Inconsistencies Common in Provider Guidelines for Respiratory Protection During Pandemic

By Marilynn Larkin

August 10, 2021

NEW YORK (Reuters Health) - Inconsistencies in national and international guidelines on respiratory protection for health care professionals (HCPs) point to a need for stronger collaborations among organizations in different countries, researchers suggest.

"Our review illustrates the scientific uncertainties regarding the routes of transmission of SARS-CoV-2, and the progressive acquisition of knowledge," Dr. Jean -Christophe Lucet of Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris told Reuters Health by email.

"There still are differences between recommendations regarding respirators - i.e., N95 or FFP2 - due to the ongoing debate around the importance of airborne transmission," he said. "The variability of aerosol-generating procedures (AGPs) considered at risk for airborne transmission also illustrates the uncertainties and the limited literature, mostly coming from the 2003 SARS outbreak."

"We need research on the respective role of airborne and droplet transmission to determine in which circumstances FFP2/N95 and/or medical face masks (MFs) are to be used, keeping in mind that using respirators requires education on proper donning -fit testing - and that using a respirator is not well tolerated when correctly used," Dr. Lucet concluded.

As reported in JAMA Network Open, Dr. Lucet and colleagues conducted a systematic review of infection-prevention and control guidelines on respiratory protection for HCPs published in 2020 by health organizations in four countries and two international organizations.

Indications for respirators were classified as recommended during aerosol-generating procedures; for targeted continuous use in high-risk areas; and during contact with individuals with suspected or confirmed infections in any circumstance.

Recommended indications for medical face masks were categorized as universal face masking; targeted continuous face masking (e.g., during continuous shifts); or during contact with individuals with suspected or confirmed infections only.

Fifty-nine guidelines were included in the review. In January 2020, all initial guidelines recommended respirators (i.e., N95, N99, FFP2 or FFP3) for HCPs in direct contact with patients with suspected or confirmed COVID-19 infection.

After February 10, 2020, the European Centre for Disease Prevention and Control (ECDC) introduced recommendation for use of medical face masks by HCPs caring for patients with COVID-19 in the absence of available respirators, followed a month later by the same recommendation from the US Centers for Disease Control and Prevention (CDC).

Respirators (i.e., FFP3 and N99) for aerosol-generating procedures were a strict ECDC and CDC recommendation.

The World Health Organization (WHO) was the first reviewed entity to strictly recommend medical face masks for HCPs in contact with patients with suspected or confirmed COVID-19, limiting the use of respirators to aerosol-generating procedures.

One week later, France and the UK followed WHO guidance by issuing new versions of their guidelines.

On March 22, 2020, Germany was the first country to recommend universal face masking for HCPs at entry to a hospital. This recommendation appeared later in other countries, including the U.S., France and the UK.

Overall, 13 different guidelines provided definitions of aerosol-generating procedures, providing lists varying from three to 14 procedures. Intubation and bronchoscopy were the most frequently cited, with intubation appearing in 13 guideline updates and bronchoscopy in 12 guideline updates.

Dr. Jonathan Parsons, a pulmonologist at The Ohio State University Wexner Medical Center in Columbus, commented in an email to Reuters Health, "I think the vast majority of the variation in policies stems from supply chain challenges for personal protective equipment and from the fact that this was a novel virus with characteristics that were not fully understood at the time many policies were adopted. As a result, a lot of policy was shaped by availability of masks and knowledge about the virus at that point in time."

Biomedical engineer Dr. David Edwards of Harvard University also commented by email, "The authors suggest that poor understanding of the airborne transmission nature of SARS-CoV-2 played a role in conflicting guidance. This is almost certainly true. The reality is that while scientific evidence of the importance of airborne transmission by small droplets has grown over the last two decades across viral and bacterial infections, the awareness and understanding of this evidence has until the COVID-19 pandemic remained constrained to a relatively small scientific community.

"It became quite clear among many aerosol scientists rather early (on) that airborne transmission was driving the pandemic," he said. "Unfortunately, the speed with which national and international healthcare bodies absorbed this information and adapted advisory strategy accordingly was far too slow."

SOURCE: JAMA Network Open, online August 4, 2021.