Improved Criteria for Emergency Medical Protective Clothing

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emergency responders with a patient on a stretcherIt is estimated there are over 1 million firefighters and an additional 500,000 Emergency Medical Technicians and other first responders engaged in emergency medical service (EMS) operations. These EMS responders routinely are exposed to a wide range of hazards, including blood borne pathogens that require the use of personal protective equipment (PPE). Requirements for emergency medical personal protective clothing and equipment have been established in the National Fire Protection Association’s (NFPA) Standard number 1999, Protective Clothing for Emergency Medicals Operations. The 2003 edition of NFPA 1999 contained a number of deficiencies identified by the responsible committee, NFPA Technical Committee on Emergency Medical Operations Protective Clothing and Equipment. These deficiencies were primarily clothing/equipment categories where industry had not responded with certified products even though these items are understood to be extensively used during emergency medical operations. To address this issue, researchers at the National Institute for Occupational Safety and Health (NIOSH) along with external partners, assessed the hazards faced by EMS workers, met with EMS responders to learn about their PPE needs, and evaluated available PPE to determine the appropriate technical performance levels necessary for a suite of PPE including: garments, gloves, footwear covers, respiratory protection, eye/face wear and head protection.

cover of NFPA 1999, 2008 edition
NFPA 1999, 2008 edition

NIOSH and its partners evaluated the PPE commercially available at the time of the research through extensive laboratory testing and user wear assessment to determine appropriate technical performance levels necessary to protect EMS responders. The majority of the research effort was undertaken during 2006 and 2007. The National Fire Protection Association (NFPA) incorporated NIOSH research results into the NFPA 1999 Standard on Protective Clothing for Emergency Medical Operations, 2008 edition. NFPA standards are recognized by numerous industries as the basis for equipment quality and performance. This is especially applicable for the first responder industry. Many NFPA standards including the NFPA 1999 Standard on Protective Clothing for Emergency Medical Operations, 2008 edition have been adopted by the Department of Homeland Security, making compliance with the standard a requirement for use of federal grant money.

PPE certified to the 2008 edition of the NFPA standard is now available, enabling a level of protection not previously provided to the nation’s EMS responders. NFPA 1999 contains requirements for certification of a range of products including single use and multiple use garments; examination, cleaning and work gloves; eye and face protection; and single use and multiple use footwear. The certification of individual products allows users to select the appropriate level of protection necessary for each response. As of November 20, 2008 there were 26 manufacturers with a total number of 82 products certified to the 2008 edition of NFPA 1999.

Two notable areas where the number of certified products has increased under the new edition are reusable footwear and work gloves. These two areas had seen relatively little or no certification efforts prior to the 2008 edition. The expectation is for this trend of additional certified products to continue with single use garments and single use footwear.

The EMS PPE study has lead to other similarly designed research projects that will address other types of protective clothing and was showcased as an example of a Research to Practice effort within NIOSH. The process instituted for the EMS study focused on optimizing existing test methods, through research, to set new, balanced, performance and design requirements. This research approach will be applied to PPE for other industries and will result in standards that define the minimum performance requirements of PPE for workers.

A final report summarizing the EMS research has been prepared and has been made available upon request and through distribution at conferences. To request a copy of the final report, contact Angie Shepherd. In addition to the detailed final report, presentations have been given at three technical conferences including the International Association of Fire Fighters (IAFF) 2007 John P. Redmond Symposium, the Technical Support Working Group (TSWG) Personal Protective Equipment 2007 Conference, and the 2008 American Industrial Hygiene Conference and Expo (AIHce). Two manuscripts are being prepared for publication, and an additional presentation is scheduled at the 2009 Fire Industry Equipment Research Organization (FIERO) PPE Fire Symposium.

—Ed Fries and Angie Shepherd

Mr. Fries serves as the Assistant Coordinator for the NIOSH PPT Program in the NIOSH National Personal Protective Technology Laboratory (NPPTL) Office of the Director.

Ms. Shepherd is a General Engineer in the Technology Research Branch in the NIOSH National Personal Protective Technology Laboratory and was the project officer for this research.

Posted 1/20/09 at 8:27 am

Posted on by Administrator

7 comments on “Improved Criteria for Emergency Medical Protective Clothing”

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    DHS full scale exercises show that emergency medical service (EMS) personnel will man/work expedient decontamination and technical decontamination corridors for chemical, biological, radiological or nuclear (CBRN) incident response. Therefore, the personal protective equipment (PPE) worn by EMS during a CBRN incident will be/may be contaminated by CBRN agents of unknown, known, or less than IDLH concentrations of toxic/harrassing compounds. In support of protecting EMS workers during CBRN incident response and incident mitigation, surrogate and actual chemical warfare agent concentration gradient exposure testing (live-agent-testing/LAT)of PPE clothing and interoperable respirators should be done on full-body articulated mannequin test platforms. These novel requirements are expected to be an ideal compliment to the existing traditional minimum performance requirements of PPE for EMS workers.

    NFPA 1994, “Standard on Protective Ensembles for First Responders to CBRN Terrorism Incidents, 2007 edition” is available from NFPA. As described in the Standard’s “Origin and Devlelopment” section: “The Technical Committee on Hazardous Materials Protective Clothing and Equipment began work on this document in 1998 to answer the need for personal protecrtive equipment for fire and emergency services personnel operating at domestic terrorism incidents involving dual-use industrial chemicals, chemical terrorism agents or biological agents. All first responders, and safety officers in more depth, should refer to this standard.

    The comment made by the gentleman with the same name shows how the attitude amongst EMS personnel must change. Protective garments must change to protect EMS workers, just as the attitude of EMS workers must change. Would a firefighter go into a burning building without his turnout gear because it covers his arms and is uncomfortable? To professionalize our industry (EMS) we must change our attitude about how we view our work, and how we choose to protect ourselves. If you want to wear a polo and be comfortable, continue your dialysis transfer. If you want to be a professional EMS worker, wear protective gear that has been proven through R & D. Protect yourself; protect our future.

    In a time where we are experiencing increasing numbers of resistant bacteria in hospitals, we are also starting to see resistant organisms in community acquired infections. One of the mechanisms for this development may be colonization of resistant organisms on the clothing of EMS personnel who have exposure both in the community and hospital settings.

    Have there been any attempts in order to try to reduce such colonization?

    Has there been any modification to the protective clothing or any policy recommendations to address this issue?

    Thank you for your comment. At this time, NIOSH has no current research activity or new policy recommendations to prevent colonization on workers’ uniforms or PPE. However, NIOSH is aware of these issues and has had discussions with some Fire Fighting and EMS personnel regarding Methicillin-resistant staphylococcus aureus (MRSA) and offer the following paragraphs toward dealing with infectious organisms on clothing.

    MRSA ( is a resistant strain of Staphylococcus aureus or “staph,” the most common skin infection seen in developed countries. Staph is so common that the CDC estimates up to 30 percent of the population is colonized with it (i.e., bacteria present but not causing infection). Infections typically occur in people with open wounds and/or weakened immune systems, as are often found in nursing homes, hospitals, and ambulances.

    What should you do if your uniform, clothing, personal protective equipment or workstation becomes contaminated with MRSA?

    ◦Wash uniforms, clothing, sheets and towels that become soiled with water and laundry detergent. Drying clothes in a hot dryer, rather than air-drying, also helps kill bacteria in clothes.
    ◦Cleaning contaminated equipment and surfaces with detergent-based cleaners or Environmental Protection Agency (EPA)-registered disinfectants is effective at removing MRSA from the environment. Because cleaners and disinfectants can be irritating and exposure has been associated with health problems such as asthma, it is important to read the instruction labels on all cleaners to make sure they are used safely and appropriately. Where disinfection is concerned, more is not necessarily better. Additional information on appropriate use of cleaners and disinfectants can be found in the Hospitals for a Healthy Environment (H2E) 10 Step Guide to Green Cleaning Implementation ( Environmental cleaners and disinfectants should not be used to treat infections. The EPA provides a list of EPA-registered products effective against MRSA: (
    More information about infection control guidelines can be found at CDC website page ( Also, in July of 2007 the Healthcare Infection Control Practices Advisory Committee (HICPAC) issued a, “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007″( . The title is slightly deceptive; the guideline is actually a comprehensive update and summary of the current best evidence for preventing spread of infections.

    The two articles ( and discuss commercial laundry controls for MRSA. The controls go well beyond the use of chlorine in garment laundering. Process controls, PPE, surface decontamination and comprehensive worker safety and health programs are also described.

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