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IOM affirms CDC guidance on N95 use in H1N1 setting

first_imgSep 3, 2009 (CIDRAP News) – The Institute of Medicine (IOM) today affirmed existing federal guidance that healthcare workers caring for H1N1 influenza patients should wear fit-tested N95 respirators, not just surgical masks, to protect them from the virus.At the same time, the IOM called for additional research on flu transmission and the effectiveness of various respiratory protection tools in clinical settings, along with efforts to develop new respiratory protection technologies to enhance safety and comfort.”Based on what we currently know about influenza, well-fitted N95 respirators offer health care workers the best protection against inhalation of viral particles,” said Kenneth Shine, chair of the committee that wrote the report, in an IOM news release.”But there is a lot we still don’t know about these viruses, and it would be a mistake for anyone to rely on respirators alone as some sort of magic shield,” added Shine, who is executive vice chancellor for health affairs in the University of Texas System, Austin, and former president of the IOM.. “Health care organizations and their employees should establish and practice a number of strategies to guard against infection, such as innovative triage processes, hand washing, disinfection, gloves, vaccination, and antiviral drug use.”But the IOM report drew criticism today from a representative of the Association of Professionals in Infection Control and Hospital Epidemiology (APIC), who said the recommendation to wear N95s fails to recognize the many practical and logistical problems related to N95 use, including discomfort, costs, shortages, and the difficulty of fit testing.In the face of unclear science concerning flu virus transmission, the IOM prepared the report at the request of the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA).The panel, which was given just 8 weeks to write the report, held a 4-day meeting, including a 1 1/2-day public workshop, in August. The panel’s assignment specifically excluded the economical and logistical considerations related to personal protective equipment (PPE).The report notes that the current CDC guidance on protection for health workers caring for H1N1 patients differs from guidance from the World Health Organization (WHO) and Canadian guidance. The CDC recommends use of N95s for all healthcare workers who enter the rooms of patients in isolation with confirmed or suspected H1N1 infection. The same advice goes for emergency medical personnel who come in close contact with such patients.In contrast, the WHO recommends “standard and droplet precautions (including a medical mask, gown, gloves, eye protection, hand hygiene) for those working in direct contact with patients and additional precautions for aerosol-generating procedures including wearing a facial particulate respirator,” the report says. The recommendation allows for “the need for sustainability” in different countries.Similarly, recently released Canadian guidelines call for using N95s only during aerosol-generating procedures and recommend using medical (surgical) masks in other situations, according to the report.On the murky question of the extent to which flu viruses spread through the air, the IOM committee concluded that studies show that “airborne (inhalation) transmission is one of the potential routes of transmission.”The panel said it found few studies comparing the effectiveness of N95 respirators and medical masks in clinical settings, although several studies are under way. Hence the group based its decisions on comparisons of the two kinds of protection in controlled experiments. Those studies show that medical masks are unlikely to be effective in preventing aerosol transmission, the report says.In view of that evidence, the panel recommends that health workers in close contact with patients who have novel H1N1 flu or flu-like illness should wear fit-tested N95 respirators or respirators that are “demonstrably more effective.” The report specifically endorses the current CDC guidance and says it should be followed until there is evidence that other forms of protection work as well or better.In addition, the report advises that employers should make sure that N95 respirators are used and fit-tested in accordance with OSHA regulations.The panel further found that the need for more research on flu transmission and PPE is “striking.” It urges federal agencies and private organizations to support and undertake research to:Answer questions about the relative contribution of different routes of flu transmissionExplore the effectiveness of different respiratory protection tools in clinical settings through randomized trialsDesign and develop new respiratory protection technologies “to enhance safety, comfort, and ability to perform work-related tasks”The IOM’s recommendation to use fit-tested N95s drew criticism on practicality grounds today from Ruth Carrico, an infection control expert at the University of Louisville School of Public Health and Information Sciences and a former APIC board member. Carrico was on a panel of experts who reviewed the IOM report in draft form.”I think the IOM has missed the mark,” Carrico told CIDRAP News.She acknowledged that the panel of authors was specifically charged with looking only at the science and not the logistical and economic issues. But she said it’s difficult to separate the scientific issues from the logistical matters, such as the ability of health workers to follow the guidance and its applicability in clinical settings.”As a human being, if you’re being told this is the best protection for your and you go to work and that protection is not available, how likely are you to go to work the next day?” she asked.Noting that the recommendation specifically calls for the use of fit-tested respirators, Carrico said there are “lots of gaps” in the information about fit testing. Given the cost and time requirements of fit testing, she said, “Does it really make sense and is it a valid point? We have to be concerned about that in our economic times.”More generally, she said, “Divorcing the recommendations from the practicality of implementation represents a serious problem for healthcare workers who are trying to figure out, ‘What do I do to provide care for my patients in a safe manner?'”Hospitals say they do fit testing as best they can, but “there’s no way to be fit tested for all the kinds of respirators used,” Carrico continued. For example, this past spring, some hospitals ran out of respirators and hence used respirators from the government’s Strategic National Stockpile. Those were a different type from what hospitals normally use, which created a need for additional fit testing, she said.Keeping respirators on hand is a continuing problem, she added. “There are back orders; there are constant calls about interruptions in supply. We simply do not have the supply line of these types of materials in order to apply these recommendations.” As a result, hospitals try to save their respirators for us in the highest-risk settings.The shortages and other problems lead to inconsistent and changing hospital policies, which confuse workers, she added. “We’re hearing about workers who will say ‘I refuse to care for this patient because I don’t feel safe,'” she said.Carrico also commented that most workers can wear N95s only a short time before they become hot and uncomfortable.”At some point you’ve got to peel the onion and say what’s really necessary, what’s really practical, and how are we going to enable our healthcare workers to do what needs to be done?” she said.She also expressed hope that the IOM’s appeal for new research will lead to some well-designed studies in clinical settings.At a press briefing today, CDC Director Dr. Thomas Frieden said the CDC has just received the IOM report and is looking at it.CDC spokesman Tom Skinner said the agency is considering the recommendations from the IOM and other expert groups on the issue of respiratory protection for health workers. “We hope to have a plan that further addresses this issue very soon,” he told CIDRAP News.See also:Sep 3 National Academy of Sciences news release about the reporthttp://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12748Table of contents page for full IOM report “Respiratory Protection for Healthcare Workers in the Workplace Against Novel H1N1 Influenza A”http://www.nap.edu/catalog.php?record_id=12748Aug 13 CIDRAP News story “Experts air practical PPE considerations to IOM”Aug 12 CIDRAP News story “IOM hears diverse findings on PPE for flu”last_img read more

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Whicker: Kershaw, deGrom turn game 1 into a showdown of arms

first_imgClayton Kershaw ambled off to the dugout after 6 2/3 innings, bathed by cheers he didn’t need to hear, surrounded by Mets on the basepaths who were excited he was leaving.“It wasn’t like we stood up and cheered,” said New York manager Terry Collins. “But it’s nice to see him walk off the field with us in the lead.”The Mets led 1-0 on Daniel Murphy’s home run in the fourth inning, the one piece of meat in a riveting famine of a playoff game. At one point Kershaw and Jacob deGrom had struck out 12 of the first 21 hitters. Kershaw had 11 strikeouts in five innings. Mets batting coach Kevin Long was getting ribbed in the dugout at that point. “They were telling him it was a good plan, seeing if we could strike out enough to drive up his pitch count,” Collins said. And it worked as well as anything else. Newsroom GuidelinesNews TipsContact UsReport an Error “As I sit here right now, he might have gone a little too far,” Collins said.First, however, the Dodgers have to make sure there is a Game 4, and to do that they have to beat either Noah Syndegaard at Dodger Stadium tonight or Matt Harvey in New York on Tuesday night, neither of which will be simple.Mattingly’s rationale was to make sure Kershaw didn’t have to face Wright for the fourth time when it mattered. In the first inning, Wright treated the fans to several souvenirs, fouling off eight pitches, six with two strikes, and going through a 12-pitch at-bat that launched Kershaw on the road to bad pitch count numbers.“(Curtis) Granderson started out by putting a good move on the first pitch (and lining out),” Murphy said. “I was afraid that it would be something like an eight-pitch inning, but David went up there and battled, and it paid dividends later. Plus, he won the at-bat (with a walk).”The crucial seventh began with a walk to Lucas Duda. “Clayton was a little out of sync there,” Mattingly said. With one out, Kershaw faced shortstop Ruben Tejada, whose defense got him playing time over Wilmer Flores’ offense. Tejada had 38 walks this year. He fell behind Kershaw 0-and-2 and fouled off two pitches, then took four balls. That was the plate appearance that put the Dodgers in check, and deGrom, a former infielder at Stetson University, moved them closer to checkmate with an expert bunt that moved up the baserunners.“Then Granderson comes up with a great left-on-left walk,” Murphy said. Kershaw tightened his lips as he snatched the ball back from A.J. Ellis, following a 3-and-2 pitch, at 95 mph, that just missed. He has been through enough postseason pickles to know when things turn sour.But it was hard to lay anything on Kershaw when you saw how much horsepower was under deGrom’s hood. The first batter he faced was Carl Crawford, and he took care of him with five pitches at the following speeds: 97, 97, 97, 97 and 98.“He beat us with velocity a lot of times,” Mattingly said. “I thought we did a good job laying off the breaking balls that he wanted us to chase. But that meant he was able to get us out with high fastballs. He was good tonight, but we had some chances.’The Dodgers were 0 for 6 with men in scoring position in the first four innings. Then deGrom began mixing in some off-speed stuff (definition: 85 to 90 mph) and he retired 11 straight Dodgers and struck out the last three he faced.The question is whether Kershaw will hear any more cheers in 2015, and for what reasons.center_img • PHOTOS: deGrom, Mets beat DodgersThis time Dodgers manager Don Mattingly lifted Kershaw to bring in reliever Pedro Baez, after Kershaw had walked three Mets, and David Wright was due to hit with two out.This decision will be second-guessed, of course, but Mattingly had perfectly sensible reasons, since Kershaw had thrown 113 pitches. The problem was not generated by Mattingly, but by a front office that had this ailment in the bullpen last year and could not find the prescription for it. Here, Baez hulked his way in, threw high-velocity fastballs, fell behind and watched Wright, one of the best Mets ever, rip a two-run single to center that put New York up 3-0 in a game it would win 3-1.deGrom left, too, after seven innings and 121 pitches. Collins had toyed with the idea of bringing back the shaggy right-hander for Game 4. last_img read more