Evaluation of a model training program for respiratory-protection preparedness at local health departments.

Introduction

Historically, local health departments (LHDs) have not had extensively developed respiratory-protection programs. For most LHDs, either no such programs were in place or the programs focused only on protection against exposure to tuberculosis (TB). New respiratory threats have surfaced, however, which could affect the health of LHD employees. These threats include naturally occurring infectious diseases such as SARS, monkeypox, and avian flu, as well as deliberate aerosolization of bioterrorism agents such as smallpox viruses or anthrax spores. Drug-resistant strains of respirable biological agents are another concern, as are environmental exposures to microbial allergens and pathogens in airborne dusts and molds.

Particularly at risk for infectious-disease exposure are employees who must conduct disease investigations, staff clinics, provide vaccinations, or dispense pharmaceuticals at mass-dispensing sites. Those at risk from environmental respiratory-disease hazards include employees who must enter moldy or dusty environments. They may be involved in cleanup or assessment of community health needs after natural disasters (hurricanes, floods) or deliberate events (terrorist bombing of structures). Environmental health specialists in health departments provide key services for many of these activities and may suffer from particulate exposures. These examples should clarify some of the current respiratory hazards facing some LHD employees. A respiratory program that focuses solely on protecting employees from TB, as such programs often do, is not sufficient to ensure protection against other respiratory hazards.

Furthermore, in December 2003, OSHA revoked the existing respiratory-protection standard for TB (Occupational Exposure to Tuberculosis, 2003). Employees covered by this standard are now covered under the provisions of the respiratory-protection standard for general industry (Respiratory Protection, 1998) except that enforcement of annual fittesting with fiscal year 2005 federal moneys has been temporarily suspended for respirators worn to protect against occupational exposure to TB (Department of Labor Consolidated Appropriations Act of 2005, 2004; North Carolina Department of Labor, 2005). The newer standard is more stringent than the former TB standard. Under the regulations for general industry, OSHA requires an ongoing respiratory-protection program when employees are required to wear respirators. The Occupational Safety and Health Division of the North Carolina Department of Labor has adopted the federal OSHA respiratory-protection standard (North Carolina Department of Labor, 2002), and the standard applies to local governments as well as industries. Therefore, LHDs may have to devote scarce resources and time to developing a program that meets OSHA standards. Furthermore, the OSHA respiratory-protection standard was initially developed to address respiratory protection in an industrial working environment. Consequently, program initiation and development templates appropriate for health departments were not available. For these reasons, Public Health Regional Surveillance Team (PHRST) industrial hygienists and the North Carolina Office of Public Health Preparedness and Response have developed a training program to facilitate the implementation of complete respiratory-protection programs at LHDs.

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North Carolina's Respiratory-Protection Preparedness Training Program

N-95 respirators are recommended for the safety of employees who may be exposed to low levels of certain respiratory infectious agents in the health care environment (Centers for Disease Control and Prevention [CDC] 2005, 2004, 2003). Therefore the respiratory training program developed for LHD employees was initially based on the use of N-95 respirators. This program included information presented on the following elements of a respiratory-protection program as required by the federal OSHA Respiratory Protection Standard 1910.134: selection of respirators appropriate for hazard; medical evaluation of employees before respirator use; fit-testing procedures; correct usage, maintenance, and care of respirators; recognition of potential respiratory hazards for employees in health departments; and program evaluation. After completion of training, all eligible employees were fit-tested. A train-the-trainer program provided more detailed instruction to the LHD-assigned program administrator on respiratory-protection programs and fit-testing procedures. This arrangement enabled LHD employees to train and fit-test staff on an annual basis.

Training materials were developed to facilitate implementation and maintenance of a respiratory-protection program. These included templates for a respiratory-protection-program policy, a medical-evaluation questionnaire, and an attendance roster for training and fit-testing. Protocols and visual aids for sensitivity and fit-testing procedures were also developed. All training materials and Power-Point presentations were made available on compact disk and distributed to the LHD respiratory-protection program administrator.

Program Evaluation

A program evaluation was conducted to assess the effectiveness of the training program at LHDs. The objectives of the evaluation were to determine

* the proportion of health departments in North Carolina that implement and maintain a respiratory-protection program,

* compliance with specific OSHA Respiratory Protection Standard (29 CFR 1910.134) elements, and

* areas of improvement for future respiratory-protection trainings.

Methods

A questionnaire was developed containing 38 questions relative to the OSHA-required elements of a respiratory-protection program and the PHRST training materials (Figure 1). The questionnaire was distributed to all North Carolina LHDs and combined health districts (CHDs) that had completed respiratory-protection training conducted by PHRST industrial hygienists. These questionnaires were self-administered by an employee of the health department, usually by the respiratory-protection program administrator. The completed questionnaires were sent to the investigators via e-mail or fax. The responses were then entered into a Microsoft Access database, and descriptive statistics were generated. To determine if the training effect was statistically significant, the authors performed Wilcoxon's matched-pairs test comparing the number of positive responses for compliance with or revision of respiratory-protection program elements before the training with the number after the training. A probability value of p < .5 was considered statistically significant.

Results

At the time the questionnaire was distributed, PHRST respiratory-protection training was completed in 83 percent (71/86) of health departments or CHDs in North Carolina. The survey response rate was 52 percent (37/71). The overall average compliance percentage for all eight OSHA requirements was 69 percent (Table 1). The element "training on seal check procedures" was the OSHA requirement for which the compliance rate was lowest (54 percent), and "medical evaluation" was the requirement for which the compliance rate was highest (95 percent) among the 37 responding health departments. Greater than 30 percent of the health departments did not have a "written respiratory protection policy," "trained fit tester," or training that covered respiratory hazards, respirator selection, respirator use, and seal check procedures. As a result of the training provided by the PHRST industrial hygienists, 24 to 51 percent (Table 1) of the responding health departments indicated that they had added or revised required program elements in their respiratory-protection programs. The overall effect of the training was statistically significant with respect to increasing the number of health departments that added required elements (p < .05) and with respect to the addition of required elements or the revision of existing elements (p < .05)

Additional information supported the conclusion that the PHRST industrial-hygienist respiratory program was beneficial to the LHDs. A large majority of responding health departments (76 percent, or 19/25) indicated that their fit-tester had been trained by the PHRST industrial hygienists. The majority of program administrators used both the written respiratory-program policy template (72 percent, or 18/25) to write their health department policy and the medical questionnaire (89 percent, or 31/35) to perform medical evaluation. Only 22 percent of the respondents (8/37), however, stated that they had specific plans to evaluate their programs.

Responses to questions on the value of training components and topics for future PHRST trainings are summarized in Table 2. Receiving instruction on the fit-testing procedure (32 percent, or 12/37) and "Correct Respiratory Use/Selection" (16 percent, or 6/37) were the two training elements of most benefit to the health departments. A few respondents (three) indicated that too much time had been spent on respirator types that were not commonly used at LHDs. Few respondents articulated topics for future trainings, but three suggested including information on other biological and chemical hazards.

Discussion and Conclusions

The PHRST respiratory-protection training program was an attempt to increase the number and improve the quality of respiratory-protection programs at health departments in North Carolina. Evaluation of this training was conducted by a self-administered survey with no follow-up validation. Furthermore, the response rate (52 percent) and the number of participating respondents (n = 37) were low. These limitations may lessen the strength of the conclusions; however, results from this evaluation clearly demonstrate a positive impact from the PHRST training program. The program increased the number of health departments with respiratory-protection programs and enhanced awareness of the components of such a program. It also improved compliance with OSHA's respiratory standard 1910.134 and increased the number of health care workers who wear correctly fitted respirators. In addition, the fit-testing train-the-trainer service has supplied health departments with on-site personnel who are trained to perform respirator fit-testing in routine and emergency events.

The evaluation demonstrated several areas in need of improvement for future trainings. More emphasis needs to be placed on the requirement for annual training in proper selection and use of respirators. Few programs (16 percent) had written policies for discarding respirators, and questions regarding procedures for safe disposal of used N-95 respirators were frequently asked during the training sessions. This circumstance emphasizes the need to provide instruction on procedures for discarding disposable respirators. Program administrators frequently did not understand how to evaluate their respiratory programs, and OSHA regulations do not provide detailed guidelines on program evaluation. Therefore, future trainings should provide information on procedures and templates to guide implementation of the program evaluation. New directions for training could also include expansion of information on non-particulate respiratory hazards and appropriate respirator selection for these hazards. The training program described here does, however, provide a model that could help other LHDs and organizations implement and improve respiratory-protection programs.

Acknowledgements: The authors thank Takashia Penny of the Public Health Regional Surveillance Team 4, Wake County Human Services, in Raleigh, North Carolina, for her invaluable help with data entry and database management. Thanks are also due to Mary Davis, Ph.D., North Carolina Center for Public Health Preparedness, Chapel Hill, NC, for her assistance with development of the questionnaire.

Corresponding Author: Edie Alfano-Sobsey, Environmental Epidemiologist, Public Health Regional Surveillance Team 4, Wake County Human Services, 10 Sunnybrook Rd., Rm. 301, Raleigh, NC 27610. E-mail: [e-mail].

REFERENCES

Centers for Disease Control and Prevention. (2003). Updated interim infection control and exposure management guidance in the healthcare and community setting for patients with possible monkeypox virus infection. Retrieved October 3, 2005 from http://www.cdc.gov/ncidod/monkeypox/infectioncontrol.htm.

Centers for Disease Control and Prevention. (2004). Interim recommendations for infection control in health-care facilities for patients with known or suspected avian influenza. Retrieved October 3, 2005, from http://www.cdc.gov/flu/avian/professional/infect-control.htm.

Centers for Disease Control and Prevention. (2005). Interim domestic guidance on the use of respirators to prevent transmission of SARS. Retrieved October 3, 2005, from http://www.cdc.gov/ncidod/sars/respirators.htm.

Department of Labor Consolidated Appropriations Act of 2005, 29 U.S.C. [section] 678 (2004) Retrieved December 9, 2005, from http://uscode.house.gov/download/pls/29c15.txt.

North Carolina Department of Labor. (2002). Administrative rules: Administered by the N.C. Department of Labor: Including amendments through 2002 (13 NCAC 07F.0101). Retrieved October 3, 2005, from http://www.nclabor.com/title13.pdf.

North Carolina Department of Labor, Division of Occupational Safety and Health. (2005). Operational procedure notice 131A. Retrieved October 3, 2005 from http://www.nclabor.com/osha/etta/publicopn/opn131A.pdf.

Occupational Exposure to Tuberculosis, 68 Federal Register 75767-75775 (proposed December 31, 2003) (to be codified at 29 C.F.R pt. 1910). Retrieved October 3, 2005, from http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=18050.

Respiratory Protection, 29 C.F.R [section] 1910.134 (1998). Retrieved June 6, 2005, from http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716.

Edie Alfano-Sobsey, Ph.D.

Bobby Kennedy, Ph.D.

Frank Beck, M.S.E.H.

Brian Combs

Wendy Kady, C.I.H.

Steven Ramsey, R.S.

Allison Stockweather

Will Service, M.S.P.H.

TABLE 1 Effect of PHRST Training on Respiratory-Protection Program
Elements at Local Health Departments*

                         LHDs in Compliance with  Element Provided
Program Element          Program Elements         Before Training

Written respiratory-     65% (24)                 22% (8)
  protection policy
Designated program       92% (34)                 59% (22)
  administrator
Medical evaluation       95% (35)                 62% (23)
Trained fit-tester       68% (25)                 16% (6)
Training on respiratory  68% (25)                 32% (12)
  hazards
Training on respirator   57% (21)                 27% (10)
  selection
Training on respirator   57% (21)                 32% (12)
  use
Training on seal check   54% (20)                 30% (11)
  procedures
Average percentage       69%                      35%

                         Element Provided  Element Provided
Program Element          After Training    or Revised After Training

Written respiratory-     30% (11)          43% (16)
  protection policy
Designated program       27% (10)          32% (12)
  administrator
Medical evaluation       22% (8)           32% (12)
Trained fit-tester       51% (19)          51% (19)
Training on respiratory  19% (7)           35% (13)
  hazards
Training on respirator    3% (8)           30% (11)
  selection
Training on respirator    2% (5)           24% (9)
  use
Training on seal check   16% (6)           24% (9)
  procedures
Average percentage       21%               34%

*() = number of positive responses; N = 37.

TABLE 2 Summary of Responses to Questions on Value of PHRST Respiratory-
Training Components and Future Training Topics*

                                                   Additional Topics
                                                   for Future
Most Valuable**           Least Valuable***        Trainings****

Fit-testing               Nothing (8)              More on respiratory
procedure (12)                                     hazards (biological
                                                   and chemical) and
                                                   updates (3)
Correct respirator        Too much on              Fit-tester training
use/selection (6)         respirator types (3)     (1)
Everything/               Incomplete training (1)  More on OSHA
thoroughness (7)                                   regulations (1)
Respiratory               Training repetitive (1)  More on program
hazards/risks (5)                                  development and
                                                   implementation (2)
Review of OSHA            Extraneous information   Uncertain (2)
policies (1910.134) (2)   not related to
                          respiratory protection
                          (1)
Interaction with          N-95 fit-testing         Program evaluation
staff/PHRST (2)           failure (1)              (1)
Written RPP template (1)  Room uncomfortable (1)   Infection control
                                                   (1)
                                                   Respirator use risks
                                                   (1)
                                                   Program updates (1)
                                                   Examples of
                                                   situations requiring
                                                   respiratory-equipment
                                                   use (1)
                                                   None (1)

*() = number of responses.
** Response rate = 86% (32/37).
*** Response rate = 43% (16/37).
**** Response Rate = 41% (15/37).