Before the COVID-19 pandemic surged across the United States in 2020, few Americans thought about respiratory protection against infectious diseases, wildfire smoke, dust storms, mold, and other airborne threats — unless they were aware they faced greater risk.

With COVID-19, all that changed rapidly. As many regions and private businesses issued mask mandates, the general population and essential workers in what became high-hazard industries — including employees in meat processing, grocery stores, and food service — sought out masks, face coverings, respirators, or other devices to protect themselves and to reduce the spread of the virus. They also had to navigate issues of inconsistent mask and respirator availability, changing guidance, and widely circulating misinformation.

More than two years into the COVID-19 pandemic, many of these uncertainties still persist, and more Americans face additional inhalation hazards, such as annual wildfires whose smoke frequently permeate the air in much of the western United States. The American public and many workers still have questions: Why do I need to wear a mask or respirator? Is it safe? What product is best to protect myself, my family, and my community?

These recent and reoccurring threats have highlighted major gaps in the nation’s system for ensuring timely access to and guidance on appropriate respiratory protection for the public and for many workers. According to a National Academies report released in February 2022, the enormity of the scale of these events and the magnitude of their impacts on public health, particularly for the most vulnerable populations, underscore the need to take action now to address the unmet respiratory protection needs of the public and all workers.

In July 2022, the National Academies hosted two webinars aimed at facilitating dialogue among federal and other stakeholders to kick-start momentum toward closing these gaps. During one of the webinars, Jonathan Samet, dean of the Colorado School of Public Health and chair of the committee that wrote the report, described the committee’s overall findings: “Respiratory protection evolved around the workplace. It’s been used in occupational settings with well-defined hazards with many mandated respiratory protection programs. But, of course, as we have learned in the pandemic, SARS-CoV-2 [the virus that causes COVID-19] has taught us many lessons about airborne transmission of infectious agents, the reach of these agents, and other hazards to populations that are not now covered and that have not previously used respiratory protection. Systems are needed to bring respiratory protection and give access to those needing them, along with guidance on how to use these devices to assure the protection is adequate.”

Respiratory Protection for All

Historically, the use of respiratory protection has been associated with protecting workers exposed to well-defined hazards, such as health care workers exposed to tuberculosis, firefighters exposed to smoke, and miners exposed to coal dust and silica, among others. Yet, threats from inhalation hazards are increasingly extending to broader populations. These include members of the public, as well as workers whose jobs typically do not require respiratory protection — such as teachers, grocery store workers, and corrections officers. In addition, in the U.S. between 100,000 and 200,000 excess deaths are attributable to air pollution each year, not including the contribution of wildfire smoke.

The current system of workplace protections, including Occupational Safety and Health Administration requirements, do not cover all workers who need respiratory protection. Moreover, the public has received little attention with respect to respiratory protection. To ensure that everyone who requires protection has access to appropriate devices and guidance on their effective use, the report urges a wide variety of stakeholders to collaborate on a respiratory protection framework that incorporates threat assessment, regulation, device production and supply, and public education efforts.

Ensuring Effective Use

A variety of devices have been available to and used by the public for a range of inhalation hazards. Air-purifying respirators, commonly used in work settings in which a respiratory protection program has been established, keep individuals from breathing in inhalation hazards. In contrast to respirators, medical masks and cloth face coverings are designed primarily to protect others nearby from any infectious particles that wearers are exhaling. Health care workers, for example, may wear medical masks to avoid spreading infectious agents to their patients, and they use respirators, such as N95 filtering facepiece respirators, when there is a need to protect themselves from becoming infected.

Research suggests that improper use of respiratory protection among the public is common, the report says. For example, researchers conducted a study in New Orleans during the cleanup following Hurricane Katrina when public health messages promoted the use of N95 respirators to protect against mold exposure during remediation activities. Sixty-eight percent of those interviewed by researchers were aware of that recommendation and at least 30 percent of those participating in remediation activities had used a NIOSH-approved respirator. However, only 24 percent were able to put on an N95 filtering facepiece respirator correctly.

The challenges with public use of respiratory protection are compounded by the lack of federal oversight, which largely is limited to occupational settings. There is no formal, coordinated system to approve devices for use by the public or to educate the public on when and how to use a device and which devices individuals, including children, should wear. Although they may receive guidance from federal agencies, no formal system is in place to coordinate the development and distribution of such guidance to state and local health agencies or the public.

During the COVID-19 pandemic, this lack of trusted guidance, along with widespread misinformation, contributed to persistent confusion and disagreement about the need to use devices and the protection provided by different types. The pandemic also exposed severe limitations in the capacity of existing supply chains to meet demands during public health emergencies.

A Path Forward

Wildfires, floods, and outbreaks of airborne infectious agents are recurring events that have the potential to expose large parts of the population to respiratory hazards. These events and the health threats they pose can and should be anticipated, the National Academies report emphasizes. Having systems in place to continuously assess inhalation hazards, identify the right devices to meet respiratory protection needs, and guide workers and the public on how to effectively use them can prevent illness and save lives.

The report details the steps needed to protect the general population and those workers not covered by a respiratory protection program. It recommends that Congress act to address gaps in OSHA’s respiratory protection requirements and that the administration establish and update standards for airborne infectious agents and particulate matter found in air pollution and wildfire smoke to trigger respiratory protection program requirements — two critical actions that would go a long way toward ensuring the safety of workers exposed to inhalation hazards.

To address the public’s needs, the report recommends establishing an entity within the federal government that would provide unified and authoritative information to the public and would be responsible for ensuring the availability and access to respiratory protection.

Establishing a system that provides the necessary oversight and regulatory authority will ensure that both the public and front-line workers alike are ready for the next inhalation hazard, whatever it may be.

• Read the report: Frameworks for Protecting Workers and the Public from Inhalation Hazards

• Watch the webinar: Respiratory Protection for Workers Without Respiratory Protection Programs

• Watch the webinar: Respiratory Protection for the Public