfy any legal considerations. The ad-ministrator should foll ow the provisions of29 CFR 1910.1020--OSHA 's rule on A ccessto Employee Exposure and Medical Records(See Appendix C).

Wr ite and/ or approve all SOPs (SOPswill be addressed later in more detail).


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S S tep 1 Conduct a TB Risk Assessment tep 1 Conduct a TB Risk Assessment Cond uct a r isk assessmen t for the ent ire facilityand for specific areas w ithin the facility. Theelements of the risk assessment a re includ edbelow for complete information on how to con-d uct the assessment. Perform a follow-up r isk assessment at the intervals ind icated by the m ostrecent risk assessment [CDC 1994, Figure 1,Table 2]. Determine wh o mu st wear a respiratorand be includ ed in the program.

1. Review the community TB profile(from p ublic health dep artmen t data).

2. Review the num ber of TB pa tientswho were treated in each area of thefacility (both inpatient and outpatient).(This information can be obtained byanalyzing laboratory surveillance dataand by reviewing discharge d iagnoses or

medical and infection-control records.)

3. Review the d ru g-suscept ibility pa t-terns of TB isolates of patients w ho w eretreated at the facility.

4. Ana lyze p ur ified pr otein d erivative(PPD)-tuberculin skin-test results of health care workers (HCWs), by area orby occupational group for HCWs not

assigned to a specific area (e.g., respira-tory therap ists).

5. To evaluate infection-control par am-eters, review m edical records of a samp leof TB patients seen at the facility.

Calculate intervals from:admission until TB suspected;ad mission u ntil TB evalu ationperformed;

ad mission u nt il acid -fast bacilli (AFB)specimens ord ered;AFB specimens ord ered u ntil AFBspecimens collected ;AFB specimens collected unt il AFBsmears performed an d rep orted;AFB specimens collected u nt il cultu resperformed and reported ;AFB specimens collected u ntil sp eciesidentification cond ucted an d reported;AFB specimens collected un til dru g-susceptibility tests p erform ed an d

reported;ad mission u ntil TB isolation initiated ;ad mission un til TB treatmen t initiated ;and d ur ation of TB isolation.

Obtain the following additional information:

Were app ropriate criteria u sed for d is-continuing isolation?Did the p atient have a history of pr ior

ad mission to the facility?Was the TB treatment regimentadequate?Were follow-up spu tum specimenscollected p rop erly?Was app ropriate discharge plann ingconducted?

6. Perform an observat ional review of TBinfection con trol p ractices.

7. Review the most recent environmen talevaluation and maintenance procedu res.

Copies of the Morbidity and Mortality WeeklyReport (October 28, 1994/ Vol. 43/ N o. RR-13)entitled "Guidelines for Preventing th e Transmis-sion of Mycobacterium tuberculosis in H ealth CareFacilities, 1994" may be obtained by calling1-800-843-6356 or is available through the CDChomepage at http:/ / ww w.cdc.gov.

TABLE 1. Elemen ts of a risk assessmen tfor tuberculosis (TB) in health care facili-ties (Reprin ted from [CD C 1994, page 8])


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collected, th e p recise level of effectiven essin protecting HCWs [health care workers]

from M . tuberculosis tran smission in healthcare settings has not been determined . In-formation concerning th e transm ission of

M . tuberculosis is incomp lete. N either thesmallest infectious d ose of M . tu berculosisnor th e highest level of exposu re to M. tu-berculosis at w hich transm ission w ill not oc-cur has been defined conclusively (59, 151,152). Furth erm ore, the size d istribution of dr oplet nu clei and the nu mber of particlescontaining viable M. tuberculosis that ar e ex-pelled by infectious TB pa tients hav e notbeen defined adequately, and accuratemethod s of measuring the concentration of infectious d roplet nu clei in a r oom h ave notbeen developed .

N evertheless, in certain settings the ad min-istrative and engineering controls may n otadequately protect HCWs from airborned rop let nu clei (e.g., in TB isolation roo m s,

treatment rooms in w hich cough-inducingor aerosol-generating procedu res are p er-formed , and ambu lances during the trans-po rt of infectiou s TB patients). Respirato ryprotective devices used in these settingsshould have characteristics that are su itablefor the organism th ey are p rotecting againstand the settings in which they are used.

A . Per form an ce Criter ia for Person al

Respirators for Protection AgainstTransmission of M. tuberculos is

Respiratory protective devices used inhealth care settings for p rotection against

M . tu berculosis should meet the followingstand ard criteria. These criteria are basedon currently available information, includ -ing a) d ata on the effectiveness of resp ira-tory protect ion against noninfect ioushazard ous m ater ials in workp laces otherthan h ealth care set t ings and on an inter-

S S tep 2 Select Respirators tep 2 Select Respirators

Introduction Introduction

Surgical masks are not respirators and are not certi-fied as such; they do not protect the user adequatelyfrom exposure to TB. Disposable respirators (e.g.,N-95s) are comm only u sed in TB isolation room s,in transport of TB cases, or in other areas of thehealth care facility. However, when high-risk pro-cedu res such as bronchoscopy or autopsy are con-du cted, respiratory protection exceeding the CDC

standard performance criteria may be needed.This protection includes full facepiece negative-pres-sure respirators, powered air-pu rifying respirators(PAPRs), or positive-pressure airline respiratorsequipped with a half-mask or full facepiece.

In addition, individual medical conditions such aslatex allergy, can influence respirator selections. La-tex-free respirators are available.

Add itional information is provided below.

I. Consideration for Selection of Respirators

Personal respiratory protection should be usedby a) persons entering rooms where patientswith know n or susp ected infectious TB are be-ing isolated, b) persons p resent du ring cough-inducing or aerosol-generating procedures per-formed on such patients, and c) persons in othersettings where administrative and engineeringcontrols are not likely to protect them from in-haling infectious airborne droplet nuclei. Theseother settings shou ld be identified on the basisof the facilitys risk assessment.

Althou gh d ata regard ing the effectivenessof respiratory p rotection from m any h az-

ardous airborne mater ials have been

Sup plem ent 4: Respiratory Protection(Reprinted from [CDC 1994, Page 97])

Respirator Selection For ProtectionRespirator Selection For ProtectionAgainst TBAgainst TB


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pre t a t i on o f how these da t a can be ap -plied to respiratory pr otection against M.tuberculosis ; b) data on the efficiency of respirator f i l ters in f i l ter ing biological

aerosols; c) da ta on face-seal leakage; andd) d ata on the character is t ics of respira-tors tha t w ere used in conjun c tion wi thadm inist ra t ive and engineer ing cont ro lsin outbreak settings where tran smission toHCWs and p atients was terminated.

1. The ability to filter p art icles 1 m in sizein the u nload ed sta te w ith a filter efficiencyof > 95% (i.e., filter leakag e < of 5%), given

flow rates of up to 50 L per m inute.

Available data suggest that infectiousdr oplet nu clei range in size from 1 m m to 5m m; therefore, respirators used in healthcare settings should be able to efficientlyfilter the smallest particles in this range.Fifty li ters per minute is a reasonableestimate of the highest airflow rate anH CW is likely to achieve du ring breathing ,even while performing s trenuous work activities.

2. The ability to be qu alitatively or qu anti-ta t ively f i t tes ted in a rel iable way toobtain a face-seal leakage of < 10% (54,55).

3. The ability to fit the d ifferen t facial sizesand characteristics of HCWs, which canusual ly be met by m aking the respirators

available in at least three sizes.

4. The ability to b e checked for facepiecefi t , in accordance with OSHA standardsand good ind ustr ia l hygiene pract ice, byHCWs each t ime they put on the i rresp irator s (54, 55).

In some settings, HCW s may be at risk fortw o types of exposure: a) inhalation of M.

tuberculosis and b ) mucous membrane

exposure to f lu ids tha t may conta inbloodbor ne pa thogen s. In these settings,protection against both types of exposu reshould be used.

When op erative procedu res (or other p roce-dures requiring a sterile field) are per-formed on patients who may have infec-tious TB, respiratory p rotection worn by theHCW should serve two functions: a) i tshould protect the sur gical field from therespiratory secretions of the H CW and b) itshould protect the HCW from infectiousdrop let nu clei that may be expelled by the

patient or generated by the procedu re. Res-pirators with expirat ion v alves and posi-tive-pressure respirators do n ot p rotect thesterile field ; therefore, a respirator that doesnot hav e a valve and th at meets the criteriain Supplement 4, Section I.A, should beused.

References reprinted from supp lement4 [CD C 1994, pag e 108 & p age 112]

54. A mer ica n N ation al Stan d ar dsInst itute . Am erican n at ional s tan-dard pract ices for respiratory p ro-tection. N ew York: Am ericanN ational Stand ard s Institute, 1992.

55. N IO SH . G u id e t o in d u st ria l r esp i-ra tory pro tect ion . Morgantown ,WV: US Depa rtm ent of H ealth andH um an Services, Public H ealth Ser-

vice, CDC, 1987; DHHS publica-tion no. (NIOSH )87-116.

5 9. CD C/ N a tio na l In st it u tes o f H e alt h.Agent : M ycobacterium tuberculosis,

M . bovis. In: Biosafety in m icrobio-logical and biomed ical laboratories.Atlanta: US Dep artm ent of H ealthand Hu man Services, Public HealthService, 1993:95; DHHS publica-

tion no . (CDC)93-8395.


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N OTE: A llow users to choose from a variety of respirators (several manufacturers and sizes) toobtain the best and most comfortable fit possible.

The minimum level of respiratory protection for TB recommended by NIOSH is the N-95 half-mask respirator.

A. Disp osable Part iculate Respirators

The NIOSH-certified disposable respiratorslabeled N , R, or P meet CDC criteria and m aybe obtained w ith or withou t exhalation valves.Most manufacturers a lso produce them ind ifferent sizes. A face shield m ay also be usedin conjunction with a half-mask disposablerespirator for protection against body fluids.

A dv antages1. The respirator is disposable and most mod -els require no cleaning or m aintenance

(See p age 28).

2. The resp i ra tor i s l igh t w eight and fa ir lycomfortable to w ear.

Disadv antages1. The respirator is a negative-pressur e d eviceus ing the suc t ion p rodu ced by inha la t ion todraw a i r th rough th e fi lt e r. The inha la t ionpr ocess, even u nd er the best of circum stances,

w ill allow some contaminated air to leak intothe facepiece.

2. A resp irator w ith exhalation valves cann otbe used w hen w orking in a s ter i le fie ld su chas an operat ing room . The exhalat ion valveal low s drop lets and par t icles exhaled by theuser to escape and poten t ia l ly contamina tethe sur gical fie ld . These respirators are alsoavailable w ithout exhalation v alves.

151. Bloom BR, Mur ray CJL. Tube rcu -losis: commen tary on a reemer gentkiller. Science 1992;257:1055-64.

152. Nardell EA. Dodging droplet nuclei:red ucing the p robability of nosoco-mial tubercu losis transm ission in theAIDS era. Am Rev Respir Dis1990;142:501-3.

DisposableParticulateRespirator withadjustable strapsand exhalationvalve.

Photo courtesyof MSA.

DisposableParticulateRespirator.

Photo courtesy of Alph a Pro Tech.

DisposableParticulate

Respirator withfixed straps and no

exhalation valve.

Photo courtesy of MSA.

Types of Respirators for Protection Types of Respirators for Protection

Against TB Against TB

See Appendix D for a list of manu facturers.

References from supp lement 4 continu ed


16/1208

The full facepiece respirator also meets CDCrequirements for respiratory protection againstexposure to TB. The respirator can be equippedwith the N, R, or P filters (HEPA filters canalso be used). It is also manufactured in morethan one size.

B. Repl aceabl e Part i cul ate Fi l terRespirators

The half-mask respirator also meets CDCrequirements. This respirator has single or dualfilters made of the same material as the N, R, and Pdisposable respirators (HEPA filters can also beused). Most manufacturers produce more than onesize. A face shield may also be used in conjunctionwith a half-mask particulate filter respirator forprotection against body fluids.

Full Facepiece Replaceable ParticulateFi l ter Respi rator

Hal f -M ask Repl aceabl e Part i cul ateFilter Respirator

Advantages1. The respi rator pr ovides a better seal thanthe half-mask and with HEPA or 100 seriesfi lt er is more protective.

2. The respi rator is durable.

3. The respi rator pr ovides eye protecti on.

Disadvantage s1. The respirator cannot be used in areaswhere a sterile field is required.

2. The respi rator must be inspected, cleaned,and repaired.

3. The respi rator is a negati ve-pressure devi ceusing the suction produced by inhalation to drawair through the filter. The inhalation process, even

NOTE: Manufacturer As small size is notnecessarily the same as Manufacturer Bs small size.

Advantages1. The respirator is lightweight and does notrestri ct mobil ity .

2. The respirator is made of rubber or elastomerand is durable. Only the filters need to berepl aced when necessary.

Disadvantages1. The respirator must be routinely inspected,cleaned, disinfected, and repaired (See Step 7).

2. The respirator is a negative-pressure deviceusing the suction produced by inhalation to

draw air through the fi lter. The inhalationprocess, even under the best of circumstances,wil l allow some contaminated air to leak into thefacepiece.

3. Communication may be difficult.

4. The respirator cannot be used in areas where asterile field is required (surgical suite).

Half-M ask Repl aceabl e Part icul ate Fil ter Respi rator.

Photo (left) courtesy of Neoteri k Health TechnologiesInc. Photo (right) courtesy of NI OSH.

Full Facepi eceReplaceable

Particulate FilterRespirator.

Photo courtesy ofNIOSH.


17/1209

C. PAPRs

Tight-Fitting PAPR

These respirators also meet CDC gu idelines forpr otection against TB exposur e. The equ ipm entis batter y operated , consists of a half or fu llfacepiece, breathing tube, battery-operatedblower, and p articulate filters (H EPA only). APAPR uses a blower to pass contaminated airthrou gh a HEPA filter, w hich removes the con-taminan t and sup plies purified air to a facepiece.A PAPR is not a true positive-pressure device be-cause it can be over-breathed w hen inhaling. Aface shield may a lso be used in conjun ction w itha half-mask PAPR respirator for protectionagainst body fluids.

A dv antages1. The resp i ra tor i s more pro tec t ive than ahalf-mask respirator.

2. The resp irator is usu ally mo re com fortablebecause air is forced into the mask by theblower, p rod ucing a cooling effect.

3. The respirator is d ur able.

4. Breath ing resistan ce is lower .

Disadv antages1. The respirator cannot be used w here asterile field is required because it has anexhalation va lve and in some cases air can exitaroun d the face seal.

2. Batteries mu st be recharged and m aint ainedto assure prop er flow rates into the mask.

3. The respirator mu st be inspected, c leaned,and repaired.

4. Comm un ication may be a problem.

5. A PAPR may be bulky and noisy.

Loose Fitting PAPR

This respirator consis ts of a hood or helmet ,breathing tube, battery-operated blower, andH EPA filters. It meets CDC guidelines.

A dv antages1. More protective than a half-ma sk respirator.

2. The respirator is m ore comfortable becau seit is loose-fitting .

3. Provides a cooling e ffect in th e hood orhelmet.

Tight-Fitting PAPR.

Photo courtesyof NIOSH.

Loose-Fitting PAPR.

Photo courtesy of

Neoterik HealthTechn ologies Inc.

un der the best of circum stances, will allow somecontaminated air to leak into the facepiece.

4. Comm un ication m ay be difficult .

5 . Sp ecial lens ki ts are requ ired for thoserespirator users w ho w ear glasses.

4. The respirator is du -rable.

5. Breathing resistanceis lower .

6. Vision ma y be better.


18/12010

A dv antages1. The respirator is much m ore protective be-cause i t provides posi t ive pressure in thefacepiece and almost all leakage is outward.A pos i t ive-pr essure sup pl ied-a i r resp i ra torshould be used w hen disposable respirators ,replaceable respirators, or PAPRs d o not p ro-vide adequ ate protection.

2. Breat hin g resistan ce is m inim al.

3. The respirator is relatively comfortable towear.

D. Positive-Pressure Sup plied -AirRespirators

Sup plied-air resp irators use compr essed airfrom a s tat ionary source del ivered through ahose und er pressure to a half-mask or a ful lfacepiece. A face shield m ay also be used inconjun ction w ith a h alf-mask airline resp iratorfor protection against bod y fluid s.

Positive-PressureSupplied-AirRespirators.

Photo courtesy of NIOSH.

7. Can be w orn w ith facial hair as long as facialhair d oes not interfere with v alve or function of the respirator.

Disadv antages1. The equipm ent cannot be used w here a ster-ile field m ust b e mainta ined because air exitsaround the hood or helmet.

2. Batteries mu st be charged and maintained.

3. The respirator mu st be inspected, cleaned,and repaired.

4. Comm un ication may be difficult.

5. A PAPR may be bulky and noisy.

Disadv antages1. The airline hose r estricts th e u sers m obility.

2. This respirator exhau sts a ir contaminatedb y t h e u s e r a n d s h o u l d n o t b e w o r n d u r i n g

sterile procedu res.

3. The respirat or mu st be inspected, cleaned ,and repa i red .

4. Commu nication m ay be difficult .

5. Requires installation an d mainten ance of aregulated comp ressed air sup ply for Grad e Dbreathing air.

6. Mainten ance requ ires highly skilled, tech-nically trained p ersonnel.

7 . Length of hose and connect ion p oint mu stbe adequ ate to prevent exposur e to TB w henremoving the respirator.


19/12011

1. Administrative procedures:

A. Em ployer resp on sibilities

B. Em ployee resp on sibilities

C. Pu r ch ase of cer tified resp ir at or s

D. Inventory control

E. Issu ance of resp irators

F. Sp ecial pr oblem s (beard s, etc.)

2. Respirator selection

3. Medical surveillance

4. Respirator training program

5. Respirator face-fitting procedures

6. Maintenance p rocedu res:

A. Cleaning and san itizing

B. Insp ection

C. Rep air

D. Storage

7. Program evaluation

Guidance for an SOP fo l lows on the nextpage . Add i t iona l in format ion on SOPs may

also be avai lable from the manufacturer of the respirator.

S S tep 3 Write Standard Operating Procedures tep 3 Write Standard Operating Procedures The imp ortance of w ritten Standard OperatingProcedu res (SOPs) is emp hasized by O SH A in29 CFR Part 1910.139 wh ich sp ecifies th e firstrequirement for a m inimal acceptable (respira-tor) program as establishm ent of written SOPsgoverning th e selection and use of respirators.Part 1910.139 does not p rovid e any gu idan cefor preparing these procedures and d oes notdifferentiate between large and small users.

An SOP is a detailed w ritten procedur e that de-scribes an operation so thorou ghly that it can beaccomp lished r epeated ly and can consistentlyarrive at the same end p oint. No room for in-terp retation exists. The SOPs shou ld contain allinformation need ed to m aintain an effective res-pirator pr ogram to meet the user s ind ividu al

requirements . SOPs should be wri t ten to beuseful to those directly involved in the respira-

tor program , the program ad ministrator, thosefitting the respirators and training the w orkers,respirator maintenance workers, and the sup er-visors responsible for overseeing respirator useon the job. Generally, the procedu res shou ldcover the following top ics:

Photo courtesy of Racal Hea lth & Safety, Inc.


20/12012

Purpose:

The purpose of this standard operating procedure is to ensure the protection of all employees fromrespiratory hazards caused by exposure to TB, through the proper use of respirators.

Responsibility:

The Respirator Program Administrator (RPA) is _________________________________. She/he issolely responsible for all aspects of this program and has full authority to make the necessary decisions toensure its success. This authority includes (but is not limited to) hiring personnel, purchasing thenecessary equipment to implement the program, and operate the respiratory protection program. The RPA(or designee) will develop written detailed instructions covering each of the basic elements in this

program, and is the only person authorized to amend these instructions.

The ABC health care facility has expressly authorized the RPA to audit and change respirator usageprocedures whenever there is a chance of exposure to TB. This includes designating mandatory respiratorusage areas.

Program Elements:

1. The RPA (or designee) will develop detailed written standard operating procedures governing theselection and use of respirators, using the OSHA regulations and the NIOSH Respirator Decision Logic

as guidelines. Outside consultation, manufacturers assistance, and other recognized authorities will beconsulted if there is any doubt regarding proper selection and use of respirators. These detailedprocedures will be included as appendices to this respirator program. Only the RPA may amend theseprocedures.

2. Respirators will be selected on the basis of CDC guidelines. All selections will be made by the RPA(or designee). Only NIOSH certified respirators will be selected and used.

3. The user will be instructed and trained in the proper use of respirators and their limitations. Bothsupervisors and workers will be trained by the RPA (or designee). The training should provide the

employee an opportunity to handle the respirator, have it fitted properly, test its facepiece-to-face seal,wear it in normal air for a long familiarity period, and finally to wear it in a test atmosphere. Everyrespirator wearer will receive fitting instructions, including demonstrations and practice in how therespirator should be worn, how to adjust it, and how to determine if it fits properly.

Respirators should not be worn when conditions prevent a good face seal. Such conditions may be agrowth of beard, sideburns, a skull cap that projects under the facepiece, or temple pieces on glasses.No employees of this facility, who are required to wear tight fitting respirators may wear beards. Alsothe absence of one or both dentures can seriously affect the fit of a facepiece. The workers diligence inobserving these factors will be evaluated by periodic checks. To assure proper protection, the user seal

check will be done by the wearer each time she/he puts on the respirator. The manufactures instructionswill be followed.

ABC Health Care FacilityRespiratory Protection Program


21/12013

4. Where practicable, the respirators will be assigned to individual workers for their exclusive use.

5. Nondisposable respirators will be regularly cleaned and disinfected. Those issued for theexclusive use of one worker will be cleaned after each days use, or more often if necessary. Thoseused by more than one worker will be thoroughly cleaned and disinfected after each use. The RPAwill establish a respirator cleaning and maintenance facility and develop detailed written cleaninginstructions.

Disposable respirators will be discarded if they are soiled or are no longer functional. See themanufacturers instructions.

6. The central respirator cleaning and maintenance facility will store respirators in a clean andsanitary location.

7. Respirators used routinely will be inspected during cleaning. Worn or deteriorated parts will bereplaced.

8. Appropriate (e.g., quarterly) surveillance of work area conditions and degree of employee exposurewill be maintained.

9. There will be regular (e.g., annually) inspections and evaluations to determine the continuedeffectiveness of the program. The RPA will make frequent inspections of all areas where

respirators are used to ensure compliance with the respiratory protection programs.

10. Persons will not be assigned to tasks requiring use of respirators unless it has been determined thatthey are physically able to perform the work and use the equipment. The ABC health care facilityphysician will determine what health and physical conditions are pertinent. The respirator usersmedical status will be reviewed annually.

11. NIOSH certified respirators will be used.

Respirator Program Evaluation Checklist

In general, the respiratory protection program should be evaluated for each job or at least annually, withprogram adjustments, as appropriate, made to reflect the evaluation results. Program function can beseparated into administration and operation.

A. Program Administration

____________ (1) Is there a written policy which acknowledges employer responsibility forproviding a safe and healthful workplace, and assigns program responsibility,accountability, and authority?

____________ (2) Is program responsibility vested in one individual who is knowledgeable andwho can coordinate all aspects of the program at the health care facility?


22/12014

____________ (3) Can administrative and engineering controls eliminate the need for respirators?

____________ (4) Are there written procedures/statements covering the various aspects of therespirator program, including:

____________ (a) designation of an administrator;____________ (b) respirator selection;____________ (c) purchase of NIOSH certified respirators;____________ (d) medical aspects of respirator usage;____________ (e) issuance of equipment;____________ (f) fitting;____________ (g) training;____________ (h) maintenance, storage, and repair;____________ (i) inspection;

____________ (j) use under special conditions; and____________ (k) work area surveillance?

B. Program Operation

(1) Respiratory protective equipment selection

____________ (a) Are work area conditions and worker exposures properly surveyed?____________ (b) Are respirators selected on the basis of the hazard to which the worker

is exposed?____________ (c) Are selections made by individuals knowledgeable in proper selection

procedures?

____________ (2) Are only NIOSH certified respirators purchased and used; do they provideadequate protection for the specific hazard?

____________ (3) Has a medical evaluation of the prospective user been made to determinephysical and psychological ability to wear the selected respiratory protectiveequipment?

____________ (4) Where practical, have respirators been issued to the users for their exclusiveuse, and are there records covering issuance?

(5) Respiratory protective equipment fitting

____________ (a) Are the users given the opportunity to try on several respirators todetermine whether the respirator they will be subsequently wearing is thebest fitting one?

____________ (b) Is the fit tested at appropriate intervals?


23/12015

____________ (c) Are those users who require corrective lenses properly fitted?

____________ (d) Is the facepiece-to-faceseal tested in a test atmosphere?

____________ (e) Are workers prohibited from wearing respirators in contaminated

work areas when they have facial hair or other characteristics whichmay cause faceseal leakage?

(6) Respirator use in the work area

____________ (a) Are respirators being worn correctly (i.e., head covering over respiratorstraps)?

____________ (b) Are workers keeping respirators on all the time while in the designatedareas?

(7) Maintenance of respiratory protective equipment

Cleaning and Disinfecting

____________ (a) Are nondisposable respirators cleaned and disinfected after each usewhen different people use the same device, or as frequently as necessary fordevices issued to individual users?

____________ (b) Are proper methods of cleaning and disinfecting utilized?

Storage

____________ (a) Are respirators stored in a manner so as to protect them from dust,sunlight, heat, damaging chemicals, or excessive cold or moisture?

____________ (b) Are respirators stored in a storage facility so as to prevent them fromdeforming?

____________ (c) Is storage in lockers permitted only if the respirator is in a carrying case

or carton?

Inspection

____________ (a) Are respirators inspected before and after each use and during cleaning?

____________ (b) Are qualified individuals/users instructed in inspection techniques?


24/12016

____________ (c) Are records kept of the inspection of respiratory protective equipment?

Repair

____________ (a) Are replacement parts used in repair those of the manufacturer of the

respirator?

____________ (b) Are repairs made by trained individuals?

(8) Training and Feedback

____________ (a) Are users trained in proper respirator use, cleaning, and inspection?

____________ (b) Are users trained in the basis for selection of respirators?

____________ (c) Are users evaluated, using competency-based evaluation, before andafter training?

____________ (d) Are users periodically consulted about program issues (e.g., discomfort,fatigue, etc.)


25/12017

SAMPLE RESPIRATOR INSPECTION RECORD

1. TYPE_________________________________________ 2. NO._______________________

3. DATE:_____________________________________________________________________

A. Facepiece

B. Inhalation Valve

C. Exhalation Valve Assembly

D. Headbands / Straps

E. Filter Cartridge

F. Cartridge/Canister

G. Harness Assembly

H. Hose Assembly

I. Speaking Diaphragm

J. Gaskets

K. Connections

L. Other Defects

DEFECTS FOUND CORRECTIVE ACTION


26/12018

Respirators place several p hysiological stresseson wearersstresses that par ticularly involvethe pu lmona ry and ca rd i ac sy st ems . How -ever, respirators typ ically used by h ealth carew orkers a re genera lly l igh tw eight , and theph ysiological stresses they create are u suallysmall . Therefore, most workers can safelywear respirators.

OSHA has exempted the respirator require-men ts of the curr ent 1910.134 for p reven tion of occup ationa l transm ission of TB in health caresettings. Cur ren t OSHA regulation s (29 CFR1910.139) state that w orkers shou ld not be as-signed tasks requiring respirators un less theyhave been d etermined to be physically able toperform the work w hile using the equipment.The regulations also note that a physicianshould determ ine the criteria on wh ich to basethis determination.

No general consensus exis ts about w hat e le-ments to include in medical evaluations forrespirator use in general indu stry. Some institu-tions use only a qu estionnaire as a screeningtool; others rou tinely includ e a ph ysical exam i-nat ion and spirometry; and some includ e achest X-ray. No generally accepted criteria exist

for excluding workers from w earing respirators.Specifically, no sp irom etric criteria exist for ex-clusion. How ever, several stud ies have show nthat most workers with mild pu lmonary func-tion impairment can safely wear respirators.Thus, some jour nal articles and organizationsrecomm end th e following:

Medical c learance for those withno rma l o r m i ld pu lmona ry func t i onimpairment.

S S tep 4 Medically Screen All Users tep 4 Medically Screen All Users Medical Evaluation of Health CareMedical Evaluation of Health CareWorkers to Determine Fitness toWorkers to Determine Fitness to

Wear RespiratorsWear Respirato rs

Some restrictions (e.g., type of respirator orworkload) for those with moderateimpairment.

No resp i ra tor wear for ind iv idua lswith severe imp airment.

N OTE: Some respirators hav e a latex compon ent and should not be worn by those who are allergicto latex.

Because most health care workers w ear the verylight, disposable half-mask respirator, CDC

Guid elines [CDC 1994] recomm end that a healthquestionnaire be the initial step in the evaluation.If results from th is evaluation are essentially nor-ma l, the emp loyee can be cleared for respiratorw ear. Further evaluation, possibly includ ing adirected p hysical examination and / or spirom-etry, should be considered in cases in wh ich p o-tential problems are suggested on the basis of thequestionnaire results.

Medical reviews of this issue including practicalrecommend ations from several groups, includ ingthe American N ational Stand ards Institute (ANSI),AIHA, and the American Thoracic Society (ATS)are included in the references [ANSI 1992; AIHA1993; American Thoracic Society 1996]. Samplequestionnaires that have been u sed in health caresettings are in Append ix E.

OSHA has issued a compliance memorandu m(see App end ix B) and is developing a separatestandard which wil l address the medicalevaluation issue. H ealth care ad ministratorsshou ld be alert to developm ents in this area.

If a health care facility uses respirators forworker protection against other regulatedhazards (e.g., formaldehyde, ethylene oxide,etc.), then a respirator program must beimplemented for these hazard s u nd er 1910.134includ ing med ical evaluations by a ph ysician

or other licensed health care professional.


27/12019

S S tep 5 Provide Training tep 5 Provide Training Respir ato r Tr aining ProgramRespir ato r Training Program

Introduction Introduction

Equally imp ortant to selecting the app ropr iaterespirator is using th e selected device prop erly.Proper use can be achieved by carefully trainingboth su pervisors and w orkers in selection, use,and maintenance of respirators.

Provide the supervisor, the person issuing the respira-

tors, and the respirator user w ith adequate trainingby qualified persons to ensure that the respirator isused correctly (see Respirator Program A dministrationin the Introduction ).

The supervisor is defined as the person who over-sees one or more w orkers who need to wear respi-rators. The sup ervisors must be in close contactwith the workers to ensure that the workers arewearing respirators when necessary and that they

are being worn prop erly. The training providedshould emphasize that health and safety is an im-portant part of the management function. It is rec-ommended that the proper use of respirators shouldalso be included in the supervisor's and worker'sannual evaluation.

Who Should Receive Respirator Training

Who Should Cond uct This Training

The training must be given by a qualified personusually the Respirator Program Administrator. As analternative, the Administrator can have someonetrained to do the job or hire a consultant. See Respi-rator Program Administration in the Introduction formore information about respiratory protectiontraining.

1. Describe the nature, extent, and specific hazardsof TB in your health care facility (See Append ix F).

2. Explain the risk assessment and its relationship

What Should the Training Includ e

to the respirator program. The risk assessmentshould d efine facility areas requ iring the u se of res-pirators and the level of protection required. For ex-ample: normal operations might require only

disposable N95 respirators. Higher-risk areas, suchas autopsy rooms, could require a higher level of protection such as full facepiece negative-pressurerespirators, PAPRs, or half-mask positive-pressureairline respirators.

Also, advise the trainees that risk assessment w illbe done periodically. CDC recommends that risk assessment be conducted at least yearly in the mini-mal-risk, very-low-risk, and low-risk areas; every

6-12 months for interm ediate-risk areas; and every3 months in high risk areas. The workers shouldalso be trained to recognize signs and symbols usedto show that respirators are required in an area.

3. Explain the reason for using respirators. Forexample, the respirator needs to be used tominimize exposure to the hazards in the workp lace(in this case, TB).

Some individuals (e.g., those that are immuno-compromised are at higher risk for TB (seeappendix F). These ind ividuals need to und erstandthe risk and the need to wear their respirator.

4. Describe existing engineering controls. Engineer-ing controls are methods used to prevent the spreadand redu ce the concentration of infectious dropletnu clei. Examples are vent ilation controls (e.g.,negative-pressure isolation rooms) and laboratoryhood s. Because engineering controls may not en-

tirely eliminate the TB hazard, the respiratorwearer must be trained to know when to wear arespirator.

5. Explain the reason for selecting a p articular res-pirator for a given hazard (see Step 2). In m ost cases,the N95 disposable respirator w ill be selected. ThisNIOSH-certified respirator m eets minimum CDCcriteria for respiratory protection in TB areas.For high-risk areas, m ore p rotective respirators

may be n eeded (e.g., full facepiece respiratorsw ith PAPRs and p ositive-pressure airline respi-


28/12020

1910.139 (a)(3) The emp loyee shal luse the p rovided respiratory p rotection inaccord ance w ith instru ctions and tra iningreceived.

1910.139 (b)(3) The user sh all be in-s tructed and t rained in the proper use of respirators and their limitations.

1910.139 (e)(2) The correct respiratorshall be specified for each job. The respiratortype is usually specified in the work proce-dures by a qualified individual supervising

the respiratory protective program . The indi-

The t ra in ing recommen da t ions li s ted in the

pr eced ing section shou ld p rovid e the basis foran adequate training program and sum marizemeth ods for satisfying the OSHA requ irementslisted in 29 CFR 1910.139. These requ ire-ments are reprinted as a sum mary below andreprodu ced fully in App endix A.

OSH A Trainin g Requirements Und er 29CFR 1910.139

rator s). The respi rator chosen depend s on the se-verity of exposure.

6. Explain how the respirator works, itscapabilities, and limitations. N egative-pr essureair-purifying respirators (e.g., disposable, half-mask, and full facepiece respirators) work bydraw ing ambient air through the filter elem entd ur ing inha lation. Inh alation causes a negativepr essure to develop in the tight-fitting facep ieceand allows air to enter while the particles arecaptu red on th e filter. Air leaves the facepiecedu ring exhalation because a p ositive pressuredevelops in the facepiece and forces air out of themask through the filter (disposable) or through an

exhalation valve (replaceable and somedisposable). PAPRs are equipp ed w ith a blowerthat draws air through the filters into thefacepiece. PAPRs can be equ ipp ed w ith a tigh t-fitting facepiece or loose-fitting helmet or h ood .Airline (supp lied-air) respirators are p rovidedw ith air from a stationary sou rce (compressor)or a bott le. (See Step 2 for a discu ssion abou tthe advantages and disadvan tages of differentrespira tor classes).

7. During the training session, give the userthe chance to hand le and w ear the respiratorun til the user is proficient. Also teach the userhow to perform the user seal check and wearthe respirator in an u ncontaminated env iron-ment for a period of t ime. Instruct the u ser tofollow the manufacturer s instructions pro-vided w ith the respirator. Give workers a copyof the man ufacturers instructions.

8. Teach the user the imp ortance of and how toproperly store d isposable respirators. Teach theuser the imp ortance of and how to clean, main-tain, and stor e replaceable filter respirators (un -less there is a central maintenance facility thatprovides this service for cleaning, see Step 7).

9. Explain th at facial hair betw een the w earersskin and the sealing sur faces of the tight-fittingrespirator will prevent a good seal. A respirator

that permits negative-air pressure inside thefacepiece du ring inhalation m ay allow leakage

and , in th e case of positive p ressure d evices,w ill either red uce service time or w aste breath-ing air.

10. Provide the trainees w ith the lectur e mate-rials (or a summ ary) developed by the p rogramadm inistrator to u se as quick reference materi-als.

11. Instruct trainees to refer all respiratorproblems immed iately to the respirator pr o-gram adm inistrator.

12. Discuss th e OSHA st and ard [29 CFR 1910.139] (see Appendix A) in detail with the

trainee. Everyone must know the mand atoryregulations.

Training may need to be repeated yearly tomaintain the resp irator skills of the u sers.


29/12021

Make sure that the t rainer has a def ini teunders tanding of exac t ly what the t ra ineeshould kn ow or be able to d o as a result of thetraining. If this objective is not clear to thetrainer, i t w ill never be clear to th e t rainee.Also, sta te the object ives in such a w ay th atthe t ra iner can measure whether they havebeen achieved .

The OSH A training requ irements un d er 29 CFR1910.139 (see pr eceding section an d A pp end ixA) consist of the bare bones training respon-sibilities of the respiratory pr otection p rogram

man ager. A trainer can use various tips andstrategies to meet these obligations and t o en-

Objectives such as th e trainee w ill be mad eaw are of the need for respiratory protection orthe trainee will know how to inspect a respira-tor cannot be measur ed d irectly. Instead, statethe objectives using action terms or tasks thetrainee should be able to do. For exam ple: (1)the trainee w ill be able to nam e the areas of the facility wh ere respirators are requ ired, or

(2) the train ee will be able to insp ect a respi-rator an d id entify a defective valve. Measur-able training objectives allows the trainer todetermine wh ether people are learning wh atthey need to know .

Inform trainees about the object ives of thetraining. This knowledge provides them w ith

a framew ork for und erstanding the informa-t ion that wil l fol low and motivates them tokeep their attention focused on the imp ortantpoints.

Establish Specific Trainin g Obj ectives

Make the Objectives Measurable andObservable

Make the Object ives Known to theTrainee

Tips For Training Tips For Training Actively Involve the Trainee in theTraining

People generally learn better by doing than bywatching or listening. Ask the trainees to pu t onand remove respirators, inspect respirators, replace

filters, discuss respiratory protection issues, etc.Such activities are mu ch more effective than

han ce the effectiveness of the pr ogram . Thesetips and strategies are d iscussed in the followingsubsections.

vidual issuing them shall be adequately in-structed to insure that the correct respirator isissued.

1910.139 (e)(5) For safe use of anyrespirator, i t is essential that th e u ser beproperly instructed in its selection, use,and maintena nce. Both sup ervisors andw orkers shall be so instructed by comp e-tent persons. Training shall prov ide thew orkers an opp ortunity to hand le the res-pirator, h ave it fitted pr operly, test its face-piece-to-face seal, w ear it in nor ma l air fora long familiarity period, and, finally, tow ear it in a test atmosph ere.

1910.139 (e)(5)(i) Every respiratorw earer shall receive fitting instru ctions in-cluding demonstrations and practice inhow the respirator should be worn , how toadjust i t , and how to determine if i t fi tspr operly. Respirators shall not be w ornw hen cond itions pr event a good face seal.Such conditions may be a grow th of beard,sidebur ns, a skull cap that p rojects und erthe facepiece, or tem ple p ieces on glasses.Also, the absence of one or both den turescan seriou sly affect th e fit of a facepiece.The wor ker s diligence in observin g thesefactors shall be evaluated by periodiccheck. To assure proper protection, thefacepiece fit shall be checked by thewearer each time h e pu ts on the respirator.This may be done by following themanufacturer s facepiece fitting instruc-tions.


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No m atter how mu ch t ime and effor t are putinto developing a respiratory protectionpr ogram , it is doomed to fail if workers d o notwear the equipment properly under theprescribed conditions. Workers fail to wear

respirators for a nu mber of reasons, and it isimportant to und erstand the nature of thisresistance to overcome it. The follow ing arethe most frequently cited reasons for notwearing respirators:

1) They are hot and un comfortable.

2) They prod uce pain spots if poorlyfitted.

3) They interfere w ith commu nicationand performance.

4) They are no t easily accessible wh enyou need them.

5) They put th e burd en of safety on thewearer rather than the company.

6) They make the wearer look funny,

alarmist, not macho, or u nattractive.

Give feedback to workers during the initialtraining an d in the w orkplace to tell them w hatthey are d oing right or wrong. The feedback shou ld alw ays be positive, constructive, andspecific. Thu s comm ents such as keep up thegood w ork or good job (al though comp li-men tary) provide little information. Instead saygood job in rep lacing you r filter or John, youneed to rem ember to check your seal every timeyou pu t on your respirator. The point is not to

criticize or pu nish the individu al but to provid ecorrective instruction.

Provide Feedb ack

Provide Refresher Training

Tips For Reducing Resistance And Tips For Reducing Resistance And Promoting Safety Behaviors Promoting Safety Behaviors

Wearing a resp irator for the f irs t t ime can bea s t range an d even t rau mat ic exper ience forthe new user, par t icular ly i f the u ser is givena r e sp i r ato r and immed ia t ely pu t t o work .The barriers of respira tor usag e noted earlier( such as labored brea th ing and impai redvision) coup led w ith the dem and s of the jobmay be too grea t for man y f ir s t - t ime u sers ,increasing their intolerance to the resp iratorand reduc ing the l ike l ihood of fu turecompliance.

A l low the u se r t o g r adua l ly ad ju s t t o t herespirator by w earing it for short p eriods in arelaxed, non -work set t ing. Tell new usersthat i t is norma l to feel a l i t t le s t range a ndf r igh tened the f i r s t t ime they wear a

respirator. This information lets them knowthat their ini t ia l adverse react ion does notindicate a chronic personal intolerance toresp i ra tors and tha t the i r to le rance wi l limprove . On ce users become accus tomed tothe physical and psychological effects of w earing a resp irator, it will be easier for themto perform their normal work rou tine.

Allow Time for Adjustmen t

having trainees read about these procedur es ormerely listen to a description. Films anddemonstrat ions are useful in model ing thedesired beh avior, but i t is imp ortant to hav ethe t ra inee ac t ive ly rep l ica te what w as jus twitnessed.

Establish a schedu le for periodically evalua tingon-the-job performance and providing re-fresher training w hen ind icated. Such tr aining

is needed because un fortunately, the effects of training do n ot last forever. Forgetting or re-lapse occur s over timeespecially if the beh av-iors are not frequently p racticed or rehearsed(that is, respirators are w orn on ly occasionally),if the beh avior is costly and comp lex (for ex-ample, inspection and maintenance), and if continu ous m onitoring and corrective feedback are not provided .


31/12023

In ad dition t o feeling su sceptible to TB, workersmu st also u nd erstand its consequences to healthand w ell-being. Training program s often de-scribe the illness in abstra ct med ical term s oruse scare tactics to exaggerate the symp toms.Instead , describe the disease in a realistic andimaginab le fashion. Describe the imp act of theillness on life-style factors such as family inter-actions, hobbies, and recreational activities.Use case histories, testimonies from illness vic-

tims, and il lness simulations to help w orkersidentify with the impact of the disease on

7) They produ ce labored breathing,increased heart rate, and persp iration.

8) They impair vision and can actuallybe a safety hazard .

9) They pr odu ce feel ings of c laustro-phobia and anxie ty.

In addition to these numerous barriers toworking while wearing a respirator, thebenefits (that is, the avoid ance of d isease) ma yseem rem ote. Fur therm ore, since air contam -inated w ith infectious d roplet nu clei have no

over-wh elming noxious pr operties or ph ysicaleffects, there is n o imm ediate consequ ence fornot wearing a respirator except that the userfeels better withou t it. Therefore, the progr amman ager must work hard to overcome workerresistance to w earing respirators and prom otefull compliance with th e respiratory p rotectionprogram.

For a worker to beh ave safely, three cond itionsmu st be met: (1) the worker m ust h ave the nec-essary knowledge, skills, and ability; (2) theworker mu st be prop erly motivated; and (3)the w orker must receive the necessary environ-mental and organizational sup ports.

The first cond ition is add ressed by the tra in-ing program, the second by superv isorypr act ice, and the third by organ izat ional cl i-

mate and policy. The first factor is add ressedin t he p r eced ing s ec t i on ( Tips for Training )and the la t ter two factors are consideredbriefly as follow s.

Safety Managemen t

Supervisory Practices

Motivating w orkers to behav e safely is a majorresponsibility of the supervisor or p rogram ad-ministrator. Workers mu st not only know h owto maintain and wear respirators , they must

actually wear them when working in a haz-ard ous environmen t. To convince a worker to

Be l i eve t he i l l ne s s p ose s s e r i ousconsequ ences to health and well-being

Feel susceptible to the disease orcondit ion related to the h azard

The worker must u nd erstand that the d isease isrelated to exposure, and that symptom onsetma y be d elayed. In explaining TB, tell theworker how the inhaled drop let nu clei from aninfectious persons cough or sneeze lodgethemselves in the alveoli of the lungs, whereinfection begins. N o imm ediate symp toms willoccur as the infection spr ead s to other areas inwhich TB is most likely to d evelop. The imm un esystem u sually intervenes w ithin 2 to 10 w eeksafter infection and halts the multiplication of tubercle bacilli. Approximately 10% of those

infected w ill develop the d isease. The other 90%will remain infected but free of disease for therest of their lives. Many workers do not feelsusceptible because they have no firsthandexperience with TB and do n ot und erstand h owit develops. Cause and effect mu st be establishedin a straightforward , concrete fashion.

wear a respirator, the worker must see that the ben-efits of respirator use outw eigh the barriers. Thefirst step in th is direction is the training program ,which describes workplace hazards, their conse-quences, and the role of respirators in reducing

these hazard s. Although different mod els exist forpresenting this information, one of the most popularis the Health Belief Model developed by Becker[1974]. To use this mod el to foster respirator use, aworker must:


32/12024

Correcting improper use throu ghimmed iate constructive feedback

Acting as a role model by properlyfollowing respiratory use p rocedu res

Consistently enforcing r espirator policyfor employees

Actively monitoring respirator use

Periodically comp lementing w orkers for

prop er respirator use

In add ition to providing w orkers with the kindof information described above, the immediatesup ervisor mu st take steps to assure that w ork-ers intentions to wear respirators are carriedover and su stained in the workp lace. This is acontinuing resp onsibili ty of the su perv isormuch l ike work scheduling and product ionoversight. The sup ervisor mu st convey to thew orker his or her comm itment to the respiratorprogr am th rough actions as well as word s. Ex-amp les of what this requires from the sup ervi-sor are as follows:

Addit ional Responsibi l i t ies of theSupervisor

A safety man agement p rogram cannot succeedw ithout the sincere sup port and comm itment of the highest levels of the organ ization. A token

or sup erficial endor sement of the safety pro-gram is quickly perceived by mem bers of the or-ganization as m anipu lative an d hyp ocritical; itis likely to prod uce resentmen t and resistance.Steps an organization can take to demonstrateits level of commitm ent to the respirator y pr o-tection program might include th e following:

Developing and distributing a w rittenrespiratory protection policy

Establishing a visible and formal trainingprogram documenting worker training

Including safety as a topic on the agend aat all meetings

Tracking and documenting workertraining

Environmental and Organizat ionalSupportsWearing a resp irator is a major inconven ience

to most workers. A training program thatignores this point lacks credibility. Instead,emph asize that d espite the draw backs, wearinga respirator and protecting ones health are

w orth th e inconvenience.

The w orker mu st und erstand that the use of arespirator can effectively reduce the risk of exposur e. To convey th is inform ation, explainthe way respirators work and the importance of prop er u se, fi t-testing, and maintenan ce. Usethe fit-testing exercise to simulate leakage, andgive the w orker a sense of how a toxic agent canbe inh aled if the seal is not su fficient. Workersneed to know the basic principles of respirator

operation in order to accept them and believe theycan provide protection if used p roperly.

Believe th at the resp irator can control

the risk

Believe that the b enefits of respiratoruse outweigh th e barr iers

them selves and oth ers. Relate that preven tivedr ug therap y can result in serious health effects(e.g., liver d am age).

Make workers aware of their own role inmotivating others to wear respirators. Peerinfluences are often effective in encouragingself-protective behavior. Inform physicians thatthey often serve as role models for otherhospital workers, and that by the simp le act of

w earing a respirator, they may be encouragingmany other workers to wear respirators.Unfortunately, the op posite may also be tru e.


33/12025

Consulting users about respiratorprogram issues

Writing safety comp liance criteria intothe job d escriptions and performanceevaluations of workers and supervisors

Using eng ineering contr ols (e.g., ven-tilation) and ad ministrative controls (forexample, minimizing the nu mber of times emp loyees enter isolation room s)wh erever feasible to minimize work-place hazard s

Investing resources in pu rchasing an d

maintaining proper equipment

Reviewing (formally and open ly) res-pirator p olicy at regular intervals andmak ing r espirators easily a ccessibleto workers

Requiring respirator u se only whennecessary


34/12026

w hen the respirator fits prop erly. Such know l-ed ge is imp ortan t because TB aerosol can leak around the facepiece into the respirator and beinhaled if the respirator d oes not fit the usersface. In the December 11, 1998, MMW R article,NIOSH found that fit testing " N95 respirators isessential in progra ms emp loying these respira-tors and can eliminate poorly fitting respirators,ensu ring at least the expected level of protection.Without su rrogate fit testing, average exposu refor the 25-person panel was reduced to 33% of the am bient level, w hich is much less protectionthan expected of this class of respirator s (i.e., ex-

posu re redu ced to


35/12027

N OTE: For facilities conducting QNFTs ondisposable and replaceable half-masks, OSHArequires a minimum fit-factor (FF) of 100. When anindividual passes a QLFT, a minimum FF of 100will be assumed to have been achieved. (See

A ppendix G, OSHA M emorandu m For Regional A dministrators Regarding Fit-Testing and User Seal Checking Procedures).

N IOSH does not recommend qualitativ e fit testingusing irritant smoke because of the health risk associated with exposure to the irritant fume.

Fit-checking procedu res that have been acceptedby OSHA in 1910.134 can be found in Ap pen d ix

H. When the TB standard is promulgated,specific gu idan ce w ill be includ ed.

User Seal Checking Procedures User Seal Checking Procedures

Positive-pressureuser seal check.

Negative-pressure user seal check.

Both photos courtesy of NIOSH.

To ensure adequ ate protection, the user of a res-pirator equipped with a tight-fitting facepiecemu st check the seal of the facepiece rou tinely be-fore each entry into areas w ith p otential TB ex-posu res. This check may be accomp lished byusing the seal-check pr ocedu res recomm end edby the manufacturer or by using those describedin Appendix H.

irritation. A QNFT uses another means of detect-ing facepiece leakage and does not r equire thewearers subjective response.

Respirator m odels have inherently d ifferent fit-ting characteristics. Moreov er, each of the sev-eral brands that are marketed has slightlyd ifferent fitting char acteristics. Althou gh everyman ufacturer d esigns facepieces to fit the broad-est possible section of the working p opu lation,no single respirator fits everyone. Therefore,more than one brand or model, and varioussizes of a given type of respirator should be pu r-chased to take advantage of the different fittingcharacteristics of each and to increase the chancesof prop erly fitting all w orkers. H aving morethan one facepiece from which to choose alsogives the worker a better chance of find ing a res-pirator that provides reasonable comfort andgood protection.

The respirator program ad ministrator mu st de-cide w hether to u se QLFT or QN FT procedures.

After fit-testing, a w allet-sized card shou ld beprovided to the respirator user showing worker'snam e, date, type, brand , model, and size of res-pirator.


36/12028

A. Exam ine the facepiece of the d ispos-

S S tep 7 Inspect, Clean, Maintain, & Store Respirators tep 7 Inspect, Clean, Maintain, & Store Respirators Routine Respirator InspectionRoutine Respirator Inspection

Introduction Introduction Scrupu lous respirator inspection and maintenancemust be an integral part of the overall respiratorprogram. Follow the manufacturers instructionsfor inspection, cleaning, and maintenance to ensurethat the resp irator continues to function properly.Wearing poorly maintained or malfunctioning res-pirators may be more dangerous than not wearinga respirator at all. The worker who wears a defec-tive device may falsely assum e that p rotection is be-ing provided .

The OSHA respirator regulations require the fol-lowing [29 CFR 1910.139]:

I I nspec t ion Before And A f te r nspect i on Before And A f te r Each Use Each Use

able respirator to d etermine w hether it is fun c-tional and has structural integrity. If the filtermaterial is physically dam aged or soiled, d is-card the respirator. Also discard the respirator if there ar e nicks, abrasions, cuts, or creases in th efacepiece-to-face sealing material.

B. Check the respirator straps to be surethey are not cut or otherw ise dam aged. Thestraps should be attached at all connectionpoints.

C. Make su re that the m etal nose clip (if applicable) is in place and functions correctly.

D . Make sure that the respirator isNIOSH approved (NIOSH approval will bemarked on the filter, filter package, or resp iratorbox).

Insp ect replaceable filter half-mask respirators as follows:

A. Check the integrity of the facepiece to besure it is not cut, torn, modified, deteriorated, ordirty. The elastomer should not be abraded, andthe sealing surface should be smooth and und am-aged.

B. Check to see that the straps on the respi-rator are elastic, pliable, and have not been knottedto shorten them. The buckles and any attachmentmust be present and working correctly.

C. Inspect the inhalation and exhalationvalves to see that they are in p lace and pliable,

Check straps andbuckles.

Photocourtesy of NIOSH.

1. [b] (7) Respirators u sed rou tinely shall be in-spected d uring cleaning. Worn or deterioratedparts shall be replaced. Respirators for emergencyuse such as self-contained devices shall be thor-oughly inspected at least once a month after eachuse.

2. (f) (2) (i) All respirators shall be inspected rou-tinely before and after each use. A respirator that isnot routinely used but is kept ready for emergencyuse shall be inspected after each u se and at leastmonthly to assure that it is in satisfactory workingconditions.

3. (f) (2) (iii) Respirator inspection shall include acheck of the tightness of connections and the condi-tion of the facepiece, headbands, valves, connectingtube, and canisters. Rubber or elastomer parts shallbe inspected for pliability and signs of deterioration.Stretching and manipulating rubber or elastomerparts with a m assaging action w ill keep them p li-able and flexible and prevent them from taking aset during storage.

Inspect disposable half-mask respiratorsas follows:


37/12029

functioning prop erly, and lying flat on the sur-face of the valve seat. The sealing sur facesmu st be clean and not chipped , scratched , or

broken.

D . Make sure that th e exhalation valvecovers are present and attached to the res-pirator.

E. An app roved half-mask respiratorincludes the facepiece and filters. Check therespirato r to be sur e the correct filters for thehazard are in p lace. The filter and filter holder

threads should not be scratched, chipped, orotherwise damaged. If gaskets are requiredbetween the fil ter and fil ter holder be surethey are in place and in good cond ition. Re-move the gaskets to check for dirt un der them.

F. Make sure that th e gaskets fit prop-erly in the filter hold ers.

G . If the filters seal directly against thefacep iece, be sur e that th e sealing su rface is nottorn, chipp ed, cut, or otherw ise dam aged.

H . Inspect the filters to be sure th at thethreads are not scratched, chipped , dented, orotherwise dam aged.

I . The s t rap assembly wi l l usua l lyhave corrugations in the ru bber that holds thestrap tightly once it is placed on the head andt ightened. Be sure that the corru gat ions are

not worn off, a l l c lips a re presen t , and thestraps are attached to the mask.

Inspect replaceable filter fullfacepiece respirators as follows:

A. Check to see that the lens in a fullfacepiece respirator is not scratched , cracked,broken, or otherwise damaged. The lens shouldbe comp letely sealed around the facepiece.

B. If the respirator h as a speaking d ia-

ph ragm, make su re that it is in p lace, not pu nc-tured , and th at the gasket is in place.

C. Check the int egrity of the facepieceto be sur e it is not cut, torn , mod ified, deterio-rated , or dirty. The elastomer shou ld not beabraded and the seal ing surface should besmooth and und amaged.

D . Make sure that all the requiredclamp s are in p lace and are specific for the res-pirator being inspected.

E. Inspect the inh alat ion and exhala-t ion valves to see that th ey are in place andpliable , funct ioning p rop erly, and lying f la ton the sur face of the valve seat. The sealingsur faces mus t be c lean and not ch ipped ,scratched, or broken .

F. An ap pr oved full facepiece respira-tor includes the facepiece and the filters. Check the resp irator to be su re the correct filters forthe hazard are in place. The fil ter and fil terholder threads should not be scratched,chipp ed, or otherw ise dam aged. If gaskets arerequ ired between the fil ter and filter holderbe sure they are in place and in good cond i-tion. Remov e the gaskets to check for dirt u n-der them.

G. The strap assembly w ill usually havecorrugations in the rubber that h olds the straptightly once it is placed on the head and tight-

ened . Be sure that the corrugations are notw orn off, all clips are present, and the strapsare attached to the mask.

H . Check to see that the straps on theresp irator are elastic, pliable, and h ave not beenknotted to shorten them. The buckles and an yattachm ent mu st be present and w orking cor-rectly.

I. Make sure that the exhalation valvecovers are present and attached to the respirator.


38/12030

Generally, d isposable respirator s do not need tobe cleaned or ma intained . If they are soiled orotherwise dam aged they are discarded . How -ever, some m anu facturers m ake d isposable res-pirators that look like rep laceable respirators

(filters cannot be removed or rep lacement p artsare not ava ilable) and the facepiece may requ iresome cleaning .

Replaceable filter respirat ors m ust be carefullymaintained . The man ufacturer s recomm enda -tions should be followed to ensu re prop er fun c-tioning of the r espirator. The following d iscus-sion of maintenance procedu res should helpusers un derstan d the overall process:

The OSH A respirator regulation (see App end ixA) requires that respirators be prop erly cleaned,repaired, and stored. A proper maintenance pro-gram ensu res that the workers respirator remainsas effective as when it was new.

Cleaning, Repairing, And StoringCleaning, Repairing, And StoringRespirators Used For ProtectionRespirators Used For ProtectionAgainst TBAgainst TB

I I ntroduction ntroduction

Cleaning Cleaning

J. Make sure that th e gaskets fi t prop-erly in the filter hold ers.

K . If the filters seal directly against th efacepiece, be su re th at th e sealing surface is nottorn, chipped , cut, or otherwise dam aged.

L. Inspect the filters to be sure th at thethread s are not scratched , chipp ed, dented , orotherwise dam aged.

Insp ect PAPRs as follows:

A. Stretch out the corrugated breathingtube to insp ect i t for cuts, abrasions, and p in-

holes.

B. Inspect the blower assembly andbatteries as described by the man ufacturer.

C. The inspection p rocedur es for h alf-masks an d full facepieces used w ith PAPRs arethe same as those described above.

D . If the PAPR is equipp ed w ith a hoodor helmet, inspect according to the manu-facturers instructions.

Insp ect su

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