May 19 , 2009
As of May 15, 2009, 34 countries have officially reported 7520 confirmed cases of influenza A (H1N1) infection with 65 deaths. The Public Health Agency of Canada reports that there are 449 cases in Canada with one death.
On May 12, 2009 Alberta's daily number of confirmed cases had dropped. However, since that date there have been 14 new cases of this novel virus infection confirmed.
Everything You Need to Know About Respiratory Protection
Respirators used in health care settings should be selected according to the efficiency of respirator filters in filtering droplet and/or airborne particles.
Surgical Masks Are Not Respirators
Health care workers routinely use surgical masks as part of their personal protective equipment. However, surgical masks are not respirators and are not certified as such. They do not protect the wearer from inhaling small particles that can remain airborne for long periods of time.
Research has shown that the efficiency of the filters of surgical masks to block penetration of airborne (alveolar > 10 um and tracheobronchial-sized particles10-20 um) is highly variable. When combined with the inability to ensure a sealed fit, these factors suggest that surgical masks offer no significant protection against the inhalation of alveolar and tracheobronchial-sized particles. In addition, the efficiency of the filters of surgical masks to block penetration of nasopharyngeal-sized particles is unknown. The lack of a sealed fit on a surgical mask will allow for the inhalation of an unknown quantity of nasopharyngeal-sized particles.
N95 Respirator Masks
One of the most common respirators used in health care facilities is the type N95 respirator. N95 respirators belong to a group of air purifying particulate filters. NIOSH (National Institute for Occupational Safety and Health in the U.S.) certifies these respirators (and other respirators) and these certified products are used in Canada.
The "N95" is one of three types of filters - N (not resistant to oil, R (resistant to oil) and P (oil proof). These refer to the type of resistance they have to the degrading of their filtering efficiency. When exposed to different kinds of airborne particulates, mists, etc.
The "95" in N95 refers to the filter efficiency. There are three levels of filter efficiencies - 95% (N95), 99% (N99), and 99.97% (N100 or HEPA filter) tested against aerosol (fine mist) droplets 0.3 microns in diameter. N95 type respirators are the respirators recommended by Health Canada and the U.S. Centers for Disease Control and Prevention (CDC) for use by health care workers in contact with patients with infections that are transmitted from inhaling airborne droplets (e.g., tuberculosis (TB); and when you may be exposed to airborne particles. CDC also recommends N95 for health care staff working with patients having or suspected of having Influenza A (H1N1) infection.
One Size Does Not Fit All!
It is essential that there is an adequate seal between the respirator and the user's face otherwise know as the fit. Proper fit-testing is the major factor that determines how effective a respirator is. The size and shape of individuals' faces can vary greatly so N95 respirators come in different sizes and shapes. Disposable half-face piece filtering N-95 masks respirators vary substantially in the quality of fit that is provided to different facial structures
In order to achieve the best seal between the respirator and the user's face you need to:
o Provide training to the user in assessing the fit of the respirator each time it is used. Also training on donning and doffing of the respirator. Improper handling of a contaminated respirator when it is being taken off can lead to the spread of infection.
o Check the shape and size of the respirator to ensure that that it is adequate for that particular user.
o Fit-testing of users prior to an outbreak or stockpiling to prepare for an outbreak. Most regulatory agencies recommend annual fit testing. A non-fit-tested respirator allows gaps between the respirator and the user's face that allows inhalable particles to bypass the filter.
In order to achieve an adequate seal facial hair may have to be removed if it interferes with the seal of the respirator. However, if the individual has medical condition that does not allow them to shave they must be provided with an equal or superior form of respiratory protection or reassigned to another area.
In addition, fit-testers sometimes find that they cannot achieve an effective facial seal in some individuals. These individuals must be provided with an effective alternate form of respiratory protection or be reassigned.
How Long Can I Wear a N95 Respirator?
There is no hard and fast rule. Disposable N95 respirators can be re-used repeatedly by the same health care worker if unless they have been in contact with suspected or confirmed case of Influenza A (H1V1). Respirators must be kept in a clean dry location as humidity, dirt and crushing reduces the effectiveness of the respirator.
However, because the mask filters out particles the pores of the filter will eventually become blocked. This blockage makes breathing more difficult for the user and can result in a break in the seal to the face. If you find that breathing while wearing the N95 for some time becomes much more difficult then you should properly dispose of the N95 and replace it with a new N95 respirator.
Risk Assessment for HINI Influenza Virus
The Canadian Federation of Nurses Unions released a policy directive: H1N1 Outbreak and Personal Protective Equipment (PPE) on May 7, 2009. As part of that directive CFNU encourages it's members to work with their Joint Occupational Health and Safety Committees to conduct risk assessment to identify healthcare workers at risk and develop prevention measures that include engineering controls (single bed rooms, plexiglass partitions), administrative controls (policies, procedures, education and training) and personal protective equipment (N95 respirators, eye protection, gloves, gown).
The requirement to perform risk assessments is part of Alberta's Occupation Health and Safety Legislation. Part 2: Hazard Assessment, Elimination and Control of the Occupational Health and Safety (OHS) Code states that “employers are required to assess a worksite and identify existing or potential hazards before work begins”. The purpose of the hazard assessment process is to eliminate or control workplace hazards before they cause injury and illness. Employers are required to eliminate the hazard or implement the most effective method of control available.
In Part 35: Health Care and Industries with Biological Hazards of the OHS Code “an employer must ensure that worker exposure to biohazardous materials is kept as low as reasonably practicable” Biohazardous materials include virus, fungi, bacteria, parasites, mould, blood and body fluid and biological waste. Employers must include biological hazard when they perform hazard assessments.
Providing care to patients, clients or residents with suspected or confirmed influenza A H1N1 infections clearly poses a health risk to health care workers. Therefore, AHS should be performing hazard (risk) assessment to identify staff at risk of infection and job duties and aspects of the work environment that contribute to that risk.
In addition, nurses need to rely on their own assessment skills to determine if they need to be wearing a N95 respirator, eye protection, gloves, and gown when providing care to their patients. If the patient, client or resident is exhibiting the symptoms of an influenza A H1N1 infection then you should be erring on the side of caution and don the appropriate personal protective equipment (PPE). You need to protect yourself at the highest level available until it is confirmed that a lower level of protection is required.
If the appropriate PPE is not available then you are required by law to refuse to perform unsafe work until your employer provides you with that equipment.
Recommended precautions for health workers remain
It is the position of United Nurses of Alberta that until such time as there is scientific certainty regarding the mode of transmission of Swine Influenza A (H1N1) all Employees covered by the Multi-Employer/UNA Collective Agreement that are required to provide patient care for suspected or confirmed swine influenza A cases must be provided with an appropriate supply of fit-tested N95 respirators and mandatory education regarding the care of procedures for donning and doffing N95 respirators.
Along with respiratory protection until the manner of causation is known, in addition to routine practices, infection control measures for suspected and confirmed cases of the swine influenza should include contact precautions, respiratory hygiene, accommodation, eye protection, surveillance and reporting.
What You Need to Know:
Get Fit Tested! - The Multi-Employer/UNA Joint Committee has reached an agreement regarding N95 Respirator Provision and Fit Testing, which requires the employer to provide N95 respirator fit-testing to all employees covered by the Multi-Employer/UNA Collective Agreement. Fit-Testing is mandatory as per Article 35.02 (a)
Ensure you have enough N95 respirators - The Joint Committee agreement obligates the Employer to ensure that an appropriate supply of N95 respirators is available.
You may be temporarily transferred - In the event of an emergency Article 44: Mobility (44.05 (e)) allows the Employer to reassign Employees from any site to perform work at any other site in emergency circumstances. An emergency is defined as “an unforeseen combination of circumstances or the resulting state that calls for immediate action”. Contact you Local representative or Labour Relations Office for additional information regarding emergency transfers.
Do not report to work if you are sick - Nurses should not be reporting to work if they have influenza like illness (fever and respiratory symptoms). Nurses who do report to work are putting patients and their co-workers at risk of infection and illness. The Alberta Government is asking that individuals with flu like symptoms stay home from work and avoid public places when ill.
You do not have to put your health at risk - The agreement between the parties states that employees who have not been fit-tested for an N95 respirator or are unable to achieve an effective facial seal shall not be expected to enter or provide services in an area where a suspected or confirmed case of swine influenza A has been identified. These Employees may be deployed to another area.
You need to assess whether you believe that you need to provided with N95 respirators (fit-tested), gown and eye protection. If your employer refuses then ask to be reassigned.
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