GPs in high COVID areas should get respirators fit-tested: Experts

Doug Hendrie

4/09/2020 4:38:59 PM

GPs have one of the lowest P2/N95 fit-testing rates among Australian healthcare workers, with new research indicating it may be less than 5%.

Doctor in full PPE displaying P2/N95 mask.
GPs are one of the least fit-tested professions among Australian healthcare workers.

GPs seeing patients in high COVID prevalence areas should get fit-tested for respirators – even if they have to arrange it themselves, according to prominent GPs and occupational health experts.
The calls come after a large new survey of Australian healthcare workers found only 4% of the 138 GP respondents had been fit-tested.
‘GPs are one of the least fit-tested professions,’ one of the survey organisers, emergency doctor locum Dr Mian Bi told newsGP.
‘GPs are at such high risk because, like emergency doctors, you never know who is coming in or what might happen. [GPs] have been lucky so far, but it could be a lot worse.
‘You’ll never know [if you are safe] until you get fit-tested. If you don’t have that seal, aerosols can still get in through micro leaks. Air travels in the direction of least resistance.’
RACGP Expert Committee – Quality Care (REC–QC) member Dr Michael Tam told newsGP that GPs should consider wearing respirators in areas of higher virus prevalence, such as Victoria or hotspots in New South Wales.
‘If you’re wearing N95s, then you should be fit-tested – the whole point of it is that it provides higher levels of protection than surgical masks,’ he said.
‘Protecting healthcare workers is a really important part of ensuring we don’t have a disaster scenario with COVID. Requiring GPs to seek out fit-testing in the private sector makes no sense from a national response perspective – and it’s not just GPs, but specialists in the community and allied health.
‘Expecting that whole sector to fend for themselves doesn’t sound like a good approach.’
Infections are still occurring amongst GPs, even though the widespread shift to telehealth has afforded GPs a higher degree of protection than some other healthcare workers, given the ability to triage remotely. 
Victorian Government analysis of healthcare worker infections released in August found 36 people in GP clinics – including GPs, nurses and other staff – had contracted the virus, with an estimated 30% of these likely to have acquired it at work.
Fit-testing has become a prominent issue in Victoria, where health authorities require only fit-checking, in contrast to states where it is mandatory, such as South Australia.
Viral transmission amongst healthcare workers is now the main reason for COVID spread in Victoria, accounting for an average of 65% of the state’s new cases over the past seven days.
Alarm over the high rates of Victorian healthcare workers contracting the virus at work – estimated to be 70–80% by state health authorities – has led to loud calls for fit-testing, amongst other efforts to stamp out spread in hospitals, clinics and aged care facilities. 
The Victorian Government recently announced a trial of fit-testing would take place at the Northern Hospital. The decision to launch a trial rather than a larger roll-out was immediately criticised for being too slow by healthcare workers, medical groups and occupational health experts.

Respirators such as P2 and N95 masks must be fit-tested in order to guarantee their effectiveness.
A frontline emergency physician in a major Melbourne hospital told newsGP he had been fit-tested at his own expense. The testing proved the respirator he preferred due to comfort was not keeping him safe, while a less comfortable respirator brand did offer protection.  
‘If this is a nosocomial infection, everything should be done to the highest level to ensure healthcare workers are protected,’ said the doctor, who did not want to be named.
‘While there is no definitive data that N95 respirators eliminate the risk of infection, we should be precautionary so that the risk of further infections to colleagues is minimised as much as possible. 
‘This wouldn’t happen during wartime. It wouldn’t happen in other industries. Why are the staff that are so expensive to replace not being protected?
‘If it’s about the uncertainty of evidence – surely being more protective is better than less. If it’s about supplies, that’s unacceptable – we had six months.’ 
Leading occupational hygienist Kate Cole told newsGP fit-testing of respirators is essential to ensure a higher grade of protection than a standard surgical mask can provide.
‘As soon as you’re using P2 or N95s for protection, you need to be fit-testing – otherwise there’s no point,’ she said.
‘Face shapes are different and masks are different. Unless you have that fit validated through a test, air can just go around the seal. And then you breathe it in.
‘It is surprising we need to call for this – fit-testing is routinely applied in industries that need respiratory protection, such as asbestos removal.’
GPs in coronavirus hotspots such as Dr Ern Chang have organised their own fit-testing after waiting for months for his local Primary Health Network to arrange it.
After paying for his own fit-testing, Dr Chang found that two out of the three brands of respirators at his clinic did not fit him properly, leaving him potentially exposed.
He called on GPs in areas with higher risk to immediately undertake their own fit-testing, rather than wait for health services to arrange it.
Dr Bi often undertakes medicals for coal miners in his work, and became alarmed after realising most people in coal mining were routinely fit-tested for their respirators.
He told newsGP the common assumption that N95 American standard respirators are equivalent to the Australian standard of P2 is wrong.
P2 standard respirators have to pass a key test that N95 respirators do not, called the total inward leakage test, designed to ensure these respirators fit better on a wide range of faces.
‘P2 and N95 are not interchangeable. They never were,’ Dr Bi said.
‘You’d expect the respirators we use would pass fit-testing – but that is not the case with N95s, especially with all of these different manufacturers.’
Victorian anaesthetist Dr Pieter Peach recently made public results from fit-testing of common respirators undertaken by Australian Society of Anaesthetists experts.

The testing found fit-testing pass rates varied widely, from as low as 11% to 100%.
Overall, only 57% of disposable N95 respirators passed. By contrast, 98% of reusable elastomeric respirators passed the testing.
One complicating factor may be whether the correct size of respirators is actually available to fit the state’s diverse workforce.
Victoria is facing potential shortages of P2/N95 respirators in small size as the state waits for more supplies from South Australian manufacturer Detmold, with small size masks to arrive ‘in the next few months’ according to a 12 August update from Safer Care Victoria seen by newsGP. Supplies of medium and large masks are in stock.
Health Purchasing Victoria is currently ‘welcoming supplier offers’ of N95 respirators in small size to ‘secure additional stock’.
Ms Cole said supply shortages are not an appropriate reason to not provide a safe working environment, regardless of industry.
She has called for health services to look at reusable elastomeric respirators, which can fit a much broader range of faces compared to disposables, once fit-tested. 
Any potential shortage would pose particular issues for finding respirators for healthcare workers who are female or of Asian background, according to Dr Bi.
‘Smaller sizes are short everywhere. Historically, all these respirators were made for industry like mining, not healthcare,’ he said.
‘In healthcare, there are fewer big heavy blokes and a lot of smaller people of Asian background. They wouldn’t have a chance to fit test normal size respirators.’
A recent US research letter of respirator use in an emergency department found some types of N95s, such as duckbills, had a high failure rate, which could contribute to healthcare workers getting infected.
newsGP approached the Victorian Department of Health and Human Services for comment.
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Dr Ian Mark Light   5/09/2020 3:12:58 PM

A good face shield with double surgical masks is likely also good .
You need eye and face protection .
There is a huge variety of face shields with hoods for the head and neck that with a gown cover the body and go with face shields .
To this is added a surgical mask .
There are disposable and reusable types and would be used for procedures and contact with patients with Covid 19 or patients suspected of Covid 19 .
But you would need breaks for good fresh air in outdoor areas or in rooms with windows either in existence or built in .
Added to this is the emergence of rapid antigen tests from the saliva - cheap tests with a 15 minute turnaround like a pregnancy test in fact .
Developed in the USA and available now but not in bulk yet .

Dr Deborah Uwa Sambo   5/09/2020 10:11:23 PM

Is this site "curated and censored" for conformity?