School Settings

K–12 schools are complex environments, Kojola said. In addition to teachers, schools employ custodians, food services workers, special educators who care for students with disabilities, maintenance personnel, school nurses, administrative staff, and a host of workers in other occupations. Traditionally, most workers in K–12 school settings are not required to wear a respirator, although some workers in schools (e.g., vocational teachers teaching carpentry and masonry) may wear respiratory protective devices (RPDs). In some schools, nurses and health aides may occasionally wear respirators, especially during influenza season or during an outbreak of tuberculosis, measles, or pertussis. Similarly, some custodians and maintenance workers in schools may wear respirators when using solvents to remove graffiti or when they could potentially be exposed to asbestos. Kojola observed that in those relatively uncommon situations where workers in K–12 schools are using RPDs, these devices are often not fit tested or evaluated, workers are not educated in how to use them, and the schools do not have the comprehensive respiratory protection programs required to ensure that the respirators used are providing their employees with the intended protection.

Kojola commented on the changing respiratory risks in schools during the coronavirus disease 2019 (COVID-19) pandemic, noting that (as of August 2020) the Centers for Disease Control and Prevention (CDC) had recommended that all teachers and students wear cloth facial coverings to prevent droplet-based transmission of SARS-CoV-2¹ to others.² However, he said that cloth facial coverings do not offer sufficient protection against airborne transmission, so schools may need to provide certain school employees with respiratory protection based on assessments of their specific risks. Workers at higher risk in these settings might include, for example, nurses caring for sick children and special educators working in close contact with their students. These issues are a critical part of the discussion regarding school policies amid the ongoing COVID-19 pandemic.

Meatpacking Facilities

As in school settings, line workers in meatpacking facilities do not typically use respirators and work in settings that generally do not have a respiratory protection program established or provide respiratory protection, Kojola said. These workers usually work in close proximity to their colleagues, often standing just 2–3 feet apart side by side and 4 feet across from each other on the processing lines. Although these workers have not been traditionally thought of as needing respiratory protection, meatpacking facilities were identified as hotspots of transmission during the COVID-19 pandemic. According to Kojola, in the United States as of July 27, 2020, there had been around 37,000 reported COVID-19 cases and at least 168 of these were among meatpacking facility workers.³ One study found that COVID-19 was transmitted from as far away as 26 feet in a meatpacking plant in Germany where workers were wearing single-layer cloth masks (Guenther et al., 2020). Kojola said this finding suggests that CDC's guidance recommending the use of cloth masks is likely not adequate to prevent transmission in meatpacking facilities, and strategies for respiratory protection will need to be considered to protect meatpacking facility workers as the COVID-19 pandemic continues.

Exposure Profile, Health Risk, and Respiratory Protection for Wildland Firefighters

Between 5 and 15 percent of the time they are working, wildland firefighters are exposed to various contaminants at levels above occupational exposure limits, Domitrovich said (Reinhardt and Broyles, 2019). Although wildland firefighters typically have average levels of carbon monoxide exposure that are relatively low, they often encounter short bursts of high levels of exposure to carbon monoxide, which can vary widely in maximum intensity (Domitrovich, 2020). These workers face such a diversity of exposures that developing a standard for respiratory protection is difficult, Domitrovich said, as exposure to any given contaminant can vary greatly from one fire assignment to another. Furthermore, respirators are typically designed for high concentrations of exposure, but in the wildland firefighting context, protection is needed against low concentrations for long durations. Typical wildland firefighting shifts last approximately 14 hours, but can often exceed 24 hours depending on the fire. Domitrovich added that the short-duration exposures to high concentrations of contaminants have been linked to elevated risks of lung cancer and cardiovascular disease for both short-season and long-season wildland firefighters (Navarro et al., 2019).⁵

Studies conducted over the past several decades have sought to address the unique challenges associated with ensuring respiratory protection for wildland firefighters, Domitrovich said (NFPA, 2016). In 1984, the National Fire Protection Association (NFPA) published the first edition of its standard on respirators for wildland firefighting operations. These standards have been periodically updated, with the most recent edition published in 2016. Some respirators have failed to meet the unique needs of wildland firefighters, which include the ability to quickly don and remove the device while maintaining ease of communication and the ability to manage and use other firefighting equipment. Certain types of respirators were notably ill-suited to the needs of firefighters because they interfered with their ability to use radios for remote communication. Until recently, some wildland firefighters resorted to using conventional cloth bandanas as facial coverings in lieu of a respiratory device that meets their unique needs. Domitrovich said that education on respiratory exposure has largely, but not completely, eliminated the use of bandanas in lieu of respirators in the field. Domitrovich said that despite technological advancements in respiratory devices since the initial creation of the NFPA standards, no respirators have been tested to meet the current wildland fire respirator standard, which was first created in 1984 and most recently updated in 2010. The forthcoming new edition of the NFPA standards is expected to divide wildland firefighting respirators into three tiers: (1) particulate only; (2) particulate, vapors, and gases; and (3) particulate, vapors, gases, and additional vapors and gases not protected by the second tier. This approach was developed based on the observation that closer proximity to a wildland fire's combustion source is closely related to the presence and higher proportions of carbon monoxide, vapors, gases, and particulates in the air. Domitrovich suggested that this approach to developing wildland firefighting respirators may provide a broader range of options to help to ensure the respiratory protection of wildland firefighters in their dynamic working conditions.

California Occupational Health and Safety Administration's Emergency Regulation on Protection from Wildfire Smoke

To address concerns regarding workers' exposure to smoke, ash, and poor air quality, in 2019 the California Occupational Safety and Health Administration (Cal/OSHA) established an emergency regulation on protection from wildfire smoke.⁶ This temporary standard extends beyond the concerns of agricultural workers, covering any workers in the vicinity of wildfires where the Air Quality Index (AQI) for particulate matter (PM)_2.5⁷ is 151 or greater due to smoke and ash. The standard does not apply to wildland firefighters, and employers are exempt if workers remain in buildings or structures with mechanical ventilation or filtered air or if exposure to unfiltered air with an AQI for PM_2.5 of 151 or greater occurs less than 1 hour per shift. This standard requires employers to monitor air quality, modify work practices to reduce workers' exposure to PM_2.5 during wildfire events, and enact respiratory protection measures as necessary. Under the standard, if the AQI for PM_2.5 exceeds 150, employers are required to allow for voluntary respiratory protection, following all applicable Cal/OSHA guidelines. If the AQI for PM_2.5 exceeds 500 and employees are expected to continue working, then employers must institute mandatory respiratory protection in accordance with all Cal/OSHA guidelines, which includes providing respiratory safety information to workers and establishing a respiratory protection program. Riley added that respiratory protection standards have not traditionally extended to the agricultural industry and that it is atypical for agricultural employers to have respiratory protection programs. Therefore, implementing and enacting these new emergency standards has required a novel approach that had not yet been tested because the standard had only been in place for roughly 1 year.

Education and Outreach to the Agricultural, Day Laborer, and Domestic Worker Sectors

Riley said that LOSH has efforts under way to educate both workers and employers about the new standards set by the emergency regulation on protection from wildfire smoke, with a particular focus on ensuring that adequate protections are in place before wildfires occur. He said that day laborers and domestic workers are not typically considered to be in need of respiratory protection, but concerns about this sector—which is largely composed of informal workers—have increased as wildfires in California have become more intense. Many people in this sector work in residential areas that have been developed on the boundaries of wildfire-prone areas. By virtue of their location, such residential areas are often in wealthy communities where day laborers are hired to care for properties and families. As wildfires have occurred with increasing frequency, workers on these properties are often expected to continue working even as fires approach their residential work sites (Cotsirilos, 2019; Mejia, 2019).⁸ Riley noted that this work is often physically strenuous, and in some cases laborers are asked to attempt to defend the home from wildfires using garden hoses, trenches, and other means. Day laborers are also frequently called into these areas soon after a wildfire subsides to clean up the remnants of destroyed property or to remove soot and ash. Respirators could help protect these workers from exposure to fine particles during these types of cleanup efforts. However, given the informal nature of this work, formal respiratory programs are not in place for day laborers. More thought will be required to fully grapple with these complex issues, he said.

Riley emphasized the importance of educating both employers and employees about respiratory risks and protection. LOSH has conducted trainings on the emergency regulation on protection from wildfire smoke for agricultural workers, which covers various kinds of respiratory hazards and types of respiratory protection, including how to wear and test an N95 mask. Many of the workers who receive LOSH's training are Spanish speaking—and in some cases, workers from Mexico and Central America may only speak indigenous languages—so training mechanisms have been developed to better reach these workers. Riley added that beyond being educated about how to properly use an N95 mask, the workers also need to understand what an N95 mask can and cannot protect against. For instance, N95 masks are often used by agricultural workers, day laborers, and domestic workers under the presumption that they will protect against pesticides, paint fumes, or toxic chemicals. To address this issue, LOSH offers training focused on proper use cases for N95 masks and helping people to understand that “a mask is not a mask,” Riley said. Training and education efforts also focus on the differences between the acute impacts of exposure to respiratory hazards and the potential long-term impacts of respiratory exposures.

Challenges and Potential Ways Forward

Respiratory protection issues intersect with many other factors. Incentive structures drive the pace of work—particularly agricultural work—and these structures may disincentivize workers from prioritizing their own safety. Agricultural workers are often paid per piece, so they are disincentivized from stepping away from work if they feel overheated or from wearing a respirator that may slow their work or add a physical burden. In the case of day laborers in temporary employment who have informal relationships with their employer, it may be challenging to ensure that (1) workers have the appropriate types of RPDs they need and (2) the use of these devices does not put them at additional risk. Riley suggested focusing on forms of exposure control that, to the extent possible, do not rely on personal protective equipment (PPE).

LOSH has also found that partnering and engaging with worker organizations and community organizations reaches these workforces most effectively. Riley added that as wildfires remain an escalating concern for people in California, the emergency regulation on protection from wildfire smoke can serve as a type of natural experiment. He said that employers, employees, and regulators in sectors where this new regulation applies are all starting from square one. Moving forward, Riley said, it will be critical to evaluate and monitor the implementation of this emergency regulation, especially across the agricultural, domestic work, and day labor sectors.

Regulation of Respiratory Protection Programs for Nontraditional Users

Harrison opened the discussion by noting that several questions had been submitted in regard to the role of OSHA and regulation for nontraditional respirator wearers. He asked about the connection between OSHA-required respiratory protection programs and the nontraditional user, particularly in workplaces that historically have not considered themselves as being in need of OSHA-mandated respiratory protection programs.

Education and Training

Harrison said that there had been a number of participant comments regarding the need for education and training to facilitate understanding of the difference between a respirator and a facial covering. Riley emphasized that although workers need to be trained, employers require training as well. In particular, employers need to understand that respiratory protection is more than handing out a respirator—it is an entire program that includes standards, requirements, and employer responsibilities. Employers also need to understand the potential risks of providing a worker with an N95 in the absence of proper testing and medical evaluation, he continued. Furthermore, homeowners also require education. As wildfires in residential areas become more and more prominent, Riley said, many homeowners are relying on a response and cleanup workforce of day laborers. Homeowners need to understand the potential risks for these workers and assume some responsibility for hiring them, he said.

Integrating Respiratory Protection into Broader Safety Programs

Harrison shared a participant comment regarding the need for a respiratory protection program for the nontraditional user to be integrated with an overall occupational safety and health program that also includes skin and hearing protection. Harrison asked how a respiratory protection program for wildland firefighters integrates with overall occupational safety and health efforts. Domitrovich agreed that a holistic approach is needed to improve wildland firefighter health and safety. Over the past decade, he said, federal agencies have transitioned to considering more health and safety factors. For example, in recent years the U.S. Forest Service has put hearing conservation efforts in place, especially as pertains to aircraft noise exposure. Additionally, the U.S. Forest Service is in the initial stages of examining firefighters' dermal exposures to potential carcinogens. This represents efforts to go beyond hazard-specific PPE or mitigation measures to create holistic, complete worker health, Domitrovich said.

Hazard Assessment

Saying that a number of participant comments and questions related to hazard assessment, Harrison asked how hazard assessments can effectively determine the type of PPE necessary for nontraditional wearers, who should perform such assessments, and what kinds of respiratory protection programs should be created. He also relayed a question about whether NIOSH would be performing workplace health hazard evaluations to gather research to inform appropriate PPE determinations. Harrison reported that some hazard assessment questions pertained to COVID-19, airborne transmission, and fine particles.

Kojola replied that in regard to recommendations for respiratory protection for COVID-19, an N95 filtering facepiece respirator is the baseline. For high-level exposures, such as those that are encountered with aerosol-generating procedures, the recommendation is typically to use a powered air-purifying respirator. He added that there is no current exposure level or standard for traditional industrial hygiene sampling for SARS-CoV-2 but, from the perspective of worker protection, it is critical to move away from devices that do not offer respiratory protection. Workers who have the potential for risk and exposure should receive respiratory protection, he said, especially with evidence mounting that airborne transmission of COVID-19 exists. Kojola added that cloth face coverings are insufficient for providing protection for the user and “we owe it to ourselves to ensure that those workers are as adequately protected as possible.”

Standards Expectations for Nontraditional Users

Harrison shared a participant comment that traditional workplace regulation favors engineering controls and allows PPE to serve as an effort of last resort. Within the traditional hierarchy of controls,⁹ engineering controls are more effective than PPE, which is the least effective level of the hierarchal model. The participant noted that respiratory protections standards can be fairly restrictive for nontraditional users and asked whether this highly protective approach—involving penetrating particles sizes and fit factor—is appropriate for nontraditional users and nontraditional workplaces. Harrison added that this question arose in California with the standard on wildfire smoke for nontraditional users and asked whether an N95, even if it is not fit tested, is better than no protection at all. Harrison asked whether OSHA regulations regarding assigned protection factors, fit testing, and compliance with the OSHA respiratory standard should ever be relaxed. Finally, Harrison asked whether nontraditional users should be required to conform to the same levels of compliance and standards used for traditional users.

Kojola said that the same provision should apply to all workers who have exposure risks, which means full compliance with respiratory protection standards. He said that while “better than nothing” is a step in the right direction, it is insufficient. Efforts to protect workers in fields where there are known and extensive exposures to inhalation hazards, such as construction and manufacturing, should extend to industries and environments that typically lack respiratory protection programs, he contended. Additionally, Kojola emphasized the need to look beyond respirators to address exposures at the other stages of the hierarchy of controls. For example, a recent paper that examined airborne transmission of COVID-19 in a German meatpacking plant focused on ventilation controls (Guenther et al., 2020). Air is recirculated in this cold environment, and ventilation is thereby a major focus in protecting workers beyond the single-layer face coverings that German workers wear. Kojola maintained that engineering controls should be implemented before resorting to giving everyone respirators.

In addressing the issue of whether standards should be relaxed for nontraditional workers, Domitrovich described the respirators used by wildland firefighters in the 1990s. This apparatus resembled a snorkel, consisting of a nose clip and a small, lightweight mouthpiece that filtered out particulates. He said that these respirators would not meet the fit-test requirement. In addition, facial hair is an issue, as most federal fires are in remote locations where daily hygiene with shaving is not practical. He spoke about the facial hair he grew while fighting wildfires, not wanting to reduce any time spent sleeping in the hotel by taking time to shave. Many firefighters in these areas have long beards and handlebar mustaches, he continued, so meeting the respiratory protection needs for this environment requires some creativity to maintain protection while also being appropriate for their nonstandard working environment. He said he would not use the word “relax” in regard to protection, but rather the fact that these workers are working in an outdoor environment that has good ventilation should be “taken into account.”

Riley said that it is important not to relax OSHA standards from a protective point of view and that it is important to set expectations for employers. He maintained that even if a state OSHA program is not sufficiently enforcing standards, the framework informs employers of their responsibilities, including respiratory protection and higher levels of protection on the hierarchy controls. Riley asserted there should not be separate expectations for nontraditional workers.

John Balmes of the University of California, San Francisco, commented on the importance of assessing the risks, in order to avoid letting the perfect be the enemy of the good. For example, he contended that the risks from wildfire smoke to agricultural workers and gardeners who are healthy and do not have pre-existing heart or lung disease is not sufficiently high to require a fit-tested N95. In trying to protect a large population of workers at some risk, he said, a practical approach can provide some protection even if it is not perfect according to an OSHA respiratory protection program.

Howard Cohen of the Yale School of Medicine commented on the need for new types of respirators. Referring to Domitrovich's remarks about facial hair, Cohen said that many issues of nontraditional users apply to the public as well. Although OSHA respirator programs are needed whenever possible, he said, there inevitably will be situations that call for different types of respirators that are not yet commercially available.