Do you know how to use PAPRs?

You should use a positive-air pressure respirator (PAPR) to protect against bacteria and viruses up to 0.3 microns in length if you suspect a patient has smallpox, recommends Darlene Matsuoka, RN, BSN, CEN, CCRN, ED clinical nurse educator at Harborview Medical Center in Seattle. "It should protect against smallpox droplets, but is not a guarantee against the virus itself," she cautions.

At Harborview’s ED, all new nursing staff receive training in tuberculosis given by the employee health department. The training includes discussion about administrative controls such as policies and screening, environmental controls such as isolation rooms, and use of personal protective equipment, including PAPRs. (See "Resources" at the end of this article for information on obtaining PAPRs.) Nurses watch a video on how to check the airflow of the respirator unit by placing a pressure flow cup in the tubing assembly, which is done with each use.

"The hospital switched to the PAPRs because the hoods require only a basic fitting, are not problematic with facial hair, and have no requirements about semiannual testing like the negative-pressured masks," says Matsuoka. "We are a large teaching facility, so the testing requirement was a huge issue." Next, individual departments train nurses and provide the PAPR hoods. "I do it during the "sit-down" ED orientation day, when unit-specific issues are discussed," says Matsuoka.

In the ED, the PAPR hoods are kept in a four-drawer cart in a utility room across the hall from the isolation rooms. "The top drawer holds the flow cups and extra tubing assemblies, the second drawer holds extra hoods of both sizes, and the bottom two drawers are fitted for five PAPRs each with power charging units," she says.

It’s a mistake to assume that a mask will protect you from smallpox, says Sue C. Felt, RN, MS, MPH, CIC, associate hospital epidemiologist and infection control coordinator at San Francisco General Hospital. "All persons who were in the room or the vicinity of the patient should consider themselves exposed and get the vaccine," she says. "Public health should immediately arrange for this through the CDC." Felt says the importance of hand washing can’t be overemphasized. "Hand washing always reduces the risk of transferring illness," she says. "Though smallpox is spread via respiratory route, reminders about hand washing are always appropriate. It is the single most ignored infection control measure, everywhere."

Matsuoka advises limiting the time you spend in the isolation room. "Scrupulous hand washing, as with all body substance isolation practices, is warranted," she stresses.

Other types of personal protective equipment may not protect you from contracting smallpox, according to Felt. "I, myself, would wear an N95 mask — well placed and snug — and hope for the best," she says. "I would hope to get vaccinated within four days."


3M offers the Breathe Easy RRPAS (Rapid Response Powered Air System) and Butyl Rubber Hood (BE 10) PAPR for use when decontaminating patients. Cartridges are available for protection against many industrial chemicals and military agents. For more information, contact: 3M Occupational Health and Environmental Safety Division, 3M Center, Building 235-2E80, P.O. Box 33275, St. Paul, MN 55133-3275. Telephone: (800) 328-1667. Fax: (800) 542-9373 or (651) 736-0930. E-mail: Web:

Neoterik Health Technologies offers positive-air pressure respirators to protect first responders after accidents or terrorist events. The "First Responder" series includes the FR2 PAPR with full facepiece or the FR3PAPR with full hood. For more information, contact: Neoterik Health Technologies, 401 S. Main St., Woodsboro, MD 27198. Telephone: (301) 845-2777. Fax: (301) 845-2213. E-mail:

The University of Alabama at Birmingham Bioterrorism web site ( offers continuing education in Bioterrorism and Emerging Infectious Diseases. The site also contains information about smallpox. Click on "Emerging Infections and Potential Bioterrorist Agents," then under "Smallpox," click on "Summary" and/or "More Extensive Information."

The U.S. Army Medical Research Institute of Infectious Diseases offers a free download of its reference book, Medical Management of Biological Casualties Handbook, Fourth Edition, February 2001, at the following web address:

The UCLA Department of Epidemiology, School of Public Health has extensive resources on its web site ( Click on "Bioterrorism," and then "Smallpox."