Reviews

A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2

K Dheda, S Charalambous, A S Karat, A von Delft, U G Lalloo, R van Zyl Smit, R Perumal, B W Allwood, A Esmail, M L Wong, A G Duse, G Richards, C Feldman, M Mer, K Nyamande, U Lalla, C F N Koegelenberg, F Venter, H Dawood, S Adams, N A B Ntusi, H-M van der Westhuizen, M-Y S Moosa, N A Martinson, H Moultrie, J Nel, H Hausler, W Preiser, L Lasersohn, H J Zar, G J Churchyard

Abstract


Summary

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators (‘respirators’; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death. Recommendations Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of ‘zero harm’, aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend:

1. the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;

2. the use of respirators that meet national and international manufacturing standards;

3. evaluation of all respirators, at the least, by qualitative fit testing; and

4. the use of respirators as part of a ‘package of care’ in line with international IPC recommendations.

We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.


Authors' affiliations

K Dheda, Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom

S Charalambous, The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

A S Karat, TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom

A von Delft, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; TB Proof, South Africa

U G Lalloo, Gateway Private Hospital Medical Centre, Umhlanga Ridge, South Africa; Durban International Clinical Research Site, Durban, South Africa

R van Zyl Smit, Division of Pulmonology and Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa

R Perumal, Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa

B W Allwood, Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

A Esmail, Clinical Trials Unit, University of Cape Town Lung Institute, South Africa

M L Wong, Division of Pulmonology, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

A G Duse, Clinical Microbiology & Infectious Diseases, School of Pathology of the NHLS & University of the Witwatersrand, Johannesburg, South Africa

G Richards, Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

C Feldman, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

M Mer, Department of Medicine, Divisions of Pulmonology and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

K Nyamande, Department of Pulmonology, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa

U Lalla, Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

C F N Koegelenberg, Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa

F Venter, Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

H Dawood, Greys Hospital, Pietermaritzburg, South Africa

S Adams, Division of Occupational Medicine, School of Public Health and Family Medicine, University of Cape Town, South Africa

N A B Ntusi, Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Afric

H-M van der Westhuizen, TB Proof, South Africa; Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom

M-Y S Moosa, Department of Infectious Diseases, Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Southern African HIV Clinicians Society

N A Martinson, Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa; Johns Hopkins University Center for TB Research, Baltimore, MD, USA

H Moultrie, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa; Clinical Microbiology & Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

J Nel, Division of Infectious Diseases, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa

H Hausler, TB HIV Care, Cape Town, South Africa

W Preiser, Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town, South Africa

L Lasersohn, 3 South African Society of Anaesthesiologists; Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Division of Critical Care, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa

H J Zar, Department of Paediatrics & Child Health, Red Cross Children’s Hospital and SAMRC Unit on Child and Adolescent Health, University of Cape Town, South Africa

G J Churchyard, The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA

Full Text:

PDF (330KB)

Cite this article

African Journal of Thoracic and Critical Care Medicine 2021;27(4):. DOI:10.7196/AJTCCM.2021.v27i4.173

Article History

Date submitted: 2021-10-22
Date published: 2021-10-22

Article Views

Abstract views: 475
Full text views: 63

Refbacks

  • There are currently no refbacks.



African Journal of Thoracic and Critical Care Medicine| Online ISSN: 2617-0205

This journal is protected by a Creative Commons Attribution - NonCommercial Works License (CC BY-NC 4.0) | Read our privacy policy.

Our Journals: South African Medical Journal | African Journal of Health Professions Education | South African Journal of Bioethics and Law | South African Journal of Child Health | Southern African Journal of Critical Care | South African Respiratory Journal South African Journal of Obstetrics and Gynaecology |