CURRENTLY in Victoria, health care workers make up more than 15% of all new cases of COVID-19, a rate much higher than the general population and higher than was seen in Italy in March 2020 at the height of the first wave of the pandemic. The risk to health care workers in this pandemic is real; globally, over 3000 have died from the disease. Given that health care settings are high risk work environments for exposure and infection during an outbreak, ensuring that health care workers are reasonably protected must be a priority of governments and employers.
Much has been learned about the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the appropriate use of personal protective equipment (PPE) in the 6 months that have transpired since the pandemic was first recognised. Further understanding of the routes of transmission has been gained, including droplet, contact and airborne, even in the absence of aerosol generating procedures (here, here, and here). During the first wave of the pandemic, case numbers in Australia were low and therefore governments had opportunity to stockpile substantial amounts of PPE to avoid critical shortages and to spend time ensuring correct PPE use by health care workers. It was during this time, however, that it became apparent that many health care workers were being deprived of basic measures to ensure that the respiratory protection being provided adequately fit them.
To be effective, N95 (or P2, the Australian equivalent) masks (or respirators, to use the correct term) must form an airtight seal around the wearer’s face, verified through the process of “fit-testing”. Despite studies reinforcing the need for fit-testing of health care workers, resistance to implementation in Australia remains. Here we explore nine common myths about fit-testing and provide evidence-based counterarguments.
We don’t have enough masks to fit-test
Not according to Dr Nick Coatsworth, Deputy Chief Medical Officer of Australia, who said on 4 August 2020, “the supply of N95 masks is excellent at the moment”. Domestic manufacturing of masks and respirators has commenced in South Australia (here), and disposable products aren’t the only option. Australia could make greater use of re-usable respirators, as has been done successfully in Singapore (here).
It’s okay not to fit-test because the guidelines don’t mandate it
Infection control guidelines don’t supersede work health and safety (WHS) law and the associated duties of employers. Employers are required under WHS law to provide a working environment that is safe and free of risk to health, so far as is reasonably practicable. That’s based on many considerations including the likelihood of the hazard or risk occurring, the harm that would result, what a person knows (or should know) about the hazard or risk and ways to eliminate or reduce it, the availability and suitability of ways to eliminate or reduce the hazard or risk, and the cost of eliminating or reducing the hazard or risk. An employer is judged by the standard of behaviour expected of a reasonable person, one who is committed to providing the highest level of protection for people against risks to their health and safety, and one who is proactive in taking measures to protect the health and safety of people.
In many states (here, here and here), there are specific legal duties when providing PPE, including ensuring that it is a suitable size and fit. State WHS regulators issue a notice when there is a contravention of the law. Notices are issued where fit-testing is not undertaken.
While infection control guidelines add to the state of knowledge, they don’t negate WHS duties of employers and don’t form the sole basis for protecting workers.
We can’t fit-test during the COVID-19 pandemic due to the risk of infection
Requirements for fit-testing of close-fitting masks during the COVID-19 pandemic have not changed. Supplementary guidance (here, here, here and here) is available to assist in performing fit-testing to mitigate the risk of infection. Fit-testing during the COVID-19 pandemic can be performed safely and without adverse risk to participants.
Fit-checking is adequate
Fit-checking is a simple subjective assessment of any obvious air leaks and is not the same as fit-testing. For a mask to provide appropriate protection, it must be manufactured to an applicable standard, and the wearer must undergo fit-testing and training in the correct use of the mask. A fit-test validates whether a mask has the potential to provide an adequate fit, presuming that the wearer passes a fit-check each time it is worn. While much attention is given to the filtration efficiency of N95 masks, less attention has been paid to the fit of these devices. However, the level of protection provided by N95 masks is a function of both.
Due to the high degree of filtration efficiency of N95 masks, the level of particulate filtration becomes insignificant once leaks are present around the face mask, with face–seal leakage being a major pathway for aerosol transport into the filtering device. N95 masks can’t protect the wearer if they leak, and thus it is essential that an adequate face seal is achieved.
A study of 784 health care workers demonstrated that while 780 (99%) passed a user fit-check, only 459 (59%) of them passed subsequent fit-testing. Another study demonstrated that fit-checking wrongly “passed” 31% of the time and wrongly “failed” on 40% of occasions.
There is a gender and race difference in the pass rate for fit-testing, with less women passing fit-testing than men (here and here) and those of Asian descent reporting the highest failure rates. Given more than 78% of health care workers are female and approximately one-quarter of medical practitioners in Australia are of Asian descent, this is a critical gendered and racial issue.
Fit-testing is an essential element of a respiratory protection program. Fit-checking does not reliably detect leakage and is not adequate.
Fit-testing has not been proven to reduce infections in health care workers
WHS law, the precautionary principle and common sense all dictate that fit-testing should not be avoided for this reason. As described above, employers have express legal and implied moral obligations to keep employees safe in the workplace, which includes ensuring that the PPE they provide is literally fit for purpose. The burden of proof for this ‘myth’ lies squarely on the proposer to demonstrate non-inferiority of fit-testing, not the other way around.
A new criminal offence of workplace manslaughter was added to the Occupational Health and Safety Act 2004 in Victoria as of 1 July 2020. WorkSafe Victoria explains that the new law aims to “send a strong message that putting people’s lives at risk in the workplace will not be tolerated.” They advise that “employers and duty-holders should stop to think about the risks involved in the conduct of their business, and what steps can be taken to mitigate those risks.”
It’s too hard to fit-test this many people
South Australia Health requires health care workers to be fit-tested when they are likely to be at risk of exposure to serious airborne infections. During the COVID-19 pandemic, the Royal Free Hospital in London established a qualitative fit-testing program for thousands of staff. Whenever masks change, they retest. Outside of health care, fit-testing is performed both in Australia (here and here) and internationally (here and here), particularly in high risk industries such as coal mining, tunnelling (here and here), asbestos removal, and manufactured stone (here, here and here). Such high risk industries collectively engage more than one million workers in Australia. The absence of fit-testing has been repeatedly highlighted as a failing during reviews and inquiries into the resurgence of once-historical workplace diseases including black lung and silicosis (here, here, here and here). Non-health care industries have learnt from these failures and have therefore increased protections for workers.
As evidenced in South Australia, London, and in other industries, it is not too hard to provide a basic compliance measure for respiratory protection.
Infections are the result of mistakes by health care workers
A culture of blame is well documented within health care (here, here, here and here). Health care workers operate within a high risk environment, but that does not mean that they should accept an unsafe workplace. Operating within a high risk environment simply places a greater onus on the employer to ensure the health and safety their workers. Essentially, the more dangerous the activity, the greater the level of care and vigilance that must be used by the employer to meet their obligation to provide a safe working environment. This was demonstrated in WorkCover Authority of NSW (Inspector Stothard) v Manildra Park Pty Ltd  NSWIRComm.
It is the employer’s duty to provide the necessary information, instruction, training and supervision to enable workers to do their work in a way that is safe and without risks to health.
We can’t afford to do fit-testing
When calculating the cost of providing a control measure, such as fit-testing, it involves more than the cost of the item itself. For example, the calculation must also take into account savings from fewer incidents and illnesses, potentially improved productivity and reduced turnover of staff. The specious argument that the “cost of a mask” is too great (as the mask is “wasted” post-fit-testing) is easily offset by such savings.
Surgical masks provide adequate respiratory protection
With many months to prepare our health system for a resurgence of COVID-19, we have failed to focus on protecting those at highest risk of infection. As a result, thousands of Victorian health care workers have contracted COVID-19, with potentially significant morbidity and mortality to come.
We are now faced with an urgent choice as to how we respond. We must learn lessons from industrial sectors and previous pandemics – as detailed in the final report of the SARS Commission, the lack of a strong “safety culture” contributed to the heavy burden of severe acute respiratory syndrome (SARS) borne by health care workers in Ontario, Canada. The precautionary principle described in this report should guide our response to COVID-19.
In this article we have presented abundant evidence from a WHS perspective to refute the myths preventing fit-testing of masks for health care workers. Employers owe both legal and moral obligations to take reasonably practicable measures to ensure a safe working environment. In some jurisdictions, including Victoria where thousands of health care workers have contracted COVID-19, employers can be prosecuted for manslaughter if they fail to do so and a death results. Fit-testing must form part of a respiratory protection program in all workplaces where health care workers are at risk of occupational exposure to COVID-19. All jurisdictions are urged to expedite fit-testing of masks, particularly Victoria given the current crisis there. Further delays may be at the expense of health care workers’ lives.
Benjamin Veness is a child and adolescent psychiatry registrar in Melbourne, a Churchill Fellow and a past president of the Australian Medical Students’ Association. During the COVID-19 pandemic, he helped to establish Health Care Workers (Australia). Twitter @venessb.
Kate Cole is an Engineer, Certified Occupational Hygienist and Churchill Fellow. With a strong background in protecting workers in hazardous environments, she has supported the COVID-19 pandemic through providing specialist expertise on respiratory protection and health and safety more broadly. Twitter @kate_cole_
Professor Nancy Baxter is Head of the Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne. She is a clinical epidemiologist, colorectal surgeon and health services researcher. Before joining the University of Melbourne, she worked in Toronto where fit-testing was standard practice. She is a Fellow of both the American College of Surgeons and the Royal College of Physicians and Surgeons of Canada. Twitter @enenbee
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.