White House Letter on H1N1 PPE Guidance

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SHEA-IDSA-APIC Letter on Federal PPE Guidance November 5, 2009.OSHA) requirements concerning the use of personal protective equipment (PPE) by healthcare workers in treating suspected or confirmed cases of H1N1 influenza.

SHEA-IDSA-APIC Letter on Federal PPE Guidance November 5, 2009.OSHA) requirements concerning the use of personal protective equipment (PPE) by healthcare workers in treating suspected or confirmed cases of H1N1 influenza.


November 5, 2009
President Barack Obama
The White House 1600 Pennsylvania Avenue, NW
Washington D.C. 20500

Dear President Obama:


During this state of national emergency due to the 2009 H1N1 influenza pandemic, it is imperative that healthcare professionals and facilities receive clear, practical, and evidence-based federal guidance to ensure patient and healthcare worker safety. With this in mind, the Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), and Association of Professionals in Infection Control and Epidemiology (APIC) write to express significant concern with the federal guidance, developed by your Administration in cooperation with several agencies and recently issued by the Centers for Disease Control and Prevention (CDC), and Occupational Safety and Health Administration (OSHA) requirements concerning the use of personal protective equipment (PPE) by healthcare workers in treating suspected or confirmed cases of H1N1 influenza.


You have long championed evidence-based medicine and your Administration has laudably been committed to enactment of science-driven policies. Given these principles, it is not clear why the federal PPE guidance and requirements do not reflect the best available scientific evidence, which demonstrates that N95 respirators are not superior to surgical masks in the prevention of transmission of influenza in most patient care settings.


In October, two separate studies were presented that reinforce our viewpoint on the use of surgical masks versus respirators. In the first study (Loeb, et al. JAMA, 2009), no significant difference in influenza acquisition was observed in nurses in Toronto assigned to wear N95 respirators or surgical masks. Last week, at the IDSA Annual Meeting, investigators from Australia presented a re-evaluation of a study performed in China (MacIntyre, et al). Again, no significant difference was observed between healthcare workers wearing surgical masks or N95 respirators. Of note, the MacIntyre study was initially reported to show a significant benefit associated with use of the N95 respirators and this preliminary report was both presented to the Institute of Medicine’s Committee on Respiratory Protection for Healthcare Workers in the SHEA-IDSA-APIC Letter on Federal PPE Guidance November 5, 2009

Workplace Against Novel H1N1 Influenza and cited in its final September 3, 2009 Letter Report, which recommended the routine use of N95 respirators.


Of course, continued research concerning the route of transmission and best means of prevention is essential as the pandemic advances so that we may respond effectively should our understanding of the acquisition pathways change. But, until and unless such evidence exists, the current federal PPE guidance and OSHA requirements remain deeply flawed with considerable consequences. Due to their disconnect with scientific evidence, these documents have engendered significant confusion among healthcare professionals and facilities’ administrators; the misallocation of scarce resources to the detriment of both patient and healthcare worker protection; and the creation of skepticism toward federal public and occupational health decision-making.


During this national emergency, it is imperative that federal policy applied to healthcare facilities reflect logistical and practical concerns. In addition to providing appropriate protection for all routine patient encounters, surgical masks have the great advantage of being far more readily available, more practical to implement, more likely to be worn, and less costly than N95 respirators. Indeed, requiring the use of fit-tested respirators for routine evaluation and care of all suspect cases of H1N1 influenza could lead to unintended adverse consequences for patients and healthcare workers. Examples of possible untoward effects include the unnecessary referral of patients to already overloaded emergency rooms and the exacerbation of the existing shortage of respirators thus potentially precluding their use in situations where they are needed. In addition, because the respirators are cumbersome and make it more difficult to breathe and talk, healthcare workers may avoid their use or limit the time they spend with influenza patients.


With all of these factors in mind, our organizations strongly urge your Administration to enact the following two recommendations:


1.Modify the federal PPE guidance to reflect the position best supported by the available science—first-line use of surgical masks for routine H1N1 patient care.


2.Institute an immediate moratorium on the enforcement of OSHA’s requirement for healthcare facilities related to the use of N95 respirators in relation to H1N1 influenza. Permitting OSHA to continue to enforce a policy that is not grounded in science will force healthcare facilities to waste time and resources working to comply with a flawed requirement when they instead should be working to enact measures that will have a beneficial impact on patient care and worker safety during this national emergency.


Thank you in advance for your careful consideration and expeditious implementation of these recommendations. Our leaders stand ready to continue to work with you in responding to the 2009 H1N1 pandemic. Should you have any questions, please contact Jennifer Bright, SHEA’s executive director at 703-684-1007, Robert Guidos, IDSA’s vice president for public policy and government relations at 703-299-0202 or Lisa Tomlinson, Director of Government Affairs for APIC at 202-454-2606.




Mark E. Rupp, MD Richard Whitley, MD, FIDSA Christine Nutty, RN, MSN, CIC

SHEA President IDSA President APIC President

CC: Kathleen Sebelius, MPA, Secretary, DHHS


Tom Frieden, MD, Director, CDC

Francis Collins, MD, Director, NIH

Anthony Fauci, MD, Director, NIAID

Hilda Solis, Secretary, DOL

Jordan Barab, Acting Assistant Secretary, OSHA

Rosemary Sokas, MD, MOH Director, Office of Occupational Medicine, OSHA

Melody Barnes, JD, Director, Domestic Policy Council, The White House


About Our Organizations:


The Society for Healthcare Epidemiology of America (SHEA)


The Society for Healthcare Epidemiology of America (SHEA) was founded in 1980 to advance the application of the science of healthcare epidemiology. SHEA comprises 1,700 physicians, infection control practitioners, and other healthcare professionals who are dedicated to maintaining the utmost quality of patient care and healthcare worker safety in all healthcare settings. The Society continually strives toward better patient outcomes by applying epidemiologic principles and prevention strategies to healthcare-associated infections and a wide range of quality-of-care issues. SHEA achieves its mission through education, research, evidence-based guidance development, and public policy.


Infectious Diseases Society of America (IDSA)


The Infectious Diseases Society of America (IDSA) represents more than 9,000 infectious diseases physicians and scientists devoted to patient care, education, research, and public health. Our members care for patients with serious infections, including antimicrobial resistant bacterial infections, meningitis, pneumonia, surgical infections, HIV/AIDS, tuberculosis, and influenza.


Association for Professionals in Infection Control and Epidemiology (APIC)


APIC’s mission is to improve health and patient safety by reducing risks of infection and other adverse outcomes. The Association’s more than 12,000 members direct infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities around the globe. APIC strives to promote a culture within healthcare where targeting zero healthcare-associated infections is fully embraced. The organization advances its mission through education, research, collaboration, practice guidance, public policy and credentialing.

SHEA-IDSA-APIC Letter on Federal PPE Guidance November 5, 2009



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