Hospitals, LTC homes to use N95 respirators with COVID patients

Ontario health officials are changing a key recommendation on the use of hospital personal protective equipment (PPE) in response to the “potential” that the highly-transmissible Omicron variant can spread at a distance through the air.

Health-care workers providing care to a “suspected or confirmed” COVID-19 patient in hospitals, long-term-care homes, or in a home-care situation will now be required to also use a “fit-tested, seal-checked N95 respirator,” according to interim guidance issued by Public Health Ontario Wednesday.

Ontario hospitals’ use of loose-fitting procedure masks instead of N95 respirators has been the subject of controversy long before Omicron, with critics saying the province’s rules did not fit an increasingly certain reality that the COVID virus is airborne and capable of infecting at a distance via tiny floating “aerosol” particles.

Ontario’s Chief Medical Officer of Health Dr. Kieran Moore acknowledged the risk at a press conference Wednesday, saying the Omicron variant “is much more infectious and there is the potential that it can spread in the air.”

He added: “We’re very concerned that there could be much more aerosol spread than other strains.”

On Thursday, presenting the Ontario COVID-19 Science Advisory Table’s latest modelling on the Omicron wave, co-chair Dr. Steini Brown was more blunt: “It’s an airborne disease. I think that’s clear,” he said.

He added that the province’s specific guidance on masking is up to Moore.

Ontario Hospital Association president Anthony Dale welcomed the change in a statement Wednesday, saying that given the uncertainty around Omicron, the OHA “fully supports today’s interim recommendations from Public Health Ontario regarding the use of N95 respirators for some activities as a precautionary measure.”

As of the latest data from September, at least 860 people have died of COVID-19 in outbreaks linked to Ontario hospitals, making them the province’s second-deadliest setting for outbreaks, after long-term-care homes.

Throughout the pandemic, public health officials have argued that close contact and droplet precautions, which do not require N95s except for specific procedures, were enough to keep patients safe, even as new research supported the idea that COVID spreads through the air in a manner that could pass around looser-fitting masks.

On the question of the virus’ airborne risk, the provincial guidelines had taken substantively the same approach through every previous COVID wave, recommending that the use of surgical masks, face shields and physical distancing was generally sufficient to protect patients and staff.

As the Star reported last summer, this position was controversial, and the Ontario Nurses Association even took the provincial government to court in an effort to force airborne protocols, including the use of N95s.

The nurses argued that “Directive 5,” the document that guides PPE use for hospital and long-term-care home workers, did not apply the precautionary principle to the risk COVID could defeat droplet and contact precautions. While Directive 5 gave workers a choice whether to wear N95 masks, it does not make their use mandatory.

The Ontario Divisional Court dismissed the nurses’ action in May, saying that by allowing health professionals to take individual precautions, including the choice of wearing an N95, the precautionary principle was being observed.

Acknowledgment of the virus’s airborne ability is critical, and long overdue, said Dr. Abdu Sharkawy, an infectious diseases consultant at the University Health Network and assistant professor of medicine at the University of Toronto. Still, he said, action is much more important than any academic debate.

“Whether we call it airborne or not doesn’t matter. What matters most is the recognition that a more robust framework for level of protection of PPE and importance of optimal ventilation, is essential to controlling ongoing transmission of this virus.” He added: “Omicron has dialed up the degree of urgency for this in a really big way.”

On Wednesday, OHA’s Dale said he expects Directive 5 will be revised to replace the new interim measures.

As in the hard-hit long-term-care sector, the deadliest outbreaks in Ontario hospitals came before most patients and health-care workers had been vaccinated. There have been relatively few outbreaks in either setting since this spring.

However, experts are increasingly concerned that Omicron’s ability to infect people who have been vaccinated sets the stage for new waves of outbreaks in vulnerable settings, like hospitals and long-term care.

According to the Ontario Science Table, the variant is now dominant in the province, with cases growing at a rate that doubles every 2.2 days.

For some experts, Moore’s acknowledgment of the possibility of airborne spread of the virus was too little, too late.

“I was livid that he’s standing there with a blue rectangle on his face saying maybe there’s aerosol. It just struck me as really disingenuous,” said Colin Furness, an infection control epidemiologist at the University of Toronto, noting that Moore was wearing a loose mask at Wednesday’s news conference, not an N95.

He said public health officials have long been resistant to updating the guidelines.

“We are slaves to these guidelines and this is harming people.”