Respiratory Protection in Health-Care
Last Updated: April 2006
All health-care settings need an infection-control program
designed to ensure prompt
- airborne precautions, and
of persons who have suspected or confirmed tuberculosis (TB)
disease. There are three levels of TB infection control in
health-care settings. The first level of the infection-control
hierarchy, administrative controls, should minimize the number of
areas where exposure to Mycobacterium tuberculosis may occur.
The second level, environmental controls, should reduce the
concentration of airborne M. tuberculosis. These
administrative and environmental controls should also reduce,
although they do not eliminate, the risk in the few areas where
exposures can still occur (e.g., airborne infection isolation [AII]
rooms and rooms where cough-inducing or aerosol-generating
procedures are performed).
Because persons entering these areas may be exposed to airborne
M. tuberculosis, the third level of the hierarchy is the use
of respiratory protective equipment in situations that pose a high
risk for exposure.
Considerations for Selection of Respirators
The overall effectiveness of respiratory protection is affected
by 1) the level of respiratory protection selected (e.g., the
assigned protection factor), 2) the fit characteristics of the
respirator model, 3) the care in using the respirator, and 4) the
adequacy of the training and fit-testing program.
Particulate filter respirators certified by the Centers for
Disease Control and Prevention’s (CDC) National Institute for
Occupational Safety and Health (NIOSH) that can be used for
protection against airborne M. tuberculosis include
- Nonpowered respirators with N95,
N99, N100, R95, R99, R100, P95, P99, and P100 filters (including
disposable respirators); and
- Powered air-purifying respirators (PAPRs) with
The most essential attribute of a respirator is the ability to
fit the varying facial sizes and characteristics of health-care
workers (HCWs). Assistance with selection of respirators can be done
by referring to peer-reviewed research and through consultation with
respirator fit-testing experts, CDC, occupational health and
infection-control professional organizations, respirator
manufacturers, and from participation in advanced respirator
Implementing a Respiratory Protection Program
If respirators are used in a health-care setting, the
Occupational Safety and Health Administration (OSHA) requires the
development, implementation, administration, and periodic
reevaluation of a respiratory protection program. The most critical
elements of a respiratory protection program include 1) assignment
of responsibility, 2) training, and 3) fit testing. All HCWs who use
respirators for protection against M. tuberculosis infection
should be included in the respiratory protection program.
The health-care setting should develop a policy on the use of
respirators by visitors. Visitors to AII rooms and other areas with
patients who have suspected or confirmed infectious TB disease may
be offered respirators (e.g., N95 disposable respirators) and should
be instructed by an HCW on the use of the respirator before entering
an AII room.
To be effective and reliable, respiratory protection programs
must include at least the following elements:
- Assignment of responsibility to one person with sufficient
knowledge who is given the authority and responsibility to
manage all aspects of the program.
- Standard operating procedures that include information and
guidance for the proper selection, use, and care of respirators.
- Screening by a physician or other licensed health-care
professional of all HCWs who might need to use a respirator for
pertinent medical conditions at the time they are hired, and
then re-screening periodically.
- Annual training of HCWs with specific focus on prevention,
transmission, and symptoms.
- Selection of filtering facepiece respirators approved by
- Fit testing performed during the initial respiratory
protection program training and periodically thereafter, in
accordance with federal, state, and local regulations.
- Inspection and maintenance of respirators according to
- Evaluation of the respirator program periodically to ensure
its continued effectiveness.
Information on the development and management of a respiratory
protection program is available in technical training courses that
cover the basics of respiratory protection. Such courses are offered
by OSHA, the American Industrial Hygiene Association, the American
Conference of Governmental Industrial Hygienists, universities,
manufacturers, and private contractors.
The Centers for Disease Control and Prevention (CDC) is not a
regulatory agency; CDC recommendations on infection control provide
evidence-based guidance. For regulations in your area, refer to
state and local regulations and contact your local Occupational
Safety and Health Administration (OSHA) office. A directory of OSHA
offices may be found at
CDC. Guidelines for preventing the transmission of
Mycobacterium tuberculosis in health-care settings, 2005. MMWR
2005; 54(No. RR-17).
Occupational Safety and Health Administration. Occupational
safety and health standards, subpart I—personal protective
equipment. Respiratory protection. Title 29, Code of Federal
Regulations 2003. Section 1910.134.
CDC Division of Tuberculosis Elimination:
CDC National Institute for Occupational Safety and Health:
Occupational Safety and Health Administration:
State TB control offices:
American Industrial Hygiene Association:
American Conference of Governmental Industrial Hygienists:
Infection Control in Health-Care Settings:
Last Reviewed: 05/18/2008
Content Source: Division of Tuberculosis Elimination
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention