A close shave? Performance of P2/N95 respirators in healthcare workers with facial hair: results of the BEARDS (BEnchmarking Adequate Respiratory DefenceS) study

Prospective comprehensive evaluation of an elastic-band beard cover for filtering facepiece respirators in healthcare workers

OBJECTIVE

To undertake a healthcare-based multimodal evaluation of the combination of filtering facepiece respirator (FFR) with the elastic-band beard cover technique, including quantitative fit test (QNFT) results, skills assessment, and usability assessment.

DESIGN AND SETTING

We conducted a prospective study through the Respiratory Protection Program at the Royal Melbourne Hospital from May 2022 to January 2023.

PARTICIPANTS

Healthcare workers who required respiratory protection and could not shave for religious, cultural, or medical reasons.

INTERVENTION

Online education and personal face-to-face training on the use of FFR with the elastic-band beard cover technique.

RESULTS

Among 87 participants (median beard length 38 mm; interquartile range [IQR], 20-80), 86 (99%) passed 3 QNFTs consecutively with the elastic-band beard cover under a Trident P2 respirator and 68 (78%) passed 3 QNFTs consecutively with a 3M 1870+ Aura respirator. The first QNFT pass rate and the overall fit factors were significantly higher when using the technique than without the elastic-band beard cover. Most participants displayed a high skill level in their donning, doffing, and user seal-check techniques. Of 87 participants, 83 (95%) completed the usability assessment. The overall ease of use, comfort, and overall assessment were rated highly.

CONCLUSIONS

The elastic-band beard cover technique can provide safe and effective respiratory protection for bearded healthcare workers. The technique was easily taught, comfortable, well tolerated and accepted by healthcare workers, potentially allowing them full participation in the workforce during pandemics with airborne transmission. We recommend further research and evaluation of this technique in a broader health workforce.

A systematic review of passing fit testing of the masks and respirators used during the COVID-19 pandemic: Part 1-quantitative fit test procedures

BACKGROUND

During respiratory infection pandemics, masks and respirators are highly sought after, especially for frontline healthcare workers and patients carrying respiratory viruses. The objective of this study was to systematically review fit test pass rates and identify factors influencing the fitting characteristics.

METHODS

Potentially relevant studies were identified using PubMed, Scopus, Web of Science, and Science Direct during the COVID-19 pandemic from February 5, 2020, to March 21, 2023. The search strategy using the following keywords was conducted: Quantitative Fit Test, Condensation Nuclei Counter, Controlled Negative Pressure, PortaCount, Sibata, Accufit, Fit, Seal, Mask, Respirator, Respiratory Protective Device, Respiratory Protective Equipment, Protective Device, Personal Protective Equipment, COVID-19, Coronavirus, and SARS-CoV-2. The quality of the included studies was also assessed using the Newcastle-Ottawa scale.

RESULTS

A total of 137 articles met the eligibility criteria. Fifty articles had a quality score of less than 7 (good quality). A total of 21 studies had a fit test pass rate of less than 50%. 26 studies on disposable respirators and 11 studies on reusable respirators had an FF of less than 50 and less than 200, respectively. The most influential factors include respirator brand/model, style, gender, ethnicity, facial dimensions, facial hair, age, reuse, extensive movement, seal check, comfort and usability assessment, and training.

CONCLUSION

37.36% of the disposable respirator studies and 43% of the reusable respirator studies did not report fit test results. 67.86% of the disposable respirator studies had a fit test pass rate greater than 50%, and 35.84% of these studies had an FF greater than 100. Also, 85.71% of the reusable respirator studies had a fit test pass rate greater than 50%, and 52.77% of these studies had an FF greater than 1000. Overall, the fit test pass rate was relatively acceptable. Newly developed or modified respirators must undergo reliable testing to ensure the protection of HCWs. Subject and respirator characteristics should be considered when implementing fit testing protocols. An optimal fit test panel should be developed prior to respirator design, certification, procurement decisions, and selection procedures.

Overview of tight fit and infection prevention benefits of respirators (filtering face pieces)

Regulations for measures to protect against SARS-CoV-2 transmission vary widely around the world, with very strict regulations in Germany where respirators (filtering face piece FFP2 or comparable) are often mandatory. The efficiency of respirators, however, depends essentially on the tight facial fit avoiding the bypass of contaminated air via gaps between mask and wearer's face. The facial fit can be verified in a fit test. The aim of this review was to describe the quantitative fit test results depending on the respirator designs. A literature search revealed 29 suitable studies. Of all respirators with circumferential head straps, three-panel folded dome-shaped respirators showed the best fit (80.8% of 4625 fit tests passed), followed by rigid-dome-shaped respirators (72.4% of 8234 fit tests passed), duckbill-shaped respirators (31.6% of 2120 fit tests passed), and coffee-filter-shaped respirators (30.9% of 3392 fit tests passed). Respirators with ear loops showed very poor tight fit (3.6% of 222 fit tests passed). In four randomized control trials, single-use respirators were not shown to be superior to surgical masks for the prevention of laboratory-confirmed viral respiratory infections, even when adjusted with a fit test. Therefore, we consider the mandatory use of respirators to be disproportionate and not supported by evidence. Further evidence should be generated, in which scenarios respirators might provide an effective benefit as part of occupational health and safety. For situations with confirmed benefits, only high-quality disposable respirators with head straps or respiratory protective equipment of higher protective levels should be used.

Qualitative fit test outcomes for N95 filtering facepiece respirators in health care workers

BACKGROUND

We analyzed the qualitative fit test results of the filtering facepiece respirators (FFRs) used at our institution to determine their performance and utility.

METHODS

We retrospectively analyzed 12,582 qualitative fit testing results for several FFR models among 8,809 health care workers (HCWs).

RESULTS

The overall failure rate for HCWs was 15.2%. Nearly one-third (2933/8809, 33.3%) had multiple FFRs fit tested. HCW sex was a statistically significant indicator of fit testing failure (χ² = 29.9, df = 1, P < .001), with women having a 44% higher likelihood (OR, 1.4; 95% CI: 1.27-1.65) than men. There were statistically significant differences in the failure rate across FFRs (Fig 4, F[5, 12475] = 8.4, P < .001). Fluidshield 46867S had a significantly higher failure rate (49%) than the 3M 1860 (P = .012), 3M 1860S (P < .001), 3M 8210 (P < .001), and Safelife (P < .001) FFRs.

CONCLUSIONS

There was a large degree of variation in fit testing results for the FFRs tested. Although we were unable to find an FFR that fit more than 95% of the HCWs successfully, we identified poorly functioning FFRs that can help our institution with decision-making and budgeting for acquisition and stocking appropriate FFRs.

A Review of Filtration Performance of Protective Masks

Masks are essential and effective small protective devices used to protect the general public against infections such as COVID-19. However, available systematic reviews and summaries on the filtration performance of masks are lacking. Therefore, in order to investigate the filtration performance of masks, filtration mechanisms, mask characteristics, and the relationships between influencing factors and protective performance were first analyzed through mask evaluations. The summary of filtration mechanisms and mask characteristics provides readers with a clear and easy-to-understand theoretical cognition. Then, a detailed analysis of influencing factors and the relationships between the influencing factors and filtration performance is presented in. The influence of the aerosol size and type on filtration performance is nonlinear and nonconstant, and filtration efficiency decreases with an increase in the gas flow rate; moreover, fitness plays a decisive role in the protective effects of masks. It is recommended that the public should wear surgical masks to prevent COVID-19 infection in low-risk and non-densely populated areas. Future research should focus on fitness tests, and the formulation of standards should also be accelerated. This paper provides a systematic review that will be helpful for the design of masks and public health in the future.

Shaving Waivers in the United States Air Force and Their Impact on Promotions of Black/African-American Members

INTRODUCTION

Regulations of the United States Air Force (USAF) prohibit male members from growing beards. Shaving waivers can be issued to airmen who are not able to shave due to various medical conditions such as pseudofolliculitis barbae, a condition that predominantly affects Blacks/African-Americans. Beard growth has been anecdotally associated with a negative impact on career progression. This study sought to establish if shaving waivers are associated with delays in promotion and, if present, if this association leads to racial bias.

MATERIALS AND METHODS

An online survey that collected information relating to shaving waivers and demographic data was emailed to all air force male members at 12 randomly selected air force bases. Generalized linear models were conducted to test the waiver group difference in promotion time controlling for rank and the covariates of race/ethnicity, level of education, professional military education completion, and disciplinary action.

RESULTS

A total of 51,703 survey invitations were emailed to members, and 10,383 complete responses were received (20.08% response rate). The demographics of the study cohort closely matched that of the USAF. Shaving waivers were associated with a longer time to promotion (P = .0003). The interaction between race and waiver status was not significant, indicating that shaving waivers are associated with a similarly longer time to promotion in individuals of all races. However, 64.18% of those in the waiver group were Black/African-American despite only being 12.85% of the study cohort.

CONCLUSIONS

This study found an association between shaving waivers and delayed promotions. The majority of the waiver group was Black/African-American, which may lead to a racially discriminatory effect of the male grooming standards of the USAF.

Protocol of a prospective comprehensive evaluation of an elastic band beard cover for filtering facepiece respirators in healthcare

Individuals who are unable to be clean shaven for religious, medical or cultural reasons are unable to wear a filtering facepiece respirator (FFR), as the respirator cannot provide adequate protection against aerosol-transmissible diseases. There is currently a paucity of validated techniques to ensure the safe inclusion of bearded healthcare workers in the pandemic workforce. We propose to undertake a healthcare-based multi-modal evaluation study on the elastic band beard cover for FFR technique, examining the quantitative fit test (QNFT) results, usability and skill level of participants with repeated assessments over time. This is a prospective study conducted through the Respiratory Protection Program at the Royal Melbourne Hospital. Healthcare workers are invited to participate if they require respiratory protection and cannot shave for religious, cultural or medical reasons. An online education package on the use of respiratory protective equipment and the elastic band beard cover for FFR technique is provided. This is followed by a face-to-face session, where the participant will receive: one-on-one training; undergo a skill assessment on their donning, doffing and user seal check techniques; complete QNFTs and a usability survey. Participants will be invited to repeat the assessment within 3 months of the first session and at 12 months. This study involves multimodal and repeated assessments of an elastic band beard cover for FFRs. The findings of this study will provide information on: whether this simple technique can provide safe, consistent and effective respiratory protection; whether it will interfere with occupational activities; and whether it is comfortable and tolerable for the duration of wear. This is of significant importance to the health workforce around the world, who cannot shave but require access to respiratory protective equipment during the COVID-19 pandemic.

A Close Shave: Balancing Religious Tolerance and Patient Care in the Age of COVID-19

In this essay we discuss an ethical dilemma that recently arose in our institution, involving healthcare workers who lamented the requirement to shave their facial hair as a condition to care for COVID-19 patients. The essay represents a genuine attempt to grapple with the dilemma sensibly and vigorously. We first provide a brief introduction, focusing on the tension between religious tolerance and the institutional obligation to optimize patient care and public health in the age of COVID-19. We then discuss the complex relationship between facial hair and cultural as well as religious factors throughout history. Next, we make a case, based on several principles in Islam jurisprudence, that Muslim healthcare professionals in our institution should be expected to shave their facial hair so they could care for COVID patients. We end with considering two alternative solutions that were offered in the literature.

Does the fit of personal protective equipment affect functional performance? A systematic review across occupational domains

OBJECTIVE

To explore the effect of personal protective equipment (PPE) fit on functional performance across a range of occupational domains.

BACKGROUND

PPE introduces an ergonomic, human systems integration, and mass burden to the wearer, and these factors are thought to be amplified if PPE is ill-fitting. However, few studies have considered the role of fit (static, dynamic, and cognitive) when evaluating PPE-related performance detriments in occupational settings.

METHOD

A systematic literature review was conducted to identify relevant studies, which were then critically appraised based on methodological quality and collated to compare key findings and present evidence-based recommendations for future research directions across a range of occupational domains.

RESULTS

16 published studies met the inclusion criteria, 88% of which found that the fit of PPE had a statistically significant effect on occupational performance. Poorly sized PPE resulted in slower or increased reaction time; decreased range of motion or mobility; decreased endurance or tolerance; decreased pulmonary function; and altered muscle activation. Limited research met the inclusion criteria and those that did had risks of bias in methodology quality.

CONCLUSION

Future research evaluating the effect of PPE on performance in occupational settings should aim to recruit a more representative population; consider sex as a covariate; quantify and evaluate PPE fit and performance when integrated with all relevant equipment items; include outcome measures related to all three categories of fit (static, dynamic, cognitive); and assess performance of operationally relevant tasks.

The sex and gender dimensions of COVID-19: A narrative review of the potential underlying factors

Multiple lines of evidence indicate that the male sex is a significant risk factor for severe disease and mortality due to coronavirus disease 2019 (COVID-19). However, the precise explanation for the discrepancy is currently unclear. Immunologically, the female-biased protection against COVID-19 could presumably be due to a more rapid and robust immune response to viruses exhibited by males. The female hormones, e.g., estrogens and progesterone, may have protective roles against viral infections. In contrast, male hormones, e.g., testosterone, can act oppositely. Besides, the expression of the ACE-2 receptor in the lung and airway lining, which the SARS-CoV-2 uses to enter cells, is more pronounced in males. Estrogen potentially plays a role in downregulating the expression of ACE-2, which could be a plausible biological explanation for the reduced severity of COVID-19 in females. Comorbidities, e.g., cardiovascular diseases, diabetes, and kidney disorders, are considered significant risk factors for severe outcomes in COVID-19. Age-adjusted data shows that males are statistically more predisposed to these morbidities-amplifying risks for males with COVID-19. In addition, many sociocultural factors and gender-constructed behavior of men and women impact exposure to infections and outcomes. In many parts of the world, women are more likely to abide by health regulations, e.g., mask-wearing and handwashing, than men. In contrast, men, in general, are more involved with high-risk behaviors, e.g., smoking and alcohol consumption, and high-risk jobs that require admixing with people, which increases their risk of exposure to the infection. Overall, males and females suffer differently from COVID-19 due to a complex interplay between many biological and sociocultural factors.

P2/N95 filtering facepiece respirators: Results of a large-scale quantitative mask fit testing program in Australian health care workers

Background

In response to the COVID-19 pandemic, 6,287 Australian health care workers (HCWs) were fit tested to N95 filtering facepiece respirators (FFRs). This study determined how readily HCWs were fitted to 8 FFRs and how age and sex influenced testing.

Methods

HCWs were fit tested following the quantitative OSHA protocol. After bivariate analysis, a logistic regression model assessed the effect of FFR model, HCW age and sex on fit test results.

Results

Of 4,198 female and 2,089 male HCWs tested, 93.3% were successfully fitted. Fifty-five percent passed the first FFR, 21% required 2 and 23% required testing on 3 or more models. Males were 15% less likely to pass compared to females (P < .001). Individuals aged 18-29 were significantly more likely to pass compared to colleagues aged 30-59. Cup-style 3M 1860S was the most suitable model (95% CI: 1.94, 2.54) while the duckbill BSN TN01-11 was most likely to fail (95% CI: 0.11, 0.15).

Conclusions

Current N95 FFRs exhibit suboptimal fit such that a large proportion (45%) of HCWs require testing on multiple models. Older age and male sex were associated with significantly higher fit failure rates. QNFT programs should consider HCW characteristics like sex, age, racial and facial anthropometric measurements to improve the protection of the health workforce.

Respiratory protection preparedness in critical care healthcare workers: An observational audit of facial hair at a major tertiary hospital in Australia

BACKGROUND

Facial hair under a tight fitting P2/N95 respirator diminishes respiratory protection. There is limited guidance with respect to the threshold to be clean shaven in readiness to wear N95 respirators.

METHODS

We performed a cross sectional audit in late August 2021 to observe whether staff had facial hair that could decrease respiratory protection of tight fitting respirators. The audit was conducted in three critical care areas at a major tertiary public hospital in Australia during a period of moderate-to-high community prevalence of COVID-19. All staff observed had previously successfully completed quantitative fit testing with a clean shaven face in the preceding 12 months.

RESULTS

110 consecutive male critical care staff were observed including thirty staff who were required to wear a N95/P2 respirator at the time. Forty - five percent of male staff observed were not clean shaven in the face seal zone of their respirators.

CONCLUSIONS

The readiness to wear a tight-fitting respirator and hence the need to be clean shaven, should be guided by both state and local COVID-19 risk ratings, as well as the specific respiratory biohazard risks present in the clinical area at that time. During periods of significant community transmission of COVID-19, critical care clinical staff should be clean shaven, so they are fit-for-purpose and ready to wear a tight fitting respirator at short notice. Respiratory protection preparedness in critical care healthcare workers: An observational audit of facial hair at a major tertiary hospital in Australia.

Assessing the effect of beard hair lengths on face masks used as personal protective equipment during the COVID-19 pandemic

BACKGROUND

Globally, a large percentage of men keep a beard at least occasionally. Workplace regulations prohibit beards with N95 respirators, but there is little information on the effect of beards with face masks worn by the public for protection against SARS-CoV-2.

METHODS AND FINDINGS

We examined the fitted filtration efficiency (FFE) of five commonly worn protective face masks as a function of beard length following the US Occupational Safety and Health Administration Quantitative Fit Test: N95 (respirator), KF94 and KN95, surgical/procedure, and cloth masks. A comparison using N95 respirators was carried out in shaven and bearded men. A detailed examination was conducted for beard lengths between 0 and 10 mm (0.5 mm increments). The effect of an exercise band covering the beard on FFE was also tested. Although N95 respirators showed considerable variability among bearded men, they had the highest FFE for beard lengths up to 10 mm. KF94 and KN95 masks lost up to 40% of their FFE. Procedure and cotton masks had poor performance even on bare skin (10-30% FFE) that did not change appreciably with beard length. Marked performance improvements were observed with an exercise band worn over the beard.

CONCLUSIONS

Though variable, N95 respirators offer the best respiratory protection for bearded men. While KF94 and KN95 FFE is compromised considerably by increasing beard length, they proved better options than procedure and cotton face masks. A simple exercise band improves FFE for face masks commonly used by bearded men during the COVID-19 pandemic.

Facial Hair Decreases Fit Factor of Masks and Respirators in Healthcare Providers

In response to the current state of the COVID-19 pandemic, healthcare providers are using common surgical masks and filtering respirators in conjunction with the presence of facial hair, which could lead to a large number of particles passing into their respiratory system. The purpose of this study was to determine the fit factor effectiveness of filtering respirators and surgical masks in bearded versus non-bearded healthcare providers. A controlled randomized clinical trial (NCT04391010) was carried out, analyzing a sample of 63 healthcare providers. The fit factors of surgical masks and FFP3 filtering respirators for healthcare providers with (n = 32) and without (n = 31) facial hair were compared. Fit factors were measured during an exercises protocol in which healthcare providers wore surgical masks and FFP3 filtering respirators. Surgical mask fit factor comparisons did not show significant differences (p > 0.05) between healthcare providers with and without facial hair. In contrast, filtering respirator fit factor comparisons showed statistically significant differences (p < 0.01) between both groups, indicating that healthcare providers with facial hair showed lower fit factor scores, which implies a worse fit factor with respect to healthcare providers without facial hair. The fit factor effectiveness of filtering respirators was reduced in healthcare providers with facial hair. The authors of this paper encourage healthcare providers to trim their beards during filtering respirator use or wear full-mask filtering facepiece respirators, especially during the COVID-19 pandemic.

Powered air-purifying respirators used during the SARS-CoV-2 pandemic significantly reduce speech perception

BACKGROUND

Due to the coronavirus disease 2019 (COVID-19) pandemic, interventions in the upper airways are considered high-risk procedures for otolaryngologists and their colleagues. The purpose of this study was to evaluate limitations in hearing and communication when using a powered air-purifying respirator (PAPR) system to protect against severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) transmission and to assess the benefit of a headset.

METHODS

Acoustic properties of the PAPR system were measured using a head and torso simulator. Audiological tests (tone audiometry, Freiburg speech test, Oldenburg sentence test (OLSA)) were performed in normal-hearing subjects (n = 10) to assess hearing with PAPR. The audiological test setup also included simulation of conditions in which the target speaker used either a PAPR, a filtering face piece (FFP) 3 respirator, or a surgical face mask.

RESULTS

Audiological measurements revealed that sound insulation by the PAPR headtop and noise, generated by the blower-assisted respiratory protection system, resulted in significantly deteriorated hearing thresholds (4.0 ± 7.2 dB hearing level (HL) vs. 49.2 ± 11.0 dB HL, p < 0.001) and speech recognition scores in quiet (100.0 ± 0.0% vs. 2.5 ± 4.2%, p < 0.001; OLSA: 20.8 ± 1.8 dB vs. 61.0 ± 3.3 dB SPL, p < 0.001) when compared to hearing without PAPR. Hearing with PAPR was significantly improved when the subjects were equipped with an in-ear headset (p < 0.001). Sound attenuation by FFP3 respirators and surgical face masks had no clinically relevant impact on speech perception.

CONCLUSIONS

The PAPR system evaluated here can be considered for high-risk procedures in SARS-CoV-2-positive patients, provided that hearing and communication of the surgical team are optimized by the additional use of a headset.

Your Hair or Your Service: An Issue of Faith for Sikh Healthcare Professionals During the COVID-19 Pandemic

Sikh healthcare professionals make up a small but significant proportion of the workforce in the United Kingdom. The COVID-19 pandemic has presented healthcare staff across the country with challenges relating to safe clinical practice whilst wearing personal protective equipment (PPE). Practising Sikhs are mandated to keep their hair unshorn and have been negatively impacted by some standard PPE requirements. This article aims to raise awareness of this issue and provide suggestions on how this conflict can be resolved.

Hair today, gone tomorrow: How personal protective equipment guidance changed doctor's facial hair during the COVID-19 pandemic

OBJECTIVES

To investigate how personal protective equipment (PPE) guidance altered the facial hair of hospital doctors and explore the wider impact and implications of these changes.

METHODS

A single site uncontrolled before-after survey study examining change in facial hairstyles, and wider implications on doctor's cultural, religious, and personal wellbeing. Outcome measures included change in facial hair between January and April 2020 and whether these changes adhered to guidance set by Public Health England. Participants were also asked about the wider impact of these changes which were thematically analyzed using an inductive approach.

RESULTS

Of those who completed the survey, 257 participants met the inclusion criteria. 68% (n = 67) of doctors who could grow facial hair changed their facial hairstyle during the COVID-19 pandemic and 96% (n = 64) reported that the change was in response to PPE guidance. The odds of having a facial hairstyle that complied with PPE guidance before the pandemic was 0.32, which rose to 2.77 after guidance was released, giving an odds ratio of 8.54 (95% CI 4.49-16.23, P < .001). When compared to those who sported a shaven face prepandemic, the odds ratio of a change in style for those with prepandemic full beards was 37.92 (95% CI 7.45-192.8, P < .001), for goatees was 7.22 (95% CI 1.076-48.47, P = .04), for moustaches was 4.33 (95% CI 0.207-90.85, P = .345), and for stubble was 9.06 (95% CI 2.133-38.49, P = .003). Qualitative analysis revealed multiple themes, including skin irritation, loss of identity, and a significant impact on participants required to maintain a beard due to religious or cultural reasons.

CONCLUSIONS

Facial hairstyles have changed significantly at our hospital during the COVID-19 pandemic. Facial hair can impact upon doctors' cultural, religious, and personal wellbeing and these factors need to be considered with policy and provision of PPE.

Quantitative fit testing of filtering face-piece respirators during the COVID-19 pandemic reveals anthropometric deficits in most respirators available in Iran

PURPOSE

Frontline health care workers (HCWs) must wear a standard N95 or FFP2 respirator during worldwide pandemics of respiratory diseases including COVID-19 to protect against airborne infectious pathogens when performing care activities. This study aimed to quantitatively investigate the fit of most of the common FFRs used during the COVID-19 pandemic in Iran.

METHODS

A total of 37 volunteers were fit tested in 20 selected FFRs in a randomized order. The selected FFRs were underwent quantitative fit testing by PortaCount® model 8038. To determine the effects of face sizes on respirator fit, the participants' facial dimensions were measured using a digital caliper.

RESULTS

The rate of passing fit tests for the studied FFRs were surprisingly low with 11 out of 20 FFRs having less than 10% passing fit tests and the best performers having only 43% and 27% passing fit tests (brands 2 and 20, respectively). Cup-shaped respirators provided significantly greater fit than the vertical flat-fold ones (p < 0.001). A significantly different FFs were found among the respirator brands (F = 13.60, p < 0.001).

CONCLUSION

Overall, unacceptably low fit factors were obtained from the studied FFRs. The main reasons for this are suspected to single size and style for each studied FFR. It confirms the importance and requirement of the proper respirator selection in that way fitted optimally into facial dimensions, appropriate usage, and properly performing the fit testing procedure. A unique fit test panel should be developed to guide respirator wearers in selecting the appropriate FFR for their specific face sizes.

Fit factor compliance of masks and FFP3 respirators in nurses: A case-control gender study

Aims

To determine the fit factor and compliance with American Industrial Hygiene Association (AIHA) and Occupational Safety and Health Administration (OSHA) requirements of surgical masks and filtering respirators in male versus female nurses.

Design

A case–control gender study performed from 2016 to 2019.

Methods

A gender and age matched‐paired sample of 74 nurses was recruited and divided into men (n = 37) and women (n = 37). FFP3 filtering respirators and surgical masks fit factors were compared between male and female nurses by Mann–Whitney U tests. These measurements were tested to pass or fail according to the OSHA (≥100) and AIHA (≥50) criteria by Fisher exact tests for a 95% confidence interval.

Results

Global fit factor mean (standard deviation) was 2.86 (2.73) and 3.55 (6.34) for male and female nurses wearing surgical masks (p = .180), respectively, and nobody passed neither OSHA nor AIHA criteria (p = 1.00). Nevertheless, global fit factor were 30.82 (28.42) and 49.65 (43.04) for male and female nurses wearing FFP3 respirators, respectively, being significantly lower and worse in male nurses (p = .037). According to OSHA criteria, only 2.70% and 13.51% of male and females nurses, respectively, passed with non‐significant difference (p = .199), meanwhile 21.62% and 48.64% of male and female nurses, respectively, passed AIHA criteria showing significant differences (p = .027) wearing FFP3 respirators.

Conclusions

All male and female nurses wearing surgical masks failed to pass OSHA and AIHA criteria. Global fit factor of the proposed FFP3 filtering respirators was decreased and worse in male than female nurses.

Impact

Our recommendation is to avoid surgical masks use for protective purposes and use the proposed FFP3 filtering respirators among nurses. Each nurse should be fit tested for its own respirator with special caution in male nurses due to their lower fit factor achieved and most of them failed to pass OSHA and AIHA criteria, especially during COVID‐19 pandemic.

The critical importance of mask seals on respirator performance: An analytical and simulation approach

Filtering facepiece respirators (FFRs) and medical masks are widely used to reduce the inhalation exposure of airborne particulates and biohazardous aerosols. Their protective capacity largely depends on the fraction of these that are filtered from the incoming air volume. While the performance and physics of different filter materials have been the topic of intensive study, less well understood are the effects of mask sealing. To address this, we introduce an approach to calculate the influence of face-seal leakage on filtration ratio and fit factor based on an analytical model and a finite element method (FEM) model, both of which take into account time-dependent human respiration velocities. Using these, we calculate the filtration ratio and fit factor for a range of ventilation resistance values relevant to filter materials, 500-2500 Pa∙s∙m-1, where the filtration ratio and fit factor are calculated as a function of the mask gap dimensions, with good agreement between analytical and numerical models. The results show that the filtration ratio and fit factor are decrease markedly with even small increases in gap area. We also calculate particle filtration rates for N95 FFRs with various ventilation resistances and two commercial FFRs exemplars. Taken together, this work underscores the critical importance of forming a tight seal around the face as a factor in mask performance, where our straightforward analytical model can be readily applied to obtain estimates of mask performance.

Performance and impact of disposable and reusable respirators for healthcare workers during pandemic respiratory disease: a rapid evidence review

OBJECTIVES

To synthesise evidence concerning the range of filtering respirators suitable for patient care and guide the selection and use of different respirator types.

DESIGN

Comparative analysis of international standards for respirators and rapid review of their performance and impact in healthcare.

DATA SOURCES

Websites of international standards organisations, Medline and Embase, hand-searching of references and citations.

STUDY SELECTION

Studies of healthcare workers (including students) using disposable or reusable respirators with a range of designs. We examined respirator performance, clinician adherence and performance, comfort and impact, and perceptions of use.

RESULTS

We included standards from eight authorities across Europe, North and South America, Asia and Australasia and 39 research studies. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators.

CONCLUSION

A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to care.

Management of environmental health to prevent an outbreak of COVID-19

The World Health Organization (WHO) has recently pronounced severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a serious pandemic. It is, therefore, mandatory for public health authorities to have an environmental health management plan against COVID-19. This chapter summarizes articles and official reports related to environmental health management and prevention policies against COVID-19. Because medical sectors require comprehensive guidelines to follow in such pandemic situations, this chapter highlights the significant factors of COVID-19 transmission in our environment (e.g., air), waste management for COVID-19, and protection and disinfection policies against COVID-19. At present, scientists are still discovering more about COVID-19 and its effect on the environment and the health sector. As such, further research is required to increase knowledge about the structural and pathogenic features of COVID-19 and to find effective treatments to dominate this epidemic.

Comparative effectiveness of N95 respirators and surgical/face masks in preventing airborne infections in the era of SARS-CoV2 pandemic: A meta-analysis of randomized trials

Background

Recently, several randomized controlled trials (RCTs) have evaluated the effect of N95 respirators compared with medical masks to protect against acute respiratory infections. However, these studies are limited by modest sample sizes and inconclusive results. Therefore, the goal of the present study was to review the relevant and available published RCTs with the aid of the increased power of meta-analytic methods in order to assess the effectiveness of medical masks and N95 respirators in reducing the risk of respiratory infections.

Methods

This meta-analysis follows the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for conducting and reporting results. We searched PubMed, Web of Science, Embase, and Cochrane databases from inception through April 1, 2020 to identify potentially relevant studies. Two authors (LS and JS) independently searched the titles and abstracts of the potentially eligible articles. They independently retrieved required data from the eligible trials; the data were initially tabulated for statistical analysis. Two authors (JRL and LS) independently assessed the methodological quality of the included RCTs using the Cochrane Collaboration’s tool for assessing risk of bias.

Results

Six articles met the inclusion criteria. The pooled analysis showed that N95 respirators did not reduce the risk of infection with respiratory viruses compared with medical/surgical masks (5.7% vs. 7.9%; RR = 1.12; 95% CI: 0.88–1.41; p = 0.36); however, there was no statistically significant difference in laboratory-confirmed influenza between N95 and medical masks (RR = 0.91; 95% CI: 0.77–1.07; p = 0.26). Medical masks provided similar protection against other viruses, including coronavirus (RR = 0.74; 95% CI: 0.32–1.73; p = 0.49). Respiratory illness, as well as influenza-like illness were less frequently observed with N95 respirators.

Conclusions

Our meta-analysis suggests that there are insufficient data to definitively determine whether N95 respirators are superior to medical masks in protection against transmissible acute respiratory infections. Further randomized trials are necessary to compare the above methods of respiratory protection in the context of COVID-19 incidence.

Evaluation of the performance of replaceable particulate and powered air-purifying respirators considering non-recommended wearing methods

This study evaluated the performance of two respirators, a replaceable particulate respirator (RPR) and a powered air-purifying respirator (PAPR), worn according to non-recommended methods. Ten subjects wore either an RPR or PAPR according to the recommended method, or according to a non-recommended method, with a knit cover placed between the facepiece cushion and face, with a towel placed between the facepiece cushion and face, or with the headband on a helmet. The leakage rate of each wearing variation was then measured, according to the procedure for determining the protection factor of respiratory protective equipment, using atmospheric dust as required by JIS T8150. The average leakage rate for the RPR was 1.82-10.92%, whereas that of the PAPR was 0.18-0.42%. The performance of the RPR decreased when worn in methods outside of recommendations; however, there was no significant decrease in the performance of PAPR under any method of wear. Therefore, a PAPR is recommended for work in which a replaceable or disposable particulate respirator fails to provide sufficient protection against hazardous dust substances, or for workers who are unable to use a particulate respirator according to the recommended method owing to the work environment or health conditions.

Measurement of filtration efficiencies of healthcare and consumer materials using modified respirator fit tester setup

During the current SARS-CoV-2 pandemic there is unprecedented demand for personal protective equipment (PPE), especially N95 respirators and surgical masks. The ability of SARS-CoV-2 to be transmitted via respiratory droplets from asymptomatic individuals has necessitated increased usage of both N95 respirators in the healthcare setting and masks (both surgical and homemade) in public spaces. These precautions rely on two fundamental principles of transmission prevention: particle filtration and droplet containment. The former is the focus of NIOSH N95 testing guidelines, and the latter is an FDA guideline for respirators and surgical masks. While studies have investigated droplet containment to provide guidance for homemade mask production, limited work has been done to characterize the filtration efficiency (FE) of materials used in home mask making. In this work, we demonstrate the low-cost (<$300) conversion of standard equipment used to fit-test respirators in hospital and industrial settings into a setup that measures quantitative FEs of materials based on NIOSH N95 guidelines, and subsequently measure FEs of materials found in healthcare and consumer spaces. These materials demonstrate significant variability in filtration characteristics, even for visually similar materials. We demonstrate a FE of 96.49% and pressure drop of 25.4 mmH20 for a double-layer of sterilization wrap used in surgical suites and a FE of 90.37% for a combination of consumer-grade materials. The excellent filtration characteristics of the former demonstrate potential utility for emergent situations when N95 respirators are not available, while those of the latter demonstrate that a high FE can be achieved using publicly available materials.

Under-mask beard cover (Singh Thattha technique) for donning respirator masks in COVID-19 patient care

Tight-fitting filtering facepiece (FFP3) face masks are essential respiratory protective equipment during aerosol-generating procedures in the coronavirus disease 2019 (COVID-19) environment, and require a fit test to assess mask–face seal competency. Facial hair is considered to be an impediment for achieving a competent seal. We describe an under-mask beard cover called the Singh Thattha technique, which obtained a pass rate of 25/27 (92.6%) by qualitative and 5/5 (100%) by quantitative fit test in full-bearded individuals. Sturdier versions of FFP3 were more effective. For individuals for whom shaving is not possible, the Singh Thattha technique could offer an effective solution to safely don respirator masks.

The Importance of Proper Use of N95 Respirators by Health-Care Workers

The novel coronavirus causing the COVID-19 pandemic is spread by respiratory transmission through droplets and contact. The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend the use of personal protective equipment (PPE) including a gown, gloves, and a surgical mask or N95 respirator plus a face shield and/or goggles for health-care workers who are in direct contact with COVID-19 patients. A study in China by Wang found that health-care workers on the front line of disease treatment had inadequate training in the use of PPE, particularly for respiratory infectious diseases. Instruction in the proper use of N95 respirators, with an emphasis on performing user seal checks, as well as donning and doffing, is recommended for everyone caring for COVID-19 patients.

Transmission of COVID-19 virus by droplets and aerosols: A critical review on the unresolved dichotomy

The practice of social distancing and wearing masks has been popular worldwide in combating the contraction of COVID-19. Undeniably, although such practices help control the COVID-19 pandemic to a greater extent, the complete control of virus-laden droplet and aerosol transmission by such practices is poorly understood. This review paper intends to outline the literature concerning the transmission of virus-laden droplets and aerosols in different environmental settings and demonstrates the behavior of droplets and aerosols resulted from a cough-jet of an infected person in various confined spaces. The case studies that have come out in different countries have, with prima facie evidence, manifested that the airborne transmission plays a profound role in contracting susceptible hosts. The infection propensities in confined spaces (airplane, passenger car, and healthcare center) by the transmission of droplets and aerosols under varying ventilation conditions were discussed. Interestingly, the nosocomial transmission by airborne SARS-CoV-2 virus-laden aerosols in healthcare facilities may be plausible. Hence, clearly defined, science-based administrative, clinical, and physical measures are of paramount importance to eradicate the COVID-19 pandemic from the world.

Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis

OBJECTIVE

Previous meta-analyses concluded that there was insufficient evidence to determine the effect of N95 respirators. We aimed to assess the effectiveness of N95 respirators versus surgical masks for prevention of influenza by collecting randomized controlled trials (RCTs).

METHODS

We searched PubMed, EMbase and The Cochrane Library from the inception to January 27, 2020 to identify relevant systematic reviews. The RCTs included in systematic reviews were identified. Then we searched the latest published RCTs from the above three databases and searched ClinicalTrials.gov for unpublished RCTs. Two reviewers independently extracted the data and assessed risk of bias. Meta-analyses were conducted to calculate pooled estimates by using RevMan 5.3 software.

RESULTS

A total of six RCTs involving 9 171 participants were included. There were no statistically significant differences in preventing laboratory-confirmed influenza (RR = 1.09, 95% CI 0.92-1.28, P > .05), laboratory-confirmed respiratory viral infections (RR = 0.89, 95% CI 0.70-1.11), laboratory-confirmed respiratory infection (RR = 0.74, 95% CI 0.42-1.29) and influenzalike illness (RR = 0.61, 95% CI 0.33-1.14) using N95 respirators and surgical masks. Meta-analysis indicated a protective effect of N95 respirators against laboratory-confirmed bacterial colonization (RR = 0.58, 95% CI 0.43-0.78).

CONCLUSION

The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza. It suggests that N95 respirators should not be recommended for general public and nonhigh-risk medical staff those are not in close contact with influenza patients or suspected patients.

COVID-19 and endoscopy services in intermediately affected countries: a position statement from the saudi gastroenterology association

With the global pandemic due to coronavirus disease 2019 (COVID-19), there has been a significant strain on healthcare facilities. The infectivity rate, as well as the rate of healthcare workers who have fallen ill to the disease, has raised concerns globally on the proper management of patients as well as the role of safe healthcare provision utilizing personal protective equipment (PPE). Furthermore, the limited supply of PPEs has mandated rationing their use to achieve maximum utility and preservation. Multiple gastroenterology associations have issued guidance and statements that would help healthcare providers in navigating these unprecedented and difficult times, and the Saudi Gastroenterology Association has provided this statement in an effort to bring the most up to date information for the management of endoscopy units in terms of resources, manpower planning, scheduling, as well as infection control policies and leadership.

COVID-19 and orthopaedic surgeons: the Indian scenario

The emergence of COVID-19 has impacted orthopaedic surgery worldwide. India, with its large population and limited health resources, will be overwrought over the coming days due to the number of cases of critically ill patients with COVID-19. It is important to understand the challenges for orthopaedic (and other) surgeons in India when dealing with patients during the COVID-19 pandemic. This article highlights the challenges in the triaging of patients, care in dealing with a patient with COVID-19 in orthopaedic surgery, and the effects on academics and research activities; it also suggests immediate measures and recommendations that also apply to other specialties.

Insights into the Recent 2019 Novel Coronavirus (SARS-CoV-2) in Light of Past Human Coronavirus Outbreaks

Coronaviruses (CoVs) are RNA viruses that have become a major public health concern since the Severe Acute Respiratory Syndrome-CoV (SARS-CoV) outbreak in 2002. The continuous evolution of coronaviruses was further highlighted with the emergence of the Middle East Respiratory Syndrome-CoV (MERS-CoV) outbreak in 2012. Currently, the world is concerned about the 2019 novel CoV (SARS-CoV-2) that was initially identified in the city of Wuhan, China in December 2019. Patients presented with severe viral pneumonia and respiratory illness. The number of cases has been mounting since then. As of late February 2020, tens of thousands of cases and several thousand deaths have been reported in China alone, in addition to thousands of cases in other countries. Although the fatality rate of SARS-CoV-2 is currently lower than SARS-CoV, the virus seems to be highly contagious based on the number of infected cases to date. In this review, we discuss structure, genome organization, entry of CoVs into target cells, and provide insights into past and present outbreaks. The future of human CoV outbreaks will not only depend on how the viruses will evolve, but will also depend on how we develop efficient prevention and treatment strategies to deal with this continuous threat.