Cover Story
Clarifying face mask misconceptions crucial as PPE hits mainstream
Before COVID-19, the acronym PPE was not known by most people. Industrial workers, first responders, and healthcare workers are familiar with Personal Protective Equipment (PPE) because they use it every day. However, on an ordinary day, using the PPE acronym in a conversation, usually required some sort of explanation:
“Well, you know, PPE are safety products that protect people when they’re working… like gloves, goggles, hard hats, and face masks.”
Because of COVID-19, you don’t have to explain PPE anymore. This novel coronavirus has catapulted the acronym into the mainstream vernacular, shop talk and watercooler banter.
During this pandemic, healthcare workers and others have been scrambling for two sought-after products in the PPE pandemic world: the N95 respirator and surgical face masks. According to a survey conducted by Premier, Inc.,1 a healthcare improvement company, “Hospitals ranked the supply of N95 respirators as their top concern. . . . In addition, the availability of PPE and burn rates for PPE products were the two most commonly cited ‘surprises’ of the pandemic.”
The mayhem and fear surrounding the shortage of these items created misinformation and myths. Below we will explore five protection myths about N95 respirators, surgical face masks, and face coverings.
Myth #1: The N95 respirator and a surgical face mask are basically the same thing, offering very similar protection.
They are not the same thing and provide different types of protection. Although they serve different purposes, on March 10, the CDC updated its recommendations and advised that face masks for clinical providers are an acceptable alternative2 when there is a shortage of N95 respirators. But it is important to understand the differences between the two.
The N95 Filtering Facepiece Respirator (FFR)
Although the N95 respirator is frequently called a mask, it is a Filtering Facepiece Respirator (FFR) designed to reduce inhalation exposure to particulate contaminants, which are microscopic particles of solid or liquid matter suspended in the air.
In the industrial work force, N95 respirators are commonly used to decrease exposure to wood dust, animal dander, mold, and pollen. During the COVID-19 pandemic, healthcare facilities have been using N95 respirators — when they can get their hands on them — in their infection control programs.
The N95 respirator is tight-fitting and creates a seal on the face, whereas a face mask has gaps on the sides where particles or infectious agents can enter. The fit of a N95 respirator is so important that use of one requires annual fit-testing to ensure the wearer receives the intended 95 percent filtering of particles with mass median diameter of 0.3 micrometers. However, OSHA has temporarily suspended3 the fit-test rule during COVID-19.
The N95 includes a specialized filter that captures at least 95 percent of the airborne particles that pass through it, but it is not resistant to oil. The N95 is evaluated, tested, and approved by NIOSH as per the requirements in 42 CFR Part 84.
The surgical N95 respirator (N95s)
There is a subset of the N95 respirator worn by healthcare workers to protect the patient and themselves from the transfer of body fluids, microorganisms, and particulate airborne matter. This subset is called the surgical N95 respirator (N95s). According to the CDC, a surgical N95 respirator “is a NIOSH-approved N95 respirator that has also been cleared by the FDA as a surgical mask.” The surgical N95 respirator is like a hybrid. It is a filtering facepiece respirator with the added benefit of splash-resistant face mask material on the outside.
According to OSHA, “respirators offer the best protection for workers who must work closely (either in contact with or within 6 feet) with people who have influenza‑like symptoms.” Therefore, they should be reserved for workers who work in occupations with high exposure to pandemic influenza or COVID-19.
Respirators are considered single-use PPE and should be discarded, placed in a plastic bag, and disposed of properly when:
- They become damaged or lose their shape
- They no longer form an effective seal to the face
- They become wet or visibly dirty
- Breathing becomes more difficult because the filter is clogged with particles
- They become contaminated with blood, nasal secretions, or patient body fluids
Approved reuse of N95 Respirators via Vaporized Hydrogen Peroxide sterilizers
Normally, the N95 respirator is considered a disposable, single use PPE item. However, on April 10th, the U.S. Food and Drug Administration announced the second emergency use authorization (EUA) to decontaminate compatible N95 or N95-equivalent respirators for reuse by health care workers in hospital settings. This EUA will support decontamination of approximately 750,000 N95 respirators per day in the U.S.
“This EUA is another game changer,” said FDA Commissioner Stephen M. Hahn, M.D. “It will allow hospitals to decontaminate compatible N95 respirators using vaporized hydrogen peroxide sterilizers that are readily available in approximately 2,000 U.S. hospitals. It’s another important step forward in helping to reduce shortages in critical N95 respirators, by allowing for these important devices, when decontaminated, to be reused by health care personnel on the front lines of the COVID-19 pandemic.”
The surgical, medical, or procedure mask (face masks)
Regulated under 21 CFR 878.4040, a surgical mask is often referred to as a “face mask.” It is primarily intended to protect against saliva and respiratory secretions.
Unlike the N95, a surgical mask does not form an adequate seal to the wearer’s face, so healthcare workers cannot rely upon it to protect against airborne infectious agents. Nor does it require an annual fit-test and seal-check that is usually typical of the N95 respirator.
A surgical mask is fluid resistant and provides a physical barrier to protect the user from large droplets or splashes of blood or body fluids. It does not block or filter small particle aerosols from coughs or sneezes. Not regulated for particulate filtration, it may be labeled as a surgical, isolation, dental, or medical procedure mask. It is cleared by the U.S. Food and Drug Administration.
Surgical masks should be discarded after one patient encounter according to medical facility rules and regulations.
The CDC has a helpful infographic4 that explains the differences between the N95 respirator and the surgical face mask. It makes a great handout for training.
Myth #2: N95 respirators with exhalation valves can be used when trying to maintain a sterile environment in an operating or procedure room.
N95 respirators can be purchased with or without exhalation valves. Exhalation valves are a critical component of industrial respirators. They are designed to permit minimal inward leakage of air contaminants during inhalation and provide low resistance during exhalation.
Despite the comfort benefits of an exhalation valve for industrial workers, N95 respirators with exhalation valves should not be used when trying to maintain a sterile environment in an operating room. Although the exhalation valve makes breathing easier, any bacteria or virus expelled from the user may travel through the exhalation valve and enter the operating room, compromising the sterile environment.
Myth #3: If a health care worker is properly wearing a surgical face mask, he or she is adequately protected from inhaling airborne infectious agents, including those from a patient who is exhaling, coughing, or sneezing.
This is not true of a surgical face mask. However, it is true of N95 respirators and surgical N95 respirators. The CDC says, “If properly fitted, the filtration capabilities of N95 respirators exceed those of face masks.”
Surgical face masks do not provide protection from small particles, like airborne infectious agents. However, they trap large particles of body fluids that may contain viruses or bacteria keeping contaminated larger droplets from reaching the nose and mouth. Remember, a surgical mask does not form an adequate seal to the wearer’s face, so it cannot be relied upon for complete protection.
Myth #4: It’s OK to touch the inside and outside of your mask or respirator when putting it on or taking it off.
Just like you should avoid touching your face to help prevent contamination, you should not touch the inside or outside of a face mask or N95 respirator. With clean, sanitized hands, you should always pick up or take off the mask by its straps, ear loops, or ties. Always wash your hands or use alcohol-based hand sanitizer before and after mask/ respirator removal and be conscious that the outside of the mask is a contamination zone.
For purchased masks or respirators, always follow product instructions on use, disposal, and storage (when applicable) and follow the procedures for mask donning and removal.
Myth #5: Wearing a face covering or cloth mask in public will protect the wearer from getting infected by others.
Unfortunately, this is not true. According to the CDC, textile (cloth) masks “are not PPE, and it is uncertain whether cloth face coverings protect the wearer.”
Made-at-home face coverings or cloth masks are not a preventative measure you can take to avoid getting a highly contagious virus like COVID-19. However, wearing a cloth mask in public, like at the grocery store, will help prevent the spread of the disease to others. COVID-19 doesn’t always present symptoms, so wearing masks in public is usually a healthy thing to do, but it shouldn’t give people a false sense of protection.
Lessons learned
Hopefully, America and the world will be back at work soon, rebuilding our economy and the livelihoods so profoundly affected by this tiny but destructive virus. Although we did not know much about this novel coronavirus in the beginning, we are much smarter now. May the lessons we learned during COVID-19 carry us forward to create a safer and healthier world. By all means, let’s remember the importance of PPE and take steps to ensure our supply chains and distribution centers are well positioned to protect those who protect us.
References
1. https://hitconsultant.net/2020/04/01/hospitals-covid-19-supply-n95-masks/#.XqMXbGhKiUk
4. https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf
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