Evaluation of N95 respirator compliance among healthcare workers in a public hospital in KwaZulu-Natal, South Africa

ORIGINAL RESEARCH

PEER REVIEWED

J Kerr1, Z Mbhele2

1Department of Nursing Science, University of Zululand, KwaDlangezwa, South Africa
2Discipline of Nursing, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
Correspondence: Dr Jane Kerr. Department of Nursing Science, University of Zululand, Private Bag X1001, KwaDlangezwa, 3886. email: kerrj@unizulu.ac.za

ABSTRACT
Background:
 Occupationally acquired tuberculosis (TB) and human immunodeficiency virus (HIV) are challenges faced by healthcare workers (HCWs) dealing with TB infection and those co-infected with HIV. The South African Occupational Health and Safety Act (OHSA) of 1993 obliges employers to provide safe working environments. Protection of HCWs from healthcare-associated infections (HCAIs) at work is dependent on correct use of personal protective equipment (PPE), including N95 respirators.
Objectives: The objectives of this study were to evaluate N95 respirator compliance among HCWs, and to determine the perceived barriers to wearing these, in a public hospital in KwaZulu-Natal, South Africa.
Methods: A quantitative descriptive study was conducted from May to July 2015; 328 HCWs were randomly selected from a total population of 2 200. Of these, 280 HCWs who had been employed for at least one month participated in the study. Spearman’s chi-squared correlation was used to establish evidence of test-retest reliability for the questionnaire. SPSS Statistics was used for data analysis. The data were analysed using descriptive statistics; frequencies and percentages are reported.
Results: Two hundred and eighty responses were received (85.4%); 98.5% were from nurses. Self-reported compliance with the N95 respirator was poor; and respirators were used incorrectly. A respiratory protection policy was accessible to 42.8% of the respondents. Only 20 (7.1%) of HCWs acknowledged receiving respiratory protection training. Barriers to wearing N95 respirator were hairstyles (46.4%), make-up (42.9%), high environmental temperatures (60.7%), and interference with communication (65.7%).
Conclusion: The Department of Health, as the employer, needs to take accountability for HCW protection from TB at work by enforcing HCWs’ compliance; training HCWs to perform self-fit tests each time they don respirators; training individual fit testers to conduct fit tests; training HCWs and maintenance staff about the importance of air flows; and ensuring policy accessibility.

Keywords: tuberculosis, respiratory protection policy, HIV co-infection.

INTRODUCTION
One of the key health targets of the post-2015 Global Tuberculosis (TB) Strategy is the total eradication of TB by 2030.1 This is included in the Sustainable Development Goal 3.3.2 Although there has been a reduction in the global TB burden over the last few years, TB remains an occupational hazard for HCWs worldwide.3 In 2014, South Africa ranked second highest in the list of 20 countries with the highest TB burden, and contributed 4.6% of the global burden of all TB cases.4  About 407 000 cases of TB were notified, with KwaZulu-Natal (KZN) and the Eastern Cape provinces accounting for almost 50% of these.5 In 2016, South Africa ranked seventh in the list of countries with the highest TB burden, accounting for 64% of the total burden.6

Nosocomial infection of TB among HCWs is a serious occupational hazard in healthcare facilities in South Africa.7 The 2017-2022 South African National Strategic Plan for HIV, TB and STIs (NSP) aims at reducing TB incidence by at least 30%, from 834/100 000 population in 2015 to less than 584/100 000 by 2022.8 Addressing poor TB infection control (IC) in healthcare facilities is a response to this call, as poor IC in these facilities contributes to the high TB incidence.9-12 In 2015, South Africa accounted  for 21% of all HCWs reported to have TB.6 “In 16 countries, the number of TB cases per 100 000 HCWs, was more than double the notification rate in the general adult population”.6 In the same year, South Africa accounted for 21% of the 9 977 HCWs reported as having TB from among 67 countries.6 Healthcare workers have three times the risk of developing TB than the general population,13 and are more likely to contract TB if they are HIV co-infected,13 or work less than eight hours in a unit.14The risk of TB transmission among HCWs is highest when patients for whom they are caring have undiagnosed TB or are receiving inappropriate treatment.14

The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) proposed TB IC measures that are useful in mitigating the spread of nosocomial infections.16 These measures have been adapted for, and adopted into, the Draft National Infection and Prevention Policy for TB, MDR-TB and extensively drug-resistant TB (XDR-TB) in South Africa.17 However, the available resources for, and implementation of, TB IC are poorest in countries with the highest TB burden.3

Healthcare workers are at risk of biological exposure in their work environment, from many sources. Those in KZN are three times more likely to become TB-infected than HCWs working anywhere else in South Africa.13

Protection of HCWs from contracting healthcare-associated infections (HCAIs) depends on effective implementation of IC programmes and correct use of personal protective equipment (PPE)12 such as N95 respirators.23 The N95 respirator is a half-mask air-purifying respirator, approved by the National Institute for Occupational Safety and Health (NIOSH).24 Globally, HCWs comply poorly with respiratory protection policies.25 In public hospitals in the Free State province of South Africa, for example, research showed that compliance with IC recommendations was less than 50%, and 55% of HCWs did not wear PPE.14 Lack of knowledge and non-adherence to IC measures place HCWs at risk of repeated exposure to infection.27 Compliance with N95 respirator use is related to HCWs’ perceptions of risk exposure and susceptibility to these risks.27 Healthcare workers want comfortable and disposable respirators that interfere minimally with breathing, have low heat build-up, and  can be worn over facial hair.25

It was observed, in one public sector hospital in KZN, that windows were not opened and were often permanently locked.28 There was no mechanical ventilation or upper room ultraviolet light and sometimes the N95 respirators were not available for use, thereby increasing the risk of airborne diseases. 

The objectives of the study were to evaluate the compliance of N95 respirator use among HCWs and to determine the perceived barriers to wearing these respirators.

METHODS
A descriptive study was undertaken in a hospital in KZN, from May to July 2015. There were 2 200 HCWs employed in the hospital at the time of the study. A sample size of 328 was calculated, using the Raosoft sample size calculator (2004). Simple random sampling was implemented, but only those who had worked in TB wards for a minimum of one month were included in the study (N = 280).

A structured questionnaire was designed, based on questions from the Occupational Safety and Health Administration (2002), the 60th World Health Assembly (2007), the Centres for Disease Control and Prevention (1991), the National Institute for Safety and Health (2013), and the Reproductive Health and HIV Research Unit of the University of Witwatersrand (2009). The questionnaire was designed to collect data on demographic factors, administrative and environmental controls, the institutional IC and prevention policy, and barriers to using the N95 respirator.

The questionnaire was assessed using face and content validity. A test-retest pilot study was conducted, using 14 nursing students not employed in the selected hospital, to determine the accuracy and internal consistency of the questionnaire. The Spearman’s chi-squared correlation reliability was high (r = 0.8).

Data were analysed using SPSS version 23. Results of the descriptive analysis are reported as frequencies and percentages.

Ethics approval was obtained from the University of KwaZulu-Natal Humanities and Social Sciences Ethics Committee (HSS/0019/015M), the hospital’s ethics committee, and the KwaZulu-Natal Department of Health.

RESULTS
The response rate was 85.4%; 280 questionnaires were returned. Most respondents were nurses (276; 98.5% nurses); only four were doctors (1.5%). Most were aged 21-30 years (n = 119, 42.5%); 97 (34.6%) were aged 31-40 years (Table 1). One hundred and twenty-one (43.2%) had worked in wards admitting patients with suspected or confirmed TB, for more than a year. Work experience in these wards ranged from six months to five years.

Wearing of N95 respirator respirators
Only a quarter of HCWs (72; 25.7%) reported wearing N95 respirators as a norm, 162 (57.9%) reported never wearing a respirator in high-risk areas, and 166 (59.3%) reported wearing a respirator only in isolation rooms or when transporting TB patients. Around half (153; 54.6%) reported not performing seal checks after donning the respirator.

Less than half of the study participants (114; 40.7%) reported asking for help or trying another size or model of respirator when they could not achieve the proper fit seal.  Half of the respondents (138; 49.3%) did not immediately remove the respirator once they sensed that it was not working properly.

Policy compliance
One hundred and twenty (42.8%) HCWs reported having an accessible written respiratory protection policy, while 154 (54.0%) reported that there was an accessible policy for maintenance and care of the N95 respirators available. Two hundred and four (72.9%) reported that there was a policy describing correct disposal of used N95 respirators and 222 (79.1%) reported that they disposed of the N95 respirator as healthcare waste.

Twenty (7.1%) respondents reported that they were evaluated for potential respiratory difficulties, while 76 (27.1%) reported promptly seeking medical attention when they experienced breathing difficulties when using N95 respirators. Forty-one (14.6%) reported that there was an employee trained in the facility to perform the fit test, and 10 (3.6%) reported that they were fit tested. Few (n = 57; 20.0%) received respiratory protection training; 
231 (82.5%) stated that they received in-service education regarding IC; 78 (27.9%) reported that posters indicating the need for wearing N95 respirators were visible; and 111 (39.6%) stated that in-service training was conducted every three months.

With regard to environmental control, 40 (14.3%) reported that fans were used to increase circulation of air in their areas of work, while 15 (5.4%) knew the direction of airflow in each room, and 23 (8.2%) sat with their backs towards the direction of the airflow. Eighty-two (29.3%) reported that windows in the facility were able to open, and some kept the windows open during working hours (n = 92; 32.9%). Forty-three (15.3%) stated that there were isolation rooms where sputum could be collected. However, 230 (82.1%) indicated that there were isolation rooms where patients with suspected and confirmed TB were admitted.

Perceived barriers to N95 respirator compliance  
Perceived barriers to N95 respirator compliance included the ­respirators affected their hairstyles (n = 130; 46.4%) or make-up (n = 120; 42.9%), high temperatures (n = 170; 60.7%), and interference with communication (n = 184; 65.7%).

DISCUSSION
Nursing staff comprise the majority of personnel in healthcare facilities,30 and have close physical contact with patients through bathing patients, cleaning up body fluids and secretions, 
collecting biological samples, etc. Hence, the nursing team is the professional group most exposed to occupational risk, including that of nosocomial TB infection.31

The standard IC precaution includes a written respiratory protection programme, a designated programme administrator, and the equipment, training and medical evaluation of employees. The results of this study show that HCWs have little knowledge of whether there is a written respiratory protection programme, a designated programme administrator, or the need for medical evaluation of employees with respiratory problems.

Wearing of N95 respirators
There was poor N95 respirator compliance among the study participants; respirators were used incorrectly, and were often not available. Similar findings were reported in three hospitals in the Free State in 2015.14

In our study, 25.7% of the HCWs wore respirators as a norm. Although this is a low proportion, it is more than double that reported in Ethiopia where only 12% of HCWs regularly wore a respirator when caring for TB patients.32 Stock-outs and non-availability of respirators limits HCWs’ use of the devices, and increase their risks of developing TB, as shown in other studies.33,34,35

Policy compliance
Accessibility of a written respiratory protection policy was inconsistent. Less than half of the HCWs were aware of a written respiratory protection policy; almost half reported that there was no policy. This supports findings from a study conducted in Iran where only 50% of facilities had a written TB infection prevention and control policy.40 Moreover, in KZN, it was reported that only 22% of primary healthcare clinics (PHC) investigated had IC policies.10 It has also been reported in Australia that some HCWs have no knowledge of the contents of hospital respiratory protection policies even when they are aware of such policies, and are reluctant to comply with these policies.41

Less than 10% of HCWs in our study reported being evaluated for potential medical difficulties, and few reported promptly seeking medical attention if they experienced breathing difficulties when using N95 respirators.

For the N95 respirator to provide maximum protection, the wearer needs to be trained on fit-testing and checking procedures.42 Yet less than 5% reported that they were fit tested. This lack of fit-test training has been reported in other studies.28,44 Around 15% of the HCWs reported that there is a trained employee in the facility to perform the fit test. Wearing an N95 respirator without fit-testing constitutes partial compliance with PPE, and all healthcare facilities should have a trained administrator to perform fit tests.

Only around 20% of the HCWs in our study received respiratory protection training, but more than 80% stated that they received in-service education regarding IC. Nevertheless, there are still major gaps in training of HCWs on TB transmission in South Africa.37 Overall, the legal responsibility for occupational health and safety, and HCWs’ use and compliance with regard to N95 respirators, falls on the healthcare organisation.41

Perceived barriers to N95 respirator compliance  
HCWs in this study mentioned factors impeding them from complying with the use of N95 respirators, including communication interference, which has been previously reported in South Africa,15 Russia6 and Australia;41 high temperatures; the unattractiveness of the devices; discomfort; and the adverse effect on their relationships with patients; all of which have been reported previously.15,28,33,41,45-47 Unique impediments mentioned were interference with hairstyles and makeup. 

If HCWs are prepared to jeopardise their health by not wearing N95 respirators while taking care of TB patients, they underestimate the burden of TB. In a study in the Eastern Cape, HCWs were not particularly concerned about developing TB; around 20% of them believed they were less susceptible to developing TB after exposure than their colleagues.7 However, it has been shown that awareness of the risk of nosocomial TB transmission is raised when a colleague is infected.28

Limitations
The sampling method might not have generated a representative sample of the study population. In addition, this study was conducted at a single site in KZN. Thus, the findings cannot be generalised to the entire country or the province. Nevertheless, the findings are similar to those reported amongst HCWs in South Africa and other countries. Barriers to HCWs non-compliance to N95 respirators might be better explored using qualitative research.  

Recommendations
A written respiratory protection policy should be available and implemented, and be accessible to all HCWs. In addition, policies for the maintenance, care and disposal of the N95 respirators need to be accessible at the workplace.

N95 respirators should be used when in close contact with patients with potentially infectious diseases, as recommended by the CDC.38 Healthcare workers should wear N95 respirators consistently and check the fit seal to ensure that the respirator is functioning efficiently, whenever providing care to suspected/confirmed TB patients. A designated, knowledgeable person should be employed to manage/oversee N95 respirator usage and implement training around seal fitting. Infection prevention and control measures should be enforced. Both HCWs and visitors should not have contact with patients with suspected/confirmed TB unless they are wearing N95 respirators. In addition, ­surgical facemasks should be immediately provided to patients with ­suspected/confirmed TB and active coughs.  

HCWs should be trained on N95 respirator use during induction and in-service training programmes. Training should include the importance of room airflows and the need for windows that can be opened. Maintenance staff should be made aware of the importance of unbarring windows that cannot be opened, to reduce HCW TB infection.

Finally, the Department of Health should implement strategies to overcome perceived barriers to the use of N95 respirators.

CONCLUSION
To assist in reaching the goal of total eradication of TB by 2030, nosocomial TB should be urgently addressed. A step towards ensuring that HCWs comply with IC measures, such as the wearing of N95 respirators when dealing with suspected/confirmed TB patients, could be the introduction of sanctions against non-compliant HCWs. Healthcare workers of all ages need motivation to comply with the use of N95 respirators, through individual consultation. Senior HCWs are role models for younger HCWs, but have been reported to be less likely to use N95 respirators.28 The Department of Health is ultimately responsible for providing and enforcing a respiratory protection programme.

LESSONS LEARNED
• Healthcare worker compliance regarding N95 respirator is low.
• Healthcare worker non-compliance is due to perceptions about respirators and the lack of accessibility to policies.
• Training on the use of respirators is suboptimal.

ACKNOWLEDGEMENTS
The authors acknowledge the contribution of the study respondents for their participation in the study and the KwaZulu-Natal Department of Health for permission to conduct this study in the healthcare facility.

DECLARATION
The authors declare that this is their own work; all the sources used in this paper have been duly acknowledged and there are no conflicts of interest.

AUTHOR CONTRIBUTIONS
Conception and design of the study: ZM, JK 
Data acquisition: ZM
Data analysis: ZM
Interpretation of data: ZM, JK  
Drafting of paper: JK
Critical revision of paper: JK, ZM

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