Sep 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.
（CIDRAP News 报导）2009年9月3日，美国医学学会(IOM)今天宣布，对现行联邦政府针对甲型(H1N1)流感医护人员防病毒的建议做出肯定性意见，即应使用经过适合性检验的N95防护口罩，而不是外科手术口罩。
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.
IOM同时还提倡，应开展更深入的研究，研究流感传播和医疗机构使用各种呼吸防护措施预防流感传播的有效性，投入更多资源研发新型的更安全、更舒适的呼吸防护技术和产品。
"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.
在IOM的新闻发布会上，负责起草该报告的委员会主席Kenneth Shine先生说，“基于我们对流感的现有了解，为防止病原微生物颗粒经呼吸道吸入，使用经过适合性检验的N95防护口罩可以给医护人员提供最好的保护。”
"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."
Shine先生是奥斯汀市德克萨斯系统大学卫生事务分校的副校长，IOM的前任主席。他补充道，“由于我们对这些病毒还有很多不了解的地方，单独依靠防护口罩作为万能的防护屏障将是错误的。医疗机构及其雇员应建立并执行一系列的传染控制策略，如有针对性的患者排查程序、洗手、消毒、使用手套、接种疫苗和使用抗病毒药物等。”
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.
但IOM的报告今天也引来美国传染控制和医院流行病学专业协会(APIC)一位代表的批评，该代表认为戴N95防护口罩的建议没有考虑到和使用相关的一些现实的和供货的问题，包括不舒适、成本高、货物短缺和难以实施适合性检验等。
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).
在对流感病毒传播的实质还不是完全清楚的情况下，IOM应美国疾病预防控制中心(CDC)和职业安全健康管理局（OSHA）的要求起草了这份研究报告。
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).
起草小组实际上只有8个星期的时间用于准备这份报告。在8月份，小组召开了为期4天的会议，其中一天半用于与公众的座谈。在成员任命上，小组有意规避了与个体防护用品（PPE）相关的经济与后勤方面的考虑。
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.
报告指出，CDC当前对甲型（H1N1）流感医护人员的防护指南与世界卫生组织（WHO）和加拿大的指南不同。CDC建议所有进入确诊或疑似甲型（H1N1）流感病人隔离病房的医护人员和与该类病人近距离接触、给他们提供应急医疗服务的人员都必须使用N95防护口罩。
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.
报告说，与此不同的是，WHO建议和病人有直接接触的医护人员采取“标准的和飞沫传染预防的措施（包括使用医用外科手术口罩、罩袍、手套、眼睛防护和手部卫生），要求在产生气溶胶的治疗过程中，医护人员采取额外的防护，包括使用颗粒物防护口罩”。 WHO的建议考虑到了不同国家的“持续供应的需要”。
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.
报告介绍，加拿大近期颁布的指南和WHO的建议类似，只对从事产生气溶胶操作的人员要求使用N95防护口罩，其他情况下推荐使用外科手术口罩。
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."
面对流感病毒通过空气传播的程度如何这个晦涩的问题，IOM委员会的结论是，有研究表明“空气（吸入）传播是一个潜在的传播途径”。
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.
报告起草委员会指出，在医疗机构内开展的有关N95防护口罩和外科手术口罩有效性的比较研究非常少，尽管有些研究还在进行中，委员会的决定只能核对两种防护措施的对比研究得出，那些研究表明，外科手术口罩不太可能对气溶胶传播提供有效的防护。
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.
经对证据进行回顾，报告起草委员会建议，与甲型（H1N1）流感或有流感样症状的病人有密切接触的医护人员，应该佩戴经过适合性检验的N95防护口罩，或“的确更加有效的”其他种类的呼吸防护用品。研究报告明确指出，在有证据表明其他形式的防护同样有效或更加有效之前，应遵守CDC的现行指南。
In addition, the report advises that employers should make sure that N95 respirators are used and fit-tested in accordance with OSHA regulations.
此外，报告还建议，雇主应确保依照OSHA法规使用N95防护口罩，进行适合性检验。
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:
报告起草小组进一步发现，对流感传播和PPE使用的研究的需求非常“突出”。报告敦促联邦政府和私人机构，支持和开展以下研究：
- Answer questions about the relative contribution of different routes of flu transmission
解答不同传播途径对流感传播影响的疑问；
- Explore the effectiveness of different respiratory protection tools in clinical settings through randomized trials
通过随机试验发现，医疗机构内采取的不同呼吸防护措施有效性的差别；
- Design and develop new respiratory protection technologies "to enhance safety, comfort, and ability to perform work-related tasks"
设计、开发新型呼吸防护技术，“提高安全性、舒适性和完成所需工作的能力”。
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.
今天，IOM使用经过适合性检验的N95防护口罩的建议招致Ruth Carrico女士的批评。作为APIC前任理事会成员，美国路易斯维尔大学公共健康和信息科学学院的传染控制专家，Carrioc女士认为报告缺少可行性基础。Carrioc女士是某专家委员会的成员，该委员会曾对IOM报告草案进行过评论。
"I think the IOM has missed the mark," Carrico told CIDRAP News.
Carrico女士告诉CIDRAP News记者说：“我认为，IOM没有抓住解决问题的目标”。
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.
她认为报告起草者只是专门从科学的角度，而不是从经济和后勤角度来看待这个问题。她说，很难把科学的问题和现实条件隔离开，如医护人员对指南的依从性问题，和这些建议对医疗结构的适用性问题。
"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.
“作为一个人，如果你被告知这是最好的保护你的方法，而你在工作中得不到这样的保护，明天你还怎么去工作？”她这样问。
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."
针对建议中特别强调要使用经过适合性检验的呼吸防护口罩这一点，Carrico女士说，关于适合性检验还有很多没有被提到的信息，考虑到做适合性检验所需要的时间和成本，她说，“这样做真的有意义么？这是正当有效的么？我们必须关注这样做所付出的时间成本。”
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?'"
她说，通常讲，“把建议与执行建议的实际条件相脱离，对需要帮助解决困难的医护人员而言，这本身就是一个严重的问题，‘我该如何用一个安全的方式给病人提供护理呢？’”
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.
医院方面说他们会尽可能做适合性检验，“但没有可能对所有式样的防护口罩提供适合性检验”，Carrico女士继续讲，例如，今年春季，某些医院的防护口罩用光了，于是开始用政府的“国家策略储备计划”提供的防护口罩，而那些口罩的式样与医院过去用的不同，这就需要重新做适合性检验。
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.
保证手中留有足够的防护口罩是一个持续性的问题，她补充道，“口罩会断货，一直都有断货问题存在，我们没有能够维持此类产品供应的供应链以保证我们能够遵照这些建议执行”，结果，医院只能把口罩节省下来给那些最高风险的机构使用。
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.
货物短缺和其他一些问题导致医院政策多变，给员工带来困惑，她补充道，“我们听到员工们会这样讲‘我拒绝护理这个病人，因为我感觉不安全’”。
Carrico also commented that most workers can wear N95s only a short time before they become hot and uncomfortable.
Carrico女士同时评论说，绝大多数员工只能短时间佩戴N95防护口罩，因为长时间使用会很热，很不舒适。
"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.
她说：“对于有些问题你不得不‘剥开表皮看本质’，看看什么才是真正需要的，什么才是真正现实的，我们怎样才能使我们的医护人员去做需要他们做的工作”。
She also expressed hope that the IOM's appeal for new research will lead to some well-designed studies in clinical settings.
她也表示希望，IOM提出的开展新的研究的倡议能够带来一些在医疗机构开展的充分研究。
At a press briefing today, CDC Director Dr. Thomas Frieden said the CDC has just received the IOM report and is looking at it.
在今天的新闻发布短会上，CDC主任Thomas Frieden博士说，CDC刚刚接到IOM的报告，正在研究当中。
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.
CDC发言人Tom Skinner先生告诉CIDRAP News记者，CDC正在考虑IOM提出的建议和其他专家组对医护人员呼吸防护的建议，“我们希望能很快制订出计划来进一步研究这个问题”。
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