Health care workers are exposed to potentially infectious airborne particles while providing routine care to coughing patients. However, much is not understood about the behavior of these aerosols and the risks they pose. We used a coughing patient simulator and a breathing worker simulator to investigate the exposure of health care workers to cough aerosol droplets, and to examine the efficacy of face shields in reducing this exposure. Our results showed that 0.9% of the initial burst of aerosol from a cough can be inhaled by a worker 46 cm (18 inches) from the patient. During testing of an influenza-laden cough aerosol with a volume median diameter (VMD) of 8.5 μm, wearing a face shield reduced the inhalational exposure of the worker by 96% in the period immediately after a cough. The face shield also reduced the surface contamination of a respirator by 97%. When a smaller cough aerosol was used (VMD = 3.4 μm), the face shield was less effective, blocking only 68% of the cough and 76% of the surface contamination. In the period from 1 to 30 minutes after a cough, during which the aerosol had dispersed throughout the room and larger particles had settled, the face shield reduced aerosol inhalation by only 23%. Increasing the distance between the patient and worker to 183 cm (72 inches) reduced the exposure to influenza that occurred immediately after a cough by 92%. Our results show that health care workers can inhale infectious airborne particles while treating a coughing patient. Face shields can substantially reduce the short-term exposure of health care workers to large infectious aerosol particles, but smaller particles can remain airborne longer and flow around the face shield more easily to be inhaled. Thus, face shields provide a useful adjunct to respiratory protection for workers caring for patients with respiratory infections. However, they cannot be used as a substitute for respiratory protection when it is needed.

These results support a role for aerosol transmission and represent the first reported laboratory study of the efficacy of masks and respirators in blocking inhalation of influenza in aerosols. The results indicate that a poorly fitted respirator performs no better than a loosely fitting mask.

Aerosol particles expelled during human coughs are a potential pathway for infectious disease transmission. However, the importance of airborne transmission is unclear for many diseases. To better understand the role of cough aerosol particles in the spread of disease and the efficacy of different types of protective measures, we constructed a cough aerosol simulator that produces a humanlike cough in a controlled environment. The simulated cough has a 4.2 l volume and is based on coughs recorded from influenza patients. In one configuration, the simulator produces a cough aerosol containing particles from 0.1 to 100 µm in diameter with a volume median diameter (VMD) of 8.5 µm and a geometric standard deviation (GSD) of 2.9. In a second configuration, the cough aerosol has a size range of 0.1-30 µm, a VMD of 3.4 µm, and a GSD of 2.3. The total aerosol volume expelled during each cough is 68 µl. By generating a controlled and reproducible artificial cough, the simulator allows us to test different ventilation, disinfection, and personal protection scenarios. The system can be used with live pathogens, including influenza virus, which allows isolation precautions used in the healthcare field to be tested without risk of exposure for workers or patients. The information gained from tests with the simulator will help to better understand the transmission of infectious diseases, develop improved techniques for infection control, and improve safety for healthcare workers and patients.

Few studies have quantified the dispersion of potentially infectious bioaerosols produced by patients in the health care environment and the exposure of health care workers to these particles. Controlled studies are needed to assess the spread of bioaerosols and the efficacy of different types of respiratory personal protective equipment (PPE) in preventing airborne disease transmission. An environmental chamber was equipped to simulate a patient coughing aerosol particles into a medical examination room, and a health care worker breathing while exposed to these particles. The system has three main parts: (1) a coughing simulator that expels an aerosol-laden cough through a head form; (2) a breathing simulator with a second head form that can be fitted with respiratory PPE; and (3) aerosol particle counters to measure concentrations inside and outside the PPE and at locations throughout the room. Dispersion of aerosol particles with optical diameters from 0.3 to 7.5 μm was evaluated along with the influence of breathing rate, room ventilation, and the locations of the coughing and breathing simulators. Penetration of cough aerosol particles through nine models of surgical masks and respirators placed on the breathing simulator was measured at 32 and 85 L/min flow rates and compared with the results from a standard filter tester. Results show that cough-generated aerosol particles spread rapidly throughout the room, and that within 5 min, a worker anywhere in the room would be exposed to potentially hazardous aerosols. Aerosol exposure is highest with no personal protective equipment, followed by surgical masks, and the least exposure is seen with N95 FFRs. These differences are seen regardless of breathing rate and relative position of the coughing and breathing simulators. These results provide a better understanding of the exposure of workers to cough aerosols from patients and of the relative efficacy of different types of respiratory PPE, and they will assist investigators in providing research-based recommendations for effective respiratory protection strategies in health care settings.