Managing coronavirus (COVID-19) risks: Healthcare and social assistance industry – Respiratory Protective Equipment (RPE)

Information to provide guidance regarding the use of Respiratory Protective Equipment (RPE) to reduce the risk of exposing health care and social assistance workers to coronavirus (COVID-19).

Last updated

Tuesday 26 May 2020

Industries and topics
  • Community support services
  • Healthcare and hospitals
  • Infectious diseases

Background

This should be read together with 'Prevention and management of exposure to coronavirus (COVID-19) in the healthcare and social assistance industry.'

Coronavirus (COVID-19) may be transmitted between people through:

  • Contact transmission which is defined as direct contact with droplets from infected people, or indirect contact with surfaces contaminated with infected droplets, and then touching the eyes, nose or mouth.
    • Droplet transmission which is defined as respiratory droplets from coughing, sneezing or talking transmitting from an infected person directly onto the mucosal surfaces (eyes, nose, mouth) of another person who is in close contact (within 1.5 metres).
      • Airborne transmission which is defined as exposure to very fine droplets (≤5 micrometres (µm)) that are produced from procedures such as aerosol generated procedures (AGP), for example tracheal intubation and bronchoscopy.

        Identifying and controlling risks

        Employers have a duty to provide and maintain, so far as is reasonably practicable, a working environment that is safe and without risks to the health of employees.

        Employees have a duty to take reasonable care of the health and safety of themselves and others in the workplace, and to cooperate with any action their employer takes to comply with a requirement imposed by OHS laws.

        Where a risk to health associated with potential exposure to coronavirus (COVID-19) is identified at a workplace, employers must eliminate the risk so far as is reasonably practicable. Where it is not possible to eliminate the risk, it must be controlled so far as is reasonably practicable.

        Control measures may include the use of personal protective equipment (PPE) including RPE. However, PPE is the lowest order of control and must always be used in combination with other control measures to reduce the risk of exposure to the coronavirus (COVID-19), like preliminary phone screening of patients to identify suspected cases and hand hygiene. The WorkSafe website has information to help employers understand and use the hierarchy of control.

        Control measures

        Selection and types of RPE

        Selection of the type of RPE required to be worn by employees depends on factors including:

        • the type of activity
          • the duration of the activity
            • the likely form of transmission for the activity being undertaken (contact, droplet, or airborne)
              • the level of risk of exposure to coronavirus (COVID-19)
                • the ability to achieve an adequate fit (and therefore level of protection) with a N95/P2 respirator
                  • the availability or supply of RPE in the workplace

                    In addition to RPE, other PPE may also be required, including safety glasses/goggles or face shields, long-sleeved gowns and gloves.

                    Types of RPE

                    The most common types of RPE used in the healthcare and social assistance industry are:

                    • disposable N95 surgical respirators – designed to protect the wearer from fine and coarse aerosols, droplets, and fluid splashes or high velocity streams; are tight fitting
                      • disposable P2 and N95 non-surgical (standard) respirators – designed to protect the wearer from fine and coarse aerosols and droplets; are tight fitting
                        • surgical masks - designed to prevent the spread of larger droplets from the wearer to others, to protect the wearer from inhaling larger respiratory droplets, and to protect the wearer from fluid splashes or high velocity streams; are not tight fitting

                          Less common types of RPE used in the healthcare industry are:

                          • non-disposable half face respirators with P2 filters - designed for similar uses as disposable N95/P2 respirators
                            • powered air purifying respirators (PAPRs) - may be used in healthcare when AGPs are performed, or when the worker is not able to wear a tight-fitting N95/P2 respirator. PAPRs have a battery-powered unit that forces air into a hood through P3 filters to clean it before delivering it to the breathing zone of the wearer

                              N95 surgical and N95/P2 non-surgical respirators

                              Both N95 surgical and N95/P2 non-surgical respirators:

                              • are tight fitting, covering the nose, mouth, and chin
                                • are able to filter out very fine particles and are therefore capable of reducing exposures to aerosols containing virus particles which may arise from particular procedures (AGPs), as well as larger droplets
                                  • must be fitted correctly to achieve a tight facial seal

                                    The terms 'P2 respirator' and 'N95 respirator' are often used interchangeably in healthcare settings. They are regarded as providing an equivalent level of protection for biologically active airborne particles and aerosols. The difference between these respirators is the different regulatory standards they are required to meet around the world. In Australia, the requirements for P2 respirators are stated in the Australian/New Zealand Standard on Respiratory protective devices (AS/NZS 1716:2012). The United States National Institute of Occupational Safety and Health (NIOSH) specifies N95 respirator requirements.

                                    Differences between N95 surgical and N95/P2 non-surgical respirators are:

                                    • N95 surgical respirators are rated for fluid resistance. A key test that is performed on surgical N95 respirators is the fluid resistance test using synthetic blood at varying pressures to simulate a velocity fluid.
                                      • N95/P2 non-surgical respirators are not rated for fluid resistance.

                                        The type of N95/P2 respirator used in a particular setting should be selected based on a risk assessment.

                                        If there is fluid risk, a surgical N95 respirator should be used, or if unavailable, then a non-surgical N95/P2 respirator may be used with a face shield.  A non-surgical N95/P2 respirator should not be used on its own in fluid risk environments.

                                        Non-surgical N95/P2 respirators may be suitable for use in healthcare in non-fluid risk environments (e.g. settings where there is unlikely to be fluid spray beyond a cough or sneeze).

                                        Surgical masks

                                        Surgical masks are designed as a loose fitting barrier to prevent the wearer expelling large droplets and as a barrier to protect the wearer from fluid splashes and inhaling larger respiratory droplets. They:

                                        • are loose fitting, covering the nose, mouth, and chin 
                                          • may be worn by infected people to help reduce the spread of viruses via exhaled droplets that occur through coughing or sneezing
                                            • when worn with safety glasses or goggles or faceshields, are used to help protect healthcare workers’ mucous membranes (eyes, nose, and mouth) from droplet transmission
                                              • are worn by healthcare professionals in sterile environments to reduce exhaled droplets from contaminating the sterile field
                                                • are worn when high velocity fluid risks are present

                                                  Surgical masks do not prevent exposure to aerosols.

                                                  Homemade RPE including cloth masks

                                                  Homemade RPE, for example cloth masks, are not recommended for health care workers for the prevention of exposure to coronavirus (COVID-19).

                                                  With worldwide increase in demand for surgical masks and N95/P2 respirators, and subsequent diminished supplies, there has been a rise in use of homemade masks. Although any material may provide a physical barrier between the wearer and airborne droplets, cloth masks (unlike surgical masks) are not designed and tested to a standardised method. Homemade RPE may also result in an increased risk of infection due to moisture retention and poor filtration.

                                                  DHHS guidance on use of PPE for health workers

                                                  Wearing and fitting of surgical masks and N95/P2 respirators

                                                  A summary of how surgical masks and N95/P2 respirators should be fitted and worn is provided below.

                                                  Surgical mask

                                                  surgical mask
                                                  • loose fitting
                                                    • designed to prevent droplet transmission
                                                      • can be worn with facial hair

                                                        How to wear (donning)

                                                        • the mask is placed over the nose and under the chin
                                                          • the ties or elastics are secured at the back of the middle of the head and neck OR
                                                            • the elastic loops are positioned around the ears
                                                              how to wear a surgical mask

                                                              N95/P2 respirator disposable

                                                              healthcare P2/N95 particulate-respirator
                                                              • fit with a tight seal
                                                                • designed to prevent airborne transmission
                                                                  • must be clean-shaven or free from facial hair under the sealing surface area of the respirator
                                                                    • If a worker is unable to shave, then PAPRs that do not rely on a facial seal may be considered as an alternative. Some PAPR hoods do not need to seal to the wearer's skin to work correctly and are designed instead to fit loosely under the wearer’s chin or at their neck.

                                                                      How to wear (donning)

                                                                      • Rest the nose bridge on top of the nose and place the bottom panel or bottom of cup securely under chin.
                                                                        • The straps are secured at the back of the middle of the head and neck.
                                                                          • Position and mould nose piece (where available) around nose using fingertips of both hands.
                                                                            healthcare respirator - how to wear P2/N95 respirator

                                                                            Fit check

                                                                            • place one or both hands completely over the middle panel or cup
                                                                              • inhale and exhale sharply
                                                                                • check for air leaks around the nose
                                                                                  • adjust respirator until no leaks can be felt

                                                                                    Note: If tight fitting seal cannot be achieved with one brand of respirator, then it might be achieved with a different shaped N95/P2 respirator. If a seal cannot be achieved, then the task should not be performed.

                                                                                    How to check the fit for a P2/N95 respirator

                                                                                    Removing respiratory protection (doffing)

                                                                                    Prior to removing respiratory protection, it is important to move to a clean area to avoid exposure to any hazardous airborne contaminants.

                                                                                    It is important to be aware that any potentially infectious particles will remain on the outside of the surgical mask or N95/P2 respirator or the filter fibers. A surgical mask or N95/P2 respirator is therefore a potential source of contact contamination after use.

                                                                                    When removing a surgical mask or N95/P2 respirator, take care not to touch the outside, discard it with other potentially contaminated waste, and wash your hands immediately after handling. 

                                                                                    Refer to DHHS guidance on removing PPE for more details.

                                                                                    Time limitations

                                                                                    There is no specific time limit for the continuous use of a disposable surgical mask or N95/P2 respirator over the course of a shift.

                                                                                    A disposable N95/P2 respirator should be disposed of immediately:

                                                                                    • after an AGP is performed
                                                                                      • if the exterior is soiled or contaminated
                                                                                        • if it is damaged
                                                                                          • if it has been coughed or sneezed into
                                                                                            • if it no longer fits tightly to the face
                                                                                              • if it becomes damp

                                                                                                There is no specific time limitation for the disposal of filters in a non-disposable respirator however the manufacturer's/supplier's recommendations should be consulted.

                                                                                                Re-use of disposable surgical masks and N95/P2 respirators

                                                                                                Disposable surgical masks and N95/P2 respirators are single use and not designed to be reused. Currently there is no evidence that disposable masks and N95/P2 respirators can be safely sterilised and reused.

                                                                                                DHHS guidance on PPE

                                                                                                Additional considerations for wearing and fitting of N95/P2 respirators

                                                                                                Best practice for N95/P2 respirator use is to have a respiratory protection program in place for anyone required to wear a N95/P2 respirator. A program includes selection of a N95/P2 respirator that is appropriate for tasks, correct size and fit testing, and training on the use, storage and maintenance of respirators.  More information on respiratory protection programs can be found in the Australian/New Zealand Standard on 'Selection, use and maintenance of respiratory protective equipment' (AS/NZS 1715:2009).

                                                                                                Fit testing

                                                                                                Fit testing is the method for checking that a tightfitting N95/P2 respirator matches the wearer's facial features and seals adequately to the wearer's face. It will help to identify unsuitable styles of N95/P2 respirators that do not provide protection and should not be used by the individual wearer. It should be conducted prior to the need to use a N95/P2 respirator so that a suitable respirator can be identified for the wearer. Fit testing is not possible for surgical masks.

                                                                                                Fit testing can either be Quantitative (using an instrument to measure the leakage around the face seal) or Qualitative (relying on a wearers senses for taste, smell or irritation, to detect any leakage of the N95/P2 respirator). If a wearer is unable to achieve a pass, they should select another style of N95/P2 respirator until a pass can be achieved.

                                                                                                Fit testing involves the use of either an instrument or a test hood to detect any leakage of the N95/P2 respirator. If a wearer is unable to achieve a pass, they should select another style of N95/P2 respirator until a pass can be achieved.

                                                                                                Fit testing is an important part of a respiratory protection program per AS/NZS 1715:2009, and should be conducted so far as reasonably practicable.

                                                                                                Even when it is not reasonably practicable to undertake fit testing prior to use, people must do the following every time a N95/P2 respirator is worn:

                                                                                                • follow the instructions on how to put on the respirator (i.e. donning) described above
                                                                                                  • perform the fit check described above
                                                                                                    • make sure that they are clean-shaven where the N95/P2 respirator touches the face
                                                                                                      • make sure no clothing or jewellery gets between the N95/P2 respirator and the face

                                                                                                        Studies have shown that people still receive some reduction in exposure if they follow this procedure. However, the level of protection provided by the N95/P2 respirators may be lower without fit testing.

                                                                                                        If an employee feels unwell

                                                                                                        If an employee develops symptoms of coronavirus (COVID-19) they should isolate themselves immediately, call the coronavirus information line on 1800 675 398 or their doctor and follow the self-isolation guidance available on the DHHS website.

                                                                                                        An employer's duty to eliminate or reduce risks associated with exposure to coronavirus (COVID-19) so far as is reasonably practicable includes ensuring that:

                                                                                                        • employees know what to do or who to notify if they feel unwell or suspect they’ve been infected, according to the information provided by DHHS
                                                                                                          • any unwell employee does not attend the workplace, including employees who have been tested for coronavirus (COVID-19) or who are confirmed coronavirus (COVID-19) cases

                                                                                                            References

                                                                                                            • Victorian Department of Health and Human Services - Coronavirus (COVID-19) Healthcare Worker PPE: use of N95 respirators in clinical settings - Update 6 April 2020
                                                                                                              • Brian Rembialkowski, Margaret Sietsema & Lisa Brosseau (2017) Impact of time and assisted donning on respirator fit, Journal of Occupational and Environmental Hygiene, 14:9, 669-673.