Our next speaker, Dr. Harrison, is a public health medical defense officer with the California Department of Public Health Occupational Health Branch and clinical professor at the University of California San Francisco and the Division of Occupational and Environmental Medicine. He established the UCSF Occupational Health Services where he has diagnosed and treated thousands of work and environmental injuries and illnesses. He has designed and implemented numerous medical monitoring programs for workplace exposures and has consulted widely with employers, health care professionals, and labor organizations on the prevention of work-related injuries and illnesses. He has led many work in environmental investigations of disease outbreaks. He has served as technical and scientific consultant with Federal OSHA, the CDC, and NIOSH. He was also a member of the California Occupational Safety and Health Standards Board. His research interests include collection analysis of California national data on incidents of work-related injuries and illnesses. He has authored and co-authored more than 50 peer-reviewed journals and more than 40 book chapters. He is a co-editor of the most recent edition of the textbook of Occupational Environmental Medicine. I'm sorry I can't be there in person but for all of you who are listening virtually or seeing me gathered in person, I'm very pleased to talk to you about respiratory protection and public health implications. I'm a clinical professor at the University of California, San Francisco, my background and experience is in occupational and environmental medicine. And I'm sure like many of you. Over the last couple of years you've been really focused on the occupational and public health impact of COVID-19, and I'm going to describe to you the outcome and output of a committee convened by the National Academy of Sciences that I think includes lessons and recommendations drawn from the COVID-19 pandemic, and also the one of the most profound occupational and environmental health issues of our time which is climate change. I have no relevant financial relationships to disclose. So for those of you who want to really get into the weeds and read in depth. The process and recommendations that I'm going to describe to you today. The National Academy of Sciences has just published in the last couple of months this document called framework for protecting workers and the public from inhalation hazards. Inhalation hazards were triggered by the COVID-19 pandemic, and the increasing exposure to both occupational groups and the community to wildfire smoke. Inhalation hazards was the topic because of the fine particulate air pollution, and the airborne nature of the COVID-19 transmission. I remember in March of 2020 when the COVID-19 pandemic began, that there weren't enough N95 respirators available, particularly for frontline workers and our healthcare worker communities. There were medical students from UC San Francisco gathering on the sidewalk, just a few blocks from my house, and they were asking for donations of N95s that they were going to bring to the medical centers here in San Francisco. Healthcare workers were using face masks or cloth face coverings. It didn't have the right fit or filtration characteristics. N95s were not in the local and state public health stockpiles. And I think we really had uncovered a lack of preparedness in US domestic manufacturing. There were respirators that started to flow into the country that were not certified by the CDC or NIOSH. Websites were confusing. It was very difficult for both healthcare workers, other frontline essential workers, and the public to figure out what was the difference between a source face covering and a NIOSH certified N95 respirator. So this framework was really designed to figure our way out of this current challenge and to really pose some recommendations for future preparedness and to fill gaps in the occupational setting. I want to thank Autumn Downey, who was the study director at the National Academy of Sciences and Engineering, who really brought together the members of this really diverse advisory group, and to Bruce Lippe, one of the committee members, for providing this cartoon here, Mask Oxygen Achieving Herd Immunity. I think folks will remember that we were talking about herd immunity probably for more than a year or even longer. We've given up on the concept of herd immunity. We're simply not going to get there. And COVID-19 is now endemic. And it's a virus that is going to transition to basically living with it. So all this material is available on the National Academy of Sciences website. You can get a free copy of this full report and the slide set. Here's a member of our committee. They represented a diverse group of occupational and environmental medicine, industrial hygienists, epidemiologists, and engineers. So our task was to determine the need for guidance for the public and workers facing inhalation hazards outside of the workplaces with respiratory protection programs. Describe current and potential options for oversight and approval of respirators, and to make some recommendations for how we should move forward and who's responsible and who has the authority. So the study catalyst and background, as I've mentioned, so respiratory protection programs. Probably many of you are familiar with the NIOSH certification and the OSHA regulatory requirements for a respiratory protection program basically says, in a nutshell, that NIOSH approved respirators must be used in the context of an OSHA mandated respiratory protection program. There has to be a risk assessment, a characterization of the airborne hazards, and the appropriate respirator chosen for workers. That includes respiratory fit testing and medical clearance and training for workers so that they know how to select and use respirators. The employer is responsible for purchasing and providing respiratory protection, and OSHA, as a regulatory agency, is responsible for compliance for visiting employers, and in fact, violation of the respiratory protection standard in workplaces is one of the most common violations that OSHA will cite employers for. There are emerging threats from inhalation hazards. The wildfire season is longer in some parts of the country. It's almost all year round. Climate change has resulted in the hot becoming hotter. In California, most of the largest fires have occurred in the last five years. I don't think I need to describe in detail the devastating effects this has had on communities. And then finally, I talked about COVID-19 and these airborne infectious hazards. It took, I think, quite a long time before we had broad consensus and acceptance that the COVID-19 virus was primarily transmitted through the airborne route. I think many of us will remember that fomites or surface transmission was primarily the focus. Purchasing disinfectant, cleaning surfaces was heavily, heavily emphasized for the several months beginning in March of 2020. And there have been numerous, numerous studies published on the airborne risk of COVID-19 in the workplace from the airborne route, the fine particle inhalation. These inhalation hazards have had significant impact. And we need a coherent, consistent system for ensuring that there's access to respiratory protective devices. Now, you'll see the acronym RPD, and we use that intentionally because we wanted to cast a very broad net over face coverings that are used for source control, as well as respirators that are used for protecting the wearer. So this terminology of RPD is casting a very broad net so that we can get some regulatory and public health structure over what is available on the market and what should be certified or regulated versus what somebody could just go out and buy over the counter that has no system of regulation or certification. So here's two examples that I just want to show you to sort of highlight what some of the occupational contexts are for what we're talking about. The firefighter on the left, full disclosure, is the partner of my daughter. He works as a wildland firefighter out of Montana. He's on what's called a hotshot crew. These are 20 person crews that are deployed. There's about 100 of them, by the way, and are deployed each fire season. They're frontline. I think of them as, you know, the sort of the cutting edge in the wildfire response community. And this is a picture taken up in Alaska, building a helicopter pad. You can see the working conditions, 60, 80 hours a week, working often in remote locations, sleeping on the ground. I think My daughter's partner and his crew made a pact that they weren't going to shave until the end of the fire season. So I look at this photo and I say, Okay, how are we going to get NIOSH certified respirators on hotshot crews? Are they going to wear them? Obviously, they need to share their facial hair. That is a really a cultural challenge among these crews. There's logistical issues of just simply keeping clean shaven over a 14 day working shift. And Respirators have to be flame resistant. They add weight to a 40 to 50 pound pack that's, you know, carried over what could be several miles per day. On the right hand side of this picture is one of my favorite restaurants in San Francisco. And this was, I think, taken in April of 2020 When we were just starting to get recommendations for masks and the owner of the restaurant with two of the cooks that work in a very small space. Produce wonderful food, but in a kitchen that has probably no more than about 15 square feet. And they were all gathered together in this tight space not wearing face coverings. Now, of course, I talked to him about it. And I think a couple weeks later, everyone in the restaurant was now wearing face coverings, but they were buying cloth masks. And there was no fit. There's no respiratory protection program. There was no really, there was very limited understanding of about whether they should use a face covering for source control or whether they were wearing it. Restaurant workers, as it turns out, have some of the highest mortality rates from COVID-19. We just published a paper in California that looked at patterns of mortality from COVID-19. And I think it's important for us to understand that. in 2020. And so these two examples, I think, pose some of the challenges in at least a couple of fairly common occupations and how to move from the theory into the implementation science and practice of how we get better respiratory protection out there. So we were really looking at a function-based definition, really grappled with the idea of what's the difference between source control and respiratory protection, and came up with this RPD device terminology to cast a very broad net. So let me return back to the difference between source control and respiratory protection. You know, source control is down in the lower part of this picture, and it ranges anywhere from what you see on the left, which is a surgical mask that we hand out to visitors and healthcare workers at our medical center when you walk in the door, to cloth masks, to all sorts of handmade designs that are available on the internet, and now in practically every store on a retail level, you can buy these things. These are not regulated for source control for the general public. In 2021, the Centers for Disease Control did make very good recommendations for the public that emphasized two essential elements, and I returned to these over and over again with my friends and my risk communication to the public, fit and filtration, right? So how these fit on the face and face leakage, and the seal leakage is absolutely critical, and of course, the filter, the filtration, these fabrics, and how they provide filtration against the very small particles. So the fact that these were, and still remain largely completely unregulated for the general public, and in fact, you'll see many workers wearing these as well, derives from, I think, our need for much better education and understanding that fit and filtration are what matters for protecting the wearer against airborne viruses and fine particles, particularly in the sub 2.5 micron range. And I think we have a great deal more work to do to really get better understanding out there that these in the lower part of the picture are not the same as NIOSH respirators in the upper part of the picture. And again, it largely derives from fit and filtration. These are tested and certified by NIOSH by the lab in Morgantown, West Virginia. There are systems that are in place only for selected workplaces. These are covered by OSHA, as I mentioned, under the Respiratory Protection Standard, and there are what are called conformity assessment processes in place. So these respirators are certified. I recall that there was a lot of questions that came in about the difference between KN95s to KN94s, manufacturers from abroad that were filling the manufacturing gaps in the United States. We have internet sales, right? So I can buy a quote-unquote respirator that can arrive at my doorstep tomorrow, and they don't have to be NIOSH certified. Well, I obviously say, okay, I'm gonna buy a respirator to protect me that's only NIOSH certified. But the general public and many workers that are not covered under OSHA respiratory protection programs purchase those respirators, and they're not well-protected. Systems are not in place for many workers in the public. We paid a lot of attention in our report to diverse demographic groups, vulnerabilities and susceptibilities among workers, where the exposure scenarios are broad and poorly characterized, and we found that there was a highly fragmented regulatory landscape. We approached this from an equity and protection from all framework. We wanted to be clear that respiratory protection is the last resort. Remember, the hierarchy of controls in occupational health and respiratory protection is the last line of defense. They should not be relied upon as primary source control. For COVID-19, primary source control is vaccination, number one, right, and encouraging, or in some instances, requiring vaccination program in the workplace. So if somebody doesn't walk in with a high risk for COVID-19, then respiratory protection can be loosened in a workplace, and we're seeing that in many areas of the country. In fact, it's now a recommendation of the Centers for Disease Control. And if vaccination is not in place, then ventilation. And there are a lot of great recommendations on good ventilation practices. And then only then is respiratory protection in the form of N95s in our healthcare worker settings for suspect or known COVID-19 patients. For workers who are exposed to wildfire smoke, we have a regulation, a law on the books in California under our OSHA plan that requires outdoor workers to be provided with N95s when the PM 2.5 levels exceed air pollution standards. We recognize that decisions will be made when data is uncertain, and we need to be prepared and acknowledge the heterogeneity in the population. So we recommended in our report that we build on the foundation that has already been established through the CDC with a National Protective Technology Laboratory that certifies respirators. Because OSHA has been required under the OSHA Act to be the coordinating entity, since the OSHA Act was established in the early 1970s, they should remain the primary regulatory body for workplaces. But we have a need to expand the workers' coverage under the OSHA Act for including workers that are not presently covered. And these pertain to what are called precarious workers. They may work under contract, they're self-employed, they don't get a W-2, they're not in a formal employment relationship, gig workers, and these are not covered by OSHA. And we recommended that Congress require that OSHA expand coverage so these workers can be provided with respiratory protection. We also recommended that the capacity for certifying respirators and performing research on their application and use be expanded. For the public, we found that there were very significant gaps. You know, I like to think of this as the Wild West of face coverings and respiratory protection for the public. You know, essentially, over the last two and a half years, I think no one was really centrally in charge. And so we recommended that we needed a coordinating entity with an interim office. We recommended Health and Human Services as a public health mandate to really understand and implement a program for how we can get face coverings and respirators out to the general public in a way that they can understand and make a choice about. We need to develop some uniform set of standards to implement, and we need to have a way to communicate risk so that the public is able to make informed choices. You know, I think of it as the sort of the big box store problem. I can go and I can purchase any type of face covering. I can ask the clerk in the aisle, what do they think is the best for me? And I'm gonna get all sorts of answers when I go out to the store. I'm gonna go on the internet and I'm gonna buy a face covering. At the very least, we recommended some sort of uniform, if not a standard, then a certification process. We have a new one, relatively new one, that's on the books from ASTM, the American Society for Testing Materials. And they do have a certification, a conformity process that manufacturers can voluntarily adhere to. I think if it's sort of halfway between a face covering that anybody can make and purchase and a NIOSH approved respirator, it does require adherence to fit infiltration and could be one option to establish a better framework for the public. So moving forward, we were clear that COVID-19 and the annual wildfire and climate change has really underscored the threat from inhalation hazards that extend far beyond the traditional groups that work in factories with chemicals that can be characterized by exposure assessment from these traditional OSHA required respiratory protection program. To a much broader, diverse, both worker group and general population community group. There are plenty of N95s that are now on the market. There's no longer a shortage of N95s. We are still gonna be facing challenges with domestic manufacturing capacity. How do we prepare for the next challenge, the next pandemic so that we're not stuck once again with me walking down the street and having volunteers collect N95s to hand out to healthcare workers? And how do we not move on to the next crisis? And remember that we need to learn from this experience and take action at the highest levels of our state, local and federal governments. So with that, I'll take questions. And thank you very much for giving me the opportunity to talk with you today. So thank you so much, Dr. Harrison, if you're friendly to the idea and wanna unmute, if you have any closing comments or we can certainly entertain questions. Thank you and glad to join you all today and have the opportunity to talk about face coverings and respirators. I guess my only comment here is that, which I didn't mention is, this has been one of the most challenging and perhaps most political issues that Americans have been divided. The CDC guidance has run into differences of perspectives in different parts of the country, who's gonna wear a mask, who's gonna not wear a mask. So when I was talking about the NIS report, we were doing this in the last year, year and a half, right in the middle of this unfolding story of face coverings, which I didn't really talk about because it was sort of the context reading, you sort of have to read between the lines. So I'm glad to ask, to take questions either about the content, the science, but also about what people think is really needed at this point in time for both workers and the general public, messaging, purchasing, supply, and so on. I'd be very interested to hear what you all think. Well, I know in previous conversations, we had a panel discussion earlier in the day, and we had a physician who was a reporter and had the media perspective. And we talked about the problems and where we wanna arrive in our nation's initial response and the optics of the messaging and all, but when it became a partisan issue, whether or not it was cool to wear a mask, I think at that point, our response to the pandemic was probably less than it could have optimally been. I wasn't, I didn't hear that conversation earlier, Jeffrey, but I totally agree. Questions for Dr. Harrison from physicians as opposed to a little fat MBA? Yeah, don't cut the line here and pass the way. Thank you very much for your presentation. In your lecture, it's pretty clear that N95s will help protect us from getting an infection, but the surgical mask, basically, I just wanna confirm, wearing a surgical mask will not do anything to protect you. Is that correct? Very little, that's correct. I wouldn't say absolutely zero, but, and I think that this was really the most confusing issue, both in the workplace and in the community, is what am I wearing a face covering for? So a surgical mask will do very little to protect me from you, from those airborne particles. It does something as droplet control if I sneeze or cough or sing, but you're absolutely correct about that. I wouldn't say it's zero though. Okay, thank you. Excellent job on the presentation. Appreciate all the information. One question I have is what is your viewpoint? OSHA and CDC have been very clear that wearing of masks have been required and important, yet they will not factor in use of masks in the exposure assessment as to whether you have been exposed. So 15 minutes of exposure in 24 hours to a known COVID positive case indicates you need to quarantine, regardless of if you were wearing a N95 mask or not. Can you comment on that and some of your thoughts on that, please? Yeah, great. It's a great question. And I don't know if you or others there or in the virtual audience have advised employers about programs and how to evaluate what is a high risk versus not a high risk exposure, because if it's high risk, then you're in the isolation and quarantine world. And I've gotten a million questions about whether face coverings or respirators should be part of a high risk assessment. And if you go to the CDC, they basically will say basically no, as you've just pointed out, right? It's sort of not a triage point, or if it is, it's very difficult to understand and follow for most employers and the lay public. My personal view is that because there's such variability in how people wear masks, face coverings, and N95s, I myself have said, how do I figure out whether you're really wearing it correctly? How do I know what the fit and filtration was of what you were wearing? Now, in our medical center where I work at UCSF, I'm hoping, I can't guarantee it, but I'm hoping at least we do a better job that when people are wearing N95s, they've gone through fit testing and they're wearing it more correctly than my friend or relative on an airplane. But it's quite interesting though, is because I did a study of respirator use during H1N1, and I published this, and we actually stationed people outside of hospital rooms, and we watched to see whether the nurses and doctors were putting on N95s correctly. And as you might expect, there was a huge variation. So I guess at the end of the day, the short answer is, is because humans are frail, and we can't know whether they really wore it correctly. The recommendation was to more or less ignore it. But I think implied in your question is dissatisfaction with that answer on many people's parts, because I'll tell you what ended up happening quite a bit to me, and I don't know about others, I got employees and managers asking, well, why are you telling me to wear a face covering or a respirator if you're going to ignore it? No, there was that dichotomy, because I mean, I'm a strong believer in their efficacy, but it's mostly lay people, as you've articulated, that do not understand, and it is really an understandable. You can't be, a protection that is required, it's because it protects, yet it doesn't get credit for doing so. And I've worked very closely with the CDC on a lot of these issues. I can tell you that for the clinic staff, I've been frequently told that clinical staff that are wearing N95s and have had a known COVID exposure are not considered exposed, because they were protected, and they were healthcare providers that knew how to wear them properly, but they wouldn't apply it to a larger worker population. I would just wait, make one other comment, which I didn't go into in my talk, which comes to my mind, and that is kind of root cause analysis of how we got to where we are. And I think early on, or earlier on, if we understood with research science and policy that this virus was airborne, that in the early stages of the epidemic, if we hadn't been so focused on fomites and surface transmission, maybe the messaging would have been more clear. Very true. It evolved, and messaging evolved, and many got lost along the paths and forks in the road. Yeah, I agree. Thank you so much. Yeah, I agree. If anybody in our virtual environment has a question for Dr. Harrison, feel free to unmute yourself. Yeah. I had fun. I'm not a big basketball fan, but I did have fun when they started playing basketball again, watching the coaches who wore their mask as a chinstrap, or even worse yet, when they were angry with the player that pulled their mask down so that they could yell at them better. That was always fun. I watched it purely for comic relief. I wasn't really paying attention to the basketball. Jeffrey, I'm a big San Francisco Warriors fan, and I'm watching Steve Kerr, who's the coach of the Warriors all the time. And sometimes Steve still has his mask on, and sometimes he has it below his chin. Right, right. And I'm like standing to myself, and I'm saying to my wife, wait, what is he doing there? What is he saying? What is that message, Steve? And yeah, I call that the chinstrap. You know what I mean? You'll see that sometimes in restaurants. All of our workers are masked up. Okay, yeah, she's wearing it as a chinstrap. Thank you again. I know we contacted you a little late, and appreciate that you came through for us. Also, I was very interested that you are surfacing the other aspects. It's not just firefighters, or police, or health staff that needs now the protection that this originally came out. Dr. Everson, who's one of our members, had let us know of the panel that they were gonna have on protecting the public in general. For example, during the California fires. So really appreciate that you're helping surface that there's bigger respiratory problems than just COVID right now, and that we are not taking care of the people, the public, and also those who have no training and no knowledge of their risks. So really appreciate this talk of the bigger aspect. Thank you so much. We issued this 550-page, very big report from the National Academy of Sciences, but really the impact is seeing some good change happen for public and all the workers that we're serving and examining. So I may loop back with your organization because there's gonna be more conversations this summer with Congress and HHS to see if they'll pick up on any of our recommendations. So we can use all the organizational support. All right. Thanks so much. I think we're all out of questions and I didn't hear anyone from the virtual environment. So I appreciate you very much, Dr. Harrison. Thank you. Glad to join you from San Francisco. Have a good time there.

respiratory protection

inhalation hazards

COVID-19

climate change

N95 masks

OSHA

public health