March 19, 2020

Letter to Dr. Janice Fitzgerald re: Downgrading of N95 Respirator Use in Swabbing

Dear Dr. Janice Fitzgerald:

On behalf of the Registered Nurses’ Union of Newfoundland and Labrador (RNU), I’d like to acknowledge your strong leadership and commitment to public health as our province faces COVID-19. We appreciate the tremendous work of your team during rapidly evolving conditions.

As you know, RNU strongly maintains the position that every frontline health care worker treating a suspected and confirmed case of COVID-19 must be protected with an N95 respirator, at a minimum. I am writing today to urge you to reconsider the downgrading of N95 respirator use during nasopharyngeal (NP) swabbing for suspected COVID-19 cases.

We believe it is critically important to continue proactive infection control measures to keep our health care workers, and by extension the residents of this province, protected from COVID-19.

The science on transmission of respiratory infections, such as COVID-19, is not clear nor settled. There is little consensus on the effectiveness of surgical versus N95 masks in preventing respiratory infections, as well as limited evidence on transmission and evaluation of personal protective equipment (PPE) for COVID-19.

The “Influenza Transmission and the Role of PPE: An Assessment of the Evidence” by the Expert Panel on Influenza and Personal Protective Respiratory Equipment clearly states that “N95 respirators protect against the inhalation of nasopharyngeal, tracheo-bronchial and alveolar-sized particles.” The report does not claim that surgical masks offer this same protection. In fact, it states that while surgical masks offer no notable protection against the inhalation of alveolar and tracheobronchial-sized particles;

The efficiency of the filters of surgical masks to block penetration of nasopharyngeal-sized particles is unknown. The lack of a sealed fit on a surgical mask will allow for the inhalation of an unknown quantity of nasopharyngeal-sized particles.

A recent study in Hong Kong, which specifically evaluated infection control preparedness, found that among the 413 health care workers caring for the 42 confirmed cases of COVID-19 in this study, none of them were infected. The PPE used in this study were N95 respirators for all HCWs working in triage, caring for suspected or confirmed cases, and performing aerosol generating procedures.

The study concludes, “Appropriate hospital infection control measures could prevent nosocomial transmission of SARS-CoV-2”, now referred to as COVID-19.

Furthermore, reputable institutions such as the United States Centers for Disease Control and Prevention (CDC) and European Centre for Disease Prevention and Control (ECDC), continue to recommend N95 as the preferred minimum PPE, unless there are supply chain issues. The  ECDC in its guideline “Infection prevention and control for COVID-19 in healthcare settings March 2020” states, “Healthcare workers performing aerosol-generating procedures (AGP), such as swabbing, should wear the suggested PPE set for droplet, contact and airborne transmission (gloves, goggles, gown, and FFP2/FFP3 respirator.”

While we recognize supply considerations remain an issue, we expect the government to take immediate measures to provide solutions – rather than putting frontline health care workers at risk in an attempt to ration supplies.


Debbie Forward, RN

President, RNUNL