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The dispute over the use of N95 masks puts healthcare workers at risk again.

Critics oppose the guidelines proposed by the Centers for Disease Control and Prevention (CDC), which they say leave healthcare facilities free to minimize efforts in using N95 masks and other measures protecting workers against airborne diseases like COVID.

Warnings About Updated Infection Control Guidelines

Three years after more than 3,600 healthcare workers died due to COVID-19, occupational safety experts warn that frontline workers may once again be at risk if the CDC follows the advice of its committee regarding infection control guidelines in healthcare settings, including hospitals, nursing homes, and prisons. In early November, the committee issued a set of controversial recommendations that the CDC is considering updating, which would change those established about 16 years ago.

The Impact of CDC Disagreements with Workplace Safety Officials

The pandemic has shown how disagreements between the CDC and workplace safety officials can have serious repercussions. Recently, the large healthcare system Sutter Health in California appealed a directive from the state’s Division of Occupational Safety and Health known as Cal/OSHA, citing the changing guidance from the CDC on when and whether an N95 mask was necessary at the beginning of the pandemic. In contrast, Cal/OSHA requires employers in high-risk settings such as hospitals to improve ventilation, use air filtration, and provide N95 masks to all employees exposed to airborne diseases or those that could be transmitted through the air.

Conflicting Recommendations and Their Impact on Healthcare Workers

Agencies are once again facing a disparity in opinion. The CDC advisory committee recommends varying degrees of protection based on vaguely defined categories, such as whether a virus or bacterium is considered common or how widely it is spread in the air. As a result, occupational safety experts warn that decisions about how to classify COVID and influenza and other airborne diseases—along with the corresponding levels of protection—may once again be left to officials in hospitals, nursing homes, and prisons.

The Impact of Supply Shortages and Ambiguous Guidance

N95 masks, also known as respirators, filter more particles compared to more spacious surgical masks, but they cost about 10 times more and were in short supply in 2020. Healthcare workers of Black, Hispanic, and Asian backgrounds often went without N95 masks at a higher rate than white employees, helping to explain why positive COVID results in members of racial and ethnic minorities appeared nearly five times more often than the general population in the early months of the pandemic. (Hispanics can be of any race or a combination of racial identities.)

Enforcement and Impact on Hospitals and Healthcare Facilities

Cal/OSHA issued several citations to healthcare facilities that failed to provide N95 masks and take other measures to protect workers in 2020 and 2021. Many of them appealed, and some issues remain outstanding. In October, the agency rejected Sutter’s appeal against a $6,750 citation for failing to provide N95 masks to its medical assistants in 2020 when they accompanied patients who appeared to have COVID through clinics. Sutter pointed to CDC guidance at the beginning of the pandemic, according to court testimony. It noted that the CDC described surgical masks as an “acceptable alternative” in March 2020 and “seemed to recommend taking droplet precautions instead of airborne precautions,” suggesting that individuals were unlikely to be infected if they were more than 6 feet away from someone with COVID.

Impact

Ambiguous Guidelines for Healthcare Workers

This is an ambiguous interpretation of the CDC guidelines from 2020, which were partly made for practical reasons. Respirators were in short supply, for instance, and maintaining physical distance of 6 feet was complicated in places where people needed to congregate. Scientifically, there were clear indications that the SARS-CoV-2 virus spreads through the air, prompting Cal/OSHA to implement its clear rules created after the 2009 swine flu pandemic. Workers need stricter protections than the general population, according to Jordan Barab, a former official at the Federal Occupational Safety and Health Administration: “Healthcare workers are exposed for eight to 12 hours a day.”

Conflicting Recommendations and Impact on Healthcare Workers

The CDC advisory committee presents a weaker approach in some cases, suggesting that healthcare workers should wear surgical masks for “common respiratory pathogens primarily transmitted over short distances.” The draft guidance pays little attention to ventilation and air filtration, only recommending N95 masks for “novel or emerging diseases” and those that spread “efficiently over long distances.” Viruses, bacteria, and other airborne pathogens do not clearly fall into those categories.

Impact on Worker Safety and Final Guidelines

David Michaels, former head of OSHA, stated in an October meeting that incomplete and weak guidelines without scientific basis would significantly undermine the credibility of the CDC. Although safety agencies – not the CDC – have the authority to set rules, enforcement often occurs after damage has happened, if at all. Cal/OSHA began investigating Protective Personal Equipment only after the death of a nurse at its main Oakland hospital due to COVID, and healthcare workers complained about being barred from wearing N95 masks in shared hallways with COVID patients. More than a dozen citations from Cal/OSHA against Kaiser Permanente and Sharp Healthcare and other healthcare systems were delayed for months and years behind the complaints and protests of healthcare workers.

Impact on Law Enforcement and Guidelines Abroad

OSHA faces greater challenges in enforcement outside California. The dwindling budget has left the agency with fewer workplace inspectors than it had in 45 years at the height of the pandemic. Additionally, the Trump and Biden administrations slowed the agency’s ongoing efforts to issue regulations regarding respiratory infections. As a result, the agency pursued only about 1 in 5 COVID-related complaints formally filed by employees and worker representatives to the group from January 2020 to February 2022 – and only 4% of those submitted informally through media reports and phone calls and emails. Many deaths among healthcare workers were not reported to the agency in the first place.

Impact of Final Guidelines on Hospitals and Healthcare Facilities

Michaels, who now works at the George Washington University School of Public Health, said that if the CDC follows the final recommendations of the committee, it will further limit OSHA’s authority to penalize employers who expose workers to airborne diseases. These recommendations will leave many hospitals, healthcare facilities, prisons, and nursing homes unprepared as they were before the pandemic, according to Deborah Gold, former deputy director of health at Cal/OSHA. Strict standards encourage employers to stockpile N95 masks and improve air filtration and ventilation to avoid citations. But if CDC guidelines leave room for interpretation, she said that they could justify scaling back costly preparedness efforts.

Impact

Conflicting Guidelines for Researchers and Health Workers

Although the CDC and OSHA committees claim to follow the science, researchers have reached conflicting conclusions because the committee relied on clearly flawed experiments comparing health workers wearing surgical masks to those using N95 masks. Cal/OSHA based its standards on a variety of studies, including reviews of hospital infections and engineering research on airborne particle transmission.

The Impact of Collaboration in Guideline Development

In recent decades, the CDC’s process for developing guidelines has included representatives of workers and experts in occupational hazards. Barab was a health researcher at the public sector employees’ trade union when he helped the CDC formulate recommendations regarding HIV in the 1980s. “I remember asking how to protect healthcare workers and correctional officers who are exposed to urine or feces thrown at them,” Barab said. He noted that the CDC’s drafting researchers initially found the idea laughable, but they still valued his input as someone who understood the conditions faced by employees. “Many of these people hadn’t had medical ground experience in years, if not decades.”

Demand for Worker Inclusion in New Guidelines

The largest nursing organization in the United States, the National Nurses United, has observed the same trend. They are now gathering signatures for an online petition urging the CDC to discard the committee-issued guidelines and create new recommendations that incorporate insights from healthcare workers, many of whom are putting their lives on the line during the pandemic.

The Influence of Large Corporations on Current Guidelines

Barab attributes the lack of worker representation in the current CDC process to the growing influence of large corporations in healthcare. Hospital officials prefer not to be told what to do, especially when it comes to spending money, according to Barab.

In an email, CDC communications official Dave Daisle confirmed that before finalizing guidelines, the CDC would “review the composition of working groups and seek participation to ensure relevant expertise is included.”

KHN (Kaiser Health News) is one of the largest national news organizations producing in-depth journalism on health issues. Alongside policy analysis and surveys, KHN is one of three major operating programs of KFF (Kaiser Family Foundation). KFF is a nonprofit organization that provides information on health issues facing the nation. Amy Maxmen is a contributing reporter for KFF Health News.

Source: https://www.scientificamerican.com/article/rift-over-n95-use-puts-health-workers-at-risk-again/


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