American Journal of Infection Control 43 (2015) 1116-8
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Practices around the use of masks and respirators among hospital health care workers in 3 diverse populations Abrar Ahmad Chughtai MBBS, MPH, PhD a, *, C. Raina MacIntyre MBBS, FRACP, FAFPHM, M App Epid, PhD a, Muhammad Orooj Ashraf MBBS, MPH b, Yang Zheng MD c, Peng Yang MD c, Quanyi Wang MD, MPH c, Tham Chi Dung MD, MS, PhD d, Nguyen Tran Hien MD, MPH, PhD d, Holly Seale BSc, MPH, PhD a a
School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia National TB Control Program, Ministry of Health, Islamabad, Pakistan c The Beijing Center for Disease Prevention and Control, Beijing, China d National Institute of Hygiene and Epidemiology, Hanoi, Vietnam b
Key Words: Infectious diseases Influenza Pandemic influenza Avian influenza Tuberculosis
A cross-sectional survey was conducted in 89 secondary- and tertiary-level hospitals in 3 countries, and samples of masks and respirators were also collected and examined. Results showed varied practices around the use of masks and respirators, which are probably influenced by the available resources and local recommendations. Nonstandardized practices are common in low-resource settings, which may be placing health care workers at risk. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Masks and respirators are commonly recommended by health organizations to protect health care workers (HCWs) from acquiring healthcareeassociated infections.1,2 Although health agencies and governments may advocate for certain practices, in reality behaviors occurring in individual organizations may be very different. This study aimed to examine the clinical practices occurring in hospital departments from low- and middle-income countries around the use of masks and respirators.
* Address correspondence to Abrar Ahmad Chughtai, MBBS, MPH, PhD, Level 2, Samuels Building, School of Public Health & Community Medicine, UNSW Medicine, University of New South Wales, Sydney 2052, NSW, Australia. E-mail address: [email protected] (A.A. Chughtai). Conflicts of interest: Abrar Chughtai has had filtration testing of masks for his PhD thesis conducted by 3M Australia. 3M products were not used in his research. Professor C. Raina MacIntyre: Raina MacIntyre has held an Australian Research Council Linkage Grant with 3M as the industry partner, for investigator driven research. 3M have also contributed supplies of masks and respirators for investigator-driven clinical trials. She has received research grants and laboratory testing as in-kind support from Pfizer, GSK and Bio-CSL for investigator-driven research. Dr. Holly Seale had a NHMRC Australian based Public Health Training Fellowship at the time of the study (1012631). She has also received funding from vaccine manufacturers GSK, bio-CSL and Saniofi Pasteur for investigator-driven research and presentations. The remaining authors declare that they have no competing interests and have no non-financial interests that may be relevant to the submitted work.
METHODS A cross-sectional survey involving infection control coordinators was conducted among district- and tertiary caree level hospitals in Beijing, China (2 districts), Punjab, Pakistan (36 districts), and Hanoi, Vietnam (14 districts). Survey questions focused on policies and practices around mask and respirator use against influenza and tuberculosis (TB).1 Clean samples of mask and respirators were also collected and examined for design, size, material manufactured from, and number of layers. After the gross examination, 25 different types of masks and respirators were identified as being used across the 3 countries and tested for particle filtration efficiency.3 Ethics approval was obtained from the Human Research Ethics Advisory Panel of the University of New South Wales, Sydney, Australia (2013-7-02) and the ethics review committees in selected countries. RESULTS A total of 89 hospitals agreed to participate in the survey (Beijing: 19; Punjab: 55; Hanoi: 15). These hospitals represent 77% of the total district- and tertiary careelevel hospitals from the selected areas. Beijing hospitals reported that HCWs mostly use medical masks or
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.05.041
A.A. Chughtai et al. / American Journal of Infection Control 43 (2015) 1116-8
1117
Table 1 Types of mask or respirator used for influenza and tuberculosis in selected hospitals in 3 countries* Seasonal influenza Mask type Beijing (19 hospitals) Paper masks Cloth mask Medical mask Respirator Punjab (55 hospitals) Paper masks Cloth mask Medical mask Respirator Hanoi (15 hospitals) Paper masks Cloth mask Medical mask Respirator
Low risk
Pandemic influenza
High risk
Avian influenza
Tuberculosis
Low risk
High risk
Low risk
High risk
Low risk
High risk
1 5 15 3
(5.3) (26.3) (78.9) (15.8)
4 4 6 7
(21.1) (21.1) (31.6) (36.8)
2 2 12 3
(10.5) (10.5) (63.2) (15.8)
5 4 5 15
(26.3) (21.1) (26.3) (78.9)
6 7 0 0
(31.6) (36.8) (0.0) (0.0)
5 4 5 18
(26.3) (21.1) (26.3) (94.7)
1 2 9 8
(5.3) (10.5) (47.4) (42.1)
5 3 5 12
(26.3) (15.8) (26.3) (63.2)
0 5 6 0
(0.0) (9.1) (10.9) (0.0)
1 4 38 1
(1.8) (7.3) (69.1) (1.8)
0 1 5 0
(0.0) (1.8) (9.1) (0.0)
1 3 12 0
(1.8) (5.5) (21.8) (0.0)
0 2 5 0
(0.0) (3.6) (9.1) (0.0)
1 1 10 0
(1.8) (1.8) (18.2) (0.0)
1 8 8 0
(1.8) (14.5) (14.5) (0.0)
2 2 48 1
(3.6) (3.6) (87.3) (1.8)
11 9 9 8
(73.3) (60.0) (60.0) (53.3)
1 2 5 4
(6.7) (13.3) (33.3) (26.7)
6 5 4 8
(40.0) (33.3) (26.7) (53.3)
5 3 7 4
(33.3) (20.0) (46.7) (26.7)
7 4 5 8
(46.7) (26.7) (33.3) (53.3)
4 4 6 4
(26.7) (26.7) (40.0) (26.7)
7 4 5 8
(46.7) (26.7) (33.3) (53.3)
3 3 7 4
(20.0) (20.0) (46.7) (26.7)
NOTE. Values are n (%). *The total is >100% because most hospitals used >1 type of facemask.
Table 2 Examination of samples of masks and respirators collected from selected hospitals in 3 countries No. of layers Mask type Beijing (19 hospitals) Cloth mask Medical mask Respirator Punjab (55 hospitals) Cloth mask Medical mask Respirator Hanoi (15 hospitals) Cloth mask Medical mask Respirator
No. of samples collected 9 (12.5) 42 (58.3) 21 (29.2) 6 (2.7) 214 (96.4) 2 (0.9) 16 (21.3) 58 (77.3) 1 (1.4)
1
Shape
2
3
Flat
Cup
Penetration (%), median (range %)
2 (22.2) 0 (0) 0 (0)
7 (77.8) 42 (100) 21 (100)
5 (55.6) 42 (100) 0 (0)
4 (44.4) 0 (0) 21 (100)
85 (80-90) 7 (0.4-87) 1.5 (0.1-30)
6 (100) 0 (0) 0 (0)
0 (0) 87 (40.7) 0 (0)
0 (0) 127 (59.3) 2 (100)
6 (100) 214 (100) 0 (0)
0 (0) 0 (0) 2 (100)
66 (85-92) 87 (8.3-90) 0.1 (0.1-0.1)
0 (0) 0 (0) 0 (0)
15 (93.8) 6 (10.3) 0 (0)
1 (6.2) 52 (89.7) 1 (100)
14 (87.5) 58 (100) 0 (0)
2 (12.5) 0 (0) 1 (100)
66 (85-86) 37 (53-93) 0.3 (0.3-0.3)
0 (0) 0 (0) 0 (0)
NOTE. Values are n (%) or as otherwise indicated.
respirators to protect from influenza and TB. Generally, medical masks are used in low-risk situations, and respirators are used in high-risk situations. Medical masks were reported to be the most common type used in Punjab to protect from influenza and TB and are used mainly in high-risk situations. Different types of masks are used in Hanoi for influenza and TB, ranging from paper or cloth masks to medical masks and respirators (Table 1). Certified respirators are used in 11 Vietnamese hospitals but only 5 hospitals in Punjab. Seven Beijing hospitals reported using certified respirators. Not all sites reported providing training (14/19 in Beijing, 3/55 in Punjab, and 13/15 in Hanoi) or fit testing (4/19 in Beijing, 3/55 in Punjab, and 8/15 in Hanoi) to staff members about respirator use. Medical evaluation for HCWs was reported to occur in only 10 hospitals from the 3 countries. Masks and respirators are used for varying lengths of time in each of the 3 sites surveyed. Extended use (by the same wearer for >1 shift or day) and reuse (by the same or different wearer after decontamination) were also reported to be common practices. Of the hospitals in Hanoi, 40% faced shortages of masks in the previous year compared with only 11% in Beijing and Punjab. Participants reported that it is not uncommon for staff to purchase their own masks during periods of shortages. In addition, hospitals give priority to staff in high-risk areas, such as those who have frequent contact with patients in the examination rooms of the infectious disease department. We collected 369 samples of masks and respirators from the 3 countries (Table 2). The products were of varying size, number of
layers (2 or 3 layers), and shape (flat fold and cup shape). Overall penetration of particles through the cloth masks (median, 85.5%; range, 80%-92%) and medical masks (median, 53%; range, 0.493%) was very high compared with N95 respirators (median, 0.6%; range, 0.1%-30%). The penetration of particles was low with the certified respirators (median, 0.3%; range, 0.1%-0.7%) and higher for the noncertified respirators (median, 3%; range, 0.1%-30%). DISCUSSION We identified that various practices currently exist around the use and reuse of masks and respirators in low- and middle-income settings. Practices not only vary between the 3 countries examined, but they also vary within the districts. The data suggest that hospitals generally do not follow national policies and guidelines regarding the types of masks and respirators that should be used.1 Varying practices around the use of masks and respirators at the facility level might be caused by conflicting guidance from the World Health Organization and Centers for Disease Control and Prevention1,2 and the availability of the certain type of masks and respirators in the hospitals.4 Although respirators are reported to be more protective than medical masks,2 few hospitals in this study reported using respirators; and among those that did, registered adherence with comprehensive respiratory protection programs (ie, regulations, medical evaluation, training, fit testing) appeared to be low.5
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A.A. Chughtai et al. / American Journal of Infection Control 43 (2015) 1116-8
Because of the shortage of supplies during outbreaks and pandemic, it is perhaps not surprising that HCWs are resorting to unproven practices around mask use, such as the use of paper (a type of medical masks with a single layer) and cloth masks and double-masking, extended use, and applying various decontamination methods to extend the life of the masks or respirators.4 Paper and cloth masks are commonly used in low-resource countries4,6; however, there are a lack of data around their efficacy.2 Extended use and reuse of masks and respirators are not recommended because of the risk of self-contamination and infection. Hospital managers need to weigh the benefits against the risks and to prefer extended use over reuse in cases that it is deemed essential.7 N95 respirators may be used over multiple shifts in the event of shortages, only if the product is not visibly soiled or damaged.8 Decontamination of medical masks and N95 respirators is usually not recommended because their material is degraded with standard decontamination methods.9 For HCWs who are reusing their cloth masks over the course of the shift or attempting to decontaminate the cloth masks for use the next day, the occupational risk from influenza and other pathogens may be heightened. As expected, the penetration of particles was highest through the cloth masks samples, followed by the medical masks. Previous studies on the filtration efficiency reported penetration values ranging from 0%-99% for medical masks (median, 40%) and 95%99.5% for respirators.10 We were surprised by the variability in the penetration levels among the respirators received, which may be caused by a lack of regulation for respirator use in these countries. CONCLUSION To ensure proper use of masks and respirators in the health care setting, policies and guidelines should be clear and uniform across
the institutions. We recommend that standardization of policies and guidelines based on existing evidence and the situation in lowresources countries should be considered while developing those recommendations. Further research should be conducted around the reuse of masks and respirators, and efficacy of cloth masks should also be examined. References 1. Chughtai AA, Seale H, MacIntyre CR. Availability, consistency and evidencebase of policies and guidelines on the use of mask and respirator to protect hospital health care workers: a global analysis. BMC Res Notes 2013;6:216. 2. MacIntyre CR, Chughtai AA. Facemasks for the prevention of infection in healthcare and community settings. BMJ 2015;350:h694. 3. Standards Australia Limited/Standards New Zealand. Respiratory protective devices. AS/NZS 1716. Australia: Australian/New Zealand Standard, SAI Global Limited; 2012. 4. Chughtai AA, Seale H, Chi Dung T, Maher L, Nga PT, MacIntyre CR. Current practices and barriers to the use of facemasks and respirators among hospitalbased health care workers in Vietnam. Am J Infect Control 2015;43:72-7. 5. Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. Respiratory protection. OSHA 3079; 2002. Available from: https://www. osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=12716. Accessed March 9, 2015. 6. The Ministry of Health Vietnam. Diagnosis, treatment and prevention of infectious influenza A (H1N1) guidelines, IN Decision No. 2762/QD-BYT July 31, 2009 by the Minister of Health (Ed.). Ministry of Health Hanoi. 2009. 7. Centers for Disease Control and Prevention. Questions and answers regarding respiratory protection for preventing 2009 H1N1 influenza among healthcare personnel. 2014. Available from: http://www.cdc.gov/h1n1flu/guidelines_ infection_control_qa.htm#ex_use. Accessed August 19, 2014. 8. National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention. Respirator fact sheet. Available from: http://www.cdc. gov/niosh/npptl/topics/respirators/factsheets/respsars.html. Accessed February 15, 2014. 9. Institute of Medicine (IOM), National Academy of Sciences. Reusability of facemasks during an influenza pandemic: facing the flu. Washington, DC: The National Academies Press (NAP); 2006. 10. Gralton J, McLaws ML. Protecting healthcare workers from pandemic influenza: N95 or surgical masks? Crit Care Med 2010;38:657-67.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Practices around the use of masks and respirators among hospital health care workers in 3 diverse populations Abrar Ahmad Chughtai MBBS, MPH, PhD a, *, C. Raina MacIntyre MBBS, FRACP, FAFPHM, M App Epid, PhD a, Muhammad Orooj Ashraf MBBS, MPH b, Yang Zheng MD c, Peng Yang MD c, Quanyi Wang MD, MPH c, Tham Chi Dung MD, MS, PhD d, Nguyen Tran Hien MD, MPH, PhD d, Holly Seale BSc, MPH, PhD a a
School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, Sydney, NSW, Australia National TB Control Program, Ministry of Health, Islamabad, Pakistan c The Beijing Center for Disease Prevention and Control, Beijing, China d National Institute of Hygiene and Epidemiology, Hanoi, Vietnam b
Key Words: Infectious diseases Influenza Pandemic influenza Avian influenza Tuberculosis
A cross-sectional survey was conducted in 89 secondary- and tertiary-level hospitals in 3 countries, and samples of masks and respirators were also collected and examined. Results showed varied practices around the use of masks and respirators, which are probably influenced by the available resources and local recommendations. Nonstandardized practices are common in low-resource settings, which may be placing health care workers at risk. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Masks and respirators are commonly recommended by health organizations to protect health care workers (HCWs) from acquiring healthcareeassociated infections.1,2 Although health agencies and governments may advocate for certain practices, in reality behaviors occurring in individual organizations may be very different. This study aimed to examine the clinical practices occurring in hospital departments from low- and middle-income countries around the use of masks and respirators.
* Address correspondence to Abrar Ahmad Chughtai, MBBS, MPH, PhD, Level 2, Samuels Building, School of Public Health & Community Medicine, UNSW Medicine, University of New South Wales, Sydney 2052, NSW, Australia. E-mail address: [email protected] (A.A. Chughtai). Conflicts of interest: Abrar Chughtai has had filtration testing of masks for his PhD thesis conducted by 3M Australia. 3M products were not used in his research. Professor C. Raina MacIntyre: Raina MacIntyre has held an Australian Research Council Linkage Grant with 3M as the industry partner, for investigator driven research. 3M have also contributed supplies of masks and respirators for investigator-driven clinical trials. She has received research grants and laboratory testing as in-kind support from Pfizer, GSK and Bio-CSL for investigator-driven research. Dr. Holly Seale had a NHMRC Australian based Public Health Training Fellowship at the time of the study (1012631). She has also received funding from vaccine manufacturers GSK, bio-CSL and Saniofi Pasteur for investigator-driven research and presentations. The remaining authors declare that they have no competing interests and have no non-financial interests that may be relevant to the submitted work.
METHODS A cross-sectional survey involving infection control coordinators was conducted among district- and tertiary caree level hospitals in Beijing, China (2 districts), Punjab, Pakistan (36 districts), and Hanoi, Vietnam (14 districts). Survey questions focused on policies and practices around mask and respirator use against influenza and tuberculosis (TB).1 Clean samples of mask and respirators were also collected and examined for design, size, material manufactured from, and number of layers. After the gross examination, 25 different types of masks and respirators were identified as being used across the 3 countries and tested for particle filtration efficiency.3 Ethics approval was obtained from the Human Research Ethics Advisory Panel of the University of New South Wales, Sydney, Australia (2013-7-02) and the ethics review committees in selected countries. RESULTS A total of 89 hospitals agreed to participate in the survey (Beijing: 19; Punjab: 55; Hanoi: 15). These hospitals represent 77% of the total district- and tertiary careelevel hospitals from the selected areas. Beijing hospitals reported that HCWs mostly use medical masks or
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.05.041
A.A. Chughtai et al. / American Journal of Infection Control 43 (2015) 1116-8
1117
Table 1 Types of mask or respirator used for influenza and tuberculosis in selected hospitals in 3 countries* Seasonal influenza Mask type Beijing (19 hospitals) Paper masks Cloth mask Medical mask Respirator Punjab (55 hospitals) Paper masks Cloth mask Medical mask Respirator Hanoi (15 hospitals) Paper masks Cloth mask Medical mask Respirator
Low risk
Pandemic influenza
High risk
Avian influenza
Tuberculosis
Low risk
High risk
Low risk
High risk
Low risk
High risk
1 5 15 3
(5.3) (26.3) (78.9) (15.8)
4 4 6 7
(21.1) (21.1) (31.6) (36.8)
2 2 12 3
(10.5) (10.5) (63.2) (15.8)
5 4 5 15
(26.3) (21.1) (26.3) (78.9)
6 7 0 0
(31.6) (36.8) (0.0) (0.0)
5 4 5 18
(26.3) (21.1) (26.3) (94.7)
1 2 9 8
(5.3) (10.5) (47.4) (42.1)
5 3 5 12
(26.3) (15.8) (26.3) (63.2)
0 5 6 0
(0.0) (9.1) (10.9) (0.0)
1 4 38 1
(1.8) (7.3) (69.1) (1.8)
0 1 5 0
(0.0) (1.8) (9.1) (0.0)
1 3 12 0
(1.8) (5.5) (21.8) (0.0)
0 2 5 0
(0.0) (3.6) (9.1) (0.0)
1 1 10 0
(1.8) (1.8) (18.2) (0.0)
1 8 8 0
(1.8) (14.5) (14.5) (0.0)
2 2 48 1
(3.6) (3.6) (87.3) (1.8)
11 9 9 8
(73.3) (60.0) (60.0) (53.3)
1 2 5 4
(6.7) (13.3) (33.3) (26.7)
6 5 4 8
(40.0) (33.3) (26.7) (53.3)
5 3 7 4
(33.3) (20.0) (46.7) (26.7)
7 4 5 8
(46.7) (26.7) (33.3) (53.3)
4 4 6 4
(26.7) (26.7) (40.0) (26.7)
7 4 5 8
(46.7) (26.7) (33.3) (53.3)
3 3 7 4
(20.0) (20.0) (46.7) (26.7)
NOTE. Values are n (%). *The total is >100% because most hospitals used >1 type of facemask.
Table 2 Examination of samples of masks and respirators collected from selected hospitals in 3 countries No. of layers Mask type Beijing (19 hospitals) Cloth mask Medical mask Respirator Punjab (55 hospitals) Cloth mask Medical mask Respirator Hanoi (15 hospitals) Cloth mask Medical mask Respirator
No. of samples collected 9 (12.5) 42 (58.3) 21 (29.2) 6 (2.7) 214 (96.4) 2 (0.9) 16 (21.3) 58 (77.3) 1 (1.4)
1
Shape
2
3
Flat
Cup
Penetration (%), median (range %)
2 (22.2) 0 (0) 0 (0)
7 (77.8) 42 (100) 21 (100)
5 (55.6) 42 (100) 0 (0)
4 (44.4) 0 (0) 21 (100)
85 (80-90) 7 (0.4-87) 1.5 (0.1-30)
6 (100) 0 (0) 0 (0)
0 (0) 87 (40.7) 0 (0)
0 (0) 127 (59.3) 2 (100)
6 (100) 214 (100) 0 (0)
0 (0) 0 (0) 2 (100)
66 (85-92) 87 (8.3-90) 0.1 (0.1-0.1)
0 (0) 0 (0) 0 (0)
15 (93.8) 6 (10.3) 0 (0)
1 (6.2) 52 (89.7) 1 (100)
14 (87.5) 58 (100) 0 (0)
2 (12.5) 0 (0) 1 (100)
66 (85-86) 37 (53-93) 0.3 (0.3-0.3)
0 (0) 0 (0) 0 (0)
NOTE. Values are n (%) or as otherwise indicated.
respirators to protect from influenza and TB. Generally, medical masks are used in low-risk situations, and respirators are used in high-risk situations. Medical masks were reported to be the most common type used in Punjab to protect from influenza and TB and are used mainly in high-risk situations. Different types of masks are used in Hanoi for influenza and TB, ranging from paper or cloth masks to medical masks and respirators (Table 1). Certified respirators are used in 11 Vietnamese hospitals but only 5 hospitals in Punjab. Seven Beijing hospitals reported using certified respirators. Not all sites reported providing training (14/19 in Beijing, 3/55 in Punjab, and 13/15 in Hanoi) or fit testing (4/19 in Beijing, 3/55 in Punjab, and 8/15 in Hanoi) to staff members about respirator use. Medical evaluation for HCWs was reported to occur in only 10 hospitals from the 3 countries. Masks and respirators are used for varying lengths of time in each of the 3 sites surveyed. Extended use (by the same wearer for >1 shift or day) and reuse (by the same or different wearer after decontamination) were also reported to be common practices. Of the hospitals in Hanoi, 40% faced shortages of masks in the previous year compared with only 11% in Beijing and Punjab. Participants reported that it is not uncommon for staff to purchase their own masks during periods of shortages. In addition, hospitals give priority to staff in high-risk areas, such as those who have frequent contact with patients in the examination rooms of the infectious disease department. We collected 369 samples of masks and respirators from the 3 countries (Table 2). The products were of varying size, number of
layers (2 or 3 layers), and shape (flat fold and cup shape). Overall penetration of particles through the cloth masks (median, 85.5%; range, 80%-92%) and medical masks (median, 53%; range, 0.493%) was very high compared with N95 respirators (median, 0.6%; range, 0.1%-30%). The penetration of particles was low with the certified respirators (median, 0.3%; range, 0.1%-0.7%) and higher for the noncertified respirators (median, 3%; range, 0.1%-30%). DISCUSSION We identified that various practices currently exist around the use and reuse of masks and respirators in low- and middle-income settings. Practices not only vary between the 3 countries examined, but they also vary within the districts. The data suggest that hospitals generally do not follow national policies and guidelines regarding the types of masks and respirators that should be used.1 Varying practices around the use of masks and respirators at the facility level might be caused by conflicting guidance from the World Health Organization and Centers for Disease Control and Prevention1,2 and the availability of the certain type of masks and respirators in the hospitals.4 Although respirators are reported to be more protective than medical masks,2 few hospitals in this study reported using respirators; and among those that did, registered adherence with comprehensive respiratory protection programs (ie, regulations, medical evaluation, training, fit testing) appeared to be low.5
1118
A.A. Chughtai et al. / American Journal of Infection Control 43 (2015) 1116-8
Because of the shortage of supplies during outbreaks and pandemic, it is perhaps not surprising that HCWs are resorting to unproven practices around mask use, such as the use of paper (a type of medical masks with a single layer) and cloth masks and double-masking, extended use, and applying various decontamination methods to extend the life of the masks or respirators.4 Paper and cloth masks are commonly used in low-resource countries4,6; however, there are a lack of data around their efficacy.2 Extended use and reuse of masks and respirators are not recommended because of the risk of self-contamination and infection. Hospital managers need to weigh the benefits against the risks and to prefer extended use over reuse in cases that it is deemed essential.7 N95 respirators may be used over multiple shifts in the event of shortages, only if the product is not visibly soiled or damaged.8 Decontamination of medical masks and N95 respirators is usually not recommended because their material is degraded with standard decontamination methods.9 For HCWs who are reusing their cloth masks over the course of the shift or attempting to decontaminate the cloth masks for use the next day, the occupational risk from influenza and other pathogens may be heightened. As expected, the penetration of particles was highest through the cloth masks samples, followed by the medical masks. Previous studies on the filtration efficiency reported penetration values ranging from 0%-99% for medical masks (median, 40%) and 95%99.5% for respirators.10 We were surprised by the variability in the penetration levels among the respirators received, which may be caused by a lack of regulation for respirator use in these countries. CONCLUSION To ensure proper use of masks and respirators in the health care setting, policies and guidelines should be clear and uniform across
the institutions. We recommend that standardization of policies and guidelines based on existing evidence and the situation in lowresources countries should be considered while developing those recommendations. Further research should be conducted around the reuse of masks and respirators, and efficacy of cloth masks should also be examined. References 1. Chughtai AA, Seale H, MacIntyre CR. Availability, consistency and evidencebase of policies and guidelines on the use of mask and respirator to protect hospital health care workers: a global analysis. BMC Res Notes 2013;6:216. 2. MacIntyre CR, Chughtai AA. Facemasks for the prevention of infection in healthcare and community settings. BMJ 2015;350:h694. 3. Standards Australia Limited/Standards New Zealand. Respiratory protective devices. AS/NZS 1716. Australia: Australian/New Zealand Standard, SAI Global Limited; 2012. 4. Chughtai AA, Seale H, Chi Dung T, Maher L, Nga PT, MacIntyre CR. Current practices and barriers to the use of facemasks and respirators among hospitalbased health care workers in Vietnam. Am J Infect Control 2015;43:72-7. 5. Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. Respiratory protection. OSHA 3079; 2002. Available from: https://www. osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=12716. Accessed March 9, 2015. 6. The Ministry of Health Vietnam. Diagnosis, treatment and prevention of infectious influenza A (H1N1) guidelines, IN Decision No. 2762/QD-BYT July 31, 2009 by the Minister of Health (Ed.). Ministry of Health Hanoi. 2009. 7. Centers for Disease Control and Prevention. Questions and answers regarding respiratory protection for preventing 2009 H1N1 influenza among healthcare personnel. 2014. Available from: http://www.cdc.gov/h1n1flu/guidelines_ infection_control_qa.htm#ex_use. Accessed August 19, 2014. 8. National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention. Respirator fact sheet. Available from: http://www.cdc. gov/niosh/npptl/topics/respirators/factsheets/respsars.html. Accessed February 15, 2014. 9. Institute of Medicine (IOM), National Academy of Sciences. Reusability of facemasks during an influenza pandemic: facing the flu. Washington, DC: The National Academies Press (NAP); 2006. 10. Gralton J, McLaws ML. Protecting healthcare workers from pandemic influenza: N95 or surgical masks? Crit Care Med 2010;38:657-67.
