March 24th 2020
While the economic toll of COVID-19 hits worldwide and people face joblessness, a common narrative poses public health disease control and the economy as competing choices. We cannot wish away this pandemic and remain in denial. Without concerted disease control efforts, the epidemic will be larger, economic toll will be far greater and recovery will take much longer. Central to disease control is our health workforce at the frontline and their protection by masks, respirators and other Personal Protective Equipment (PPE). A quick overview of the different types of masks and respirators and what protection they provide can be found here.
As scientists and researchers, we can assess the information the available to us, and we can advise the government policy makers and clinicians on the best way to tackle problems we hoped we’d never have to confront.
I am seeing the plight of colleagues and friends in Australian hospitals. As an expert on Personal Protective Equipment (PPE), I am getting daily emails from distraught health workers around the world, who are forced to work without PPE or with inadequate PPE. In Italy, a doctor died after being forced to treat COVID 19 patients without gloves. In the US, hospitals are closing due to lack of PPE, and there are calls for the community to sew cloth masks for health workers, who are resorting to home-made PPE. Governments plan and stockpile for pandemics, in order to meet demand for surge capacity in the health system during pandemics. Stockpiles include medicines, vaccines and PPE, needed by patients and health workers fighting the pandemic at the front line. It seems many countries failed to stockpile even a tiny fraction of what was required for a pandemic. In research published in 2019, we showed that for Sydney alone, an epidemic lasting 6 months would require 30 million respirators to be stockpiled for clinical health workers. For reasons that need to be carefully analysed after the emergency has passed, when the bushfires hit in December 2019, we had less than 3 million masks in the national stockpile. Stockpiled masks were used for protection against bushfire smoke, and then distributed to GPs early in the pandemic. There is very little left for hospital workers, with more supplies due to arrive in late April. All of this while the epidemic surges, with no evidence of any impact on flattening the curve.
Doctors who are unable to get PPE contact me after finding my research publications, because I have published the largest body of clinical research on face masks and respirators. I am hearing anecdotal reports from doctors in hospitals in Australia who work on the wards that they are already forced to see coughing patients without a mask at all, and that they are desperately searching online to buy what they can. Some tell me that masks are only made available for staff in ICU or emergency, and they are looking to buy their own. Yet most online vendors do not have disposable masks or respirators available, or are charging exorbitant prices. On a chat group of doctors, people are sending me pictures of what they have managed to buy from hardware store Bunnings. Others are making plans to protect their families. One couple who are both doctors made a decision that the wife would give up her private practice to stay home to take care of their children, while the husband braced for his work as a specialist in a Sydney hospital, where he is unable to get a mask for his clinical work.
The health system is preparing for a tsunami to hit. Doctors and nurses working in other speciality areas are preparing to be deployed to treat COVID-19 patients. This is the true face of the epidemic and these are the people we will rely on when we get sick.
There is a small, but growing group of us who believe, despite our best hopes, that we are on same trajectory as the US and Italy, failing to learn the lessons we see unfolding daily in those countries, and feel overwhelming despair at the human toll this will take. In the US, the public is being asked to sew masks for hospitals, and health workers are making their own masks from office supplies. When the epidemic began, the US CDC recommended respirators for health workers treating COVID 19 patients. As the epidemic hit the US and catastrophic PPE shortages unfolded, they downgraded their recommendations to surgical masks. Who would have imagined we would then see the US CDC saying bandanas can substitute for a mask as a last resort.
Recommendations for healthcare workers who cannot access appropriate PPE
Do not work without PPE or with inadequate PPE.
When desperate health workers are looking for answers, they look up the research evidence, and the only RCT of cloth masks that has been published is one I led. It showed that health workers who used cloth masks had higher rates of infection than surgical masks or a control “no mask” group, and appear unsafe.
The question health workers are asking me is “(do) you still believe that health care workers are safer not wearing a face mask compared to wearing a cloth face mask?” My research did not account for this question, as it assumed HCWs would have a choice between different kinds of masks. However the current situation we find ourselves in requires an answer. The most important point is that the paper does not say “do not wear a mask” - the message was that hospitals and governments should plan and stockpile proper disposable products such as surgical masks instead of cloth masks, to protect their workers.
We cannot ask health workers to work anywhere in a hospital or health system during a pandemic without a mask or PPE – that is a breach of work health and safety obligations. Not only is it a life or death matter, it will also affect our ability to continue treating patients, if half our workforce is infected with COVID-19 due to a lack of appropriate protection and some are dead. And it is unethical to force HCW to work without PPE. Should HCW decide to work in inadequate PPE, see 2-4 below.
Any physical barrier over the nose and mouth should give some protection, but may not protect as well as a respirator.
Here is the answer I gave a US doctor today: “If there is nothing else, OF COURSE you should use whatever (mask) you can get or make your own. The physical barrier may afford some protection.” However, HCWs should not have a false sense of confidence that a home-made mask will protect as well as a N95 respirator, and guidelines should not convey a false sense of security about makeshift PPE. Experts advise that T-shirt material is not suitable for making a mask and can be easily penetrated by viruses. Cloth masks are not as good as a surgical mask. Layered fabric may be a better choice, but again, we lack evidence. There are many different DIY cloth masks guides available, but no evidence to support one method over another. General principles: the material should be hydrophobic, should have 2 layers at least; should be designed to provide good fit around the face (use of elastic for example). Some studies suggest cotton is a poor choice, but others suggest it is good. This might be related to the weave and number of layers. Some designs can also have a pouch for placing a disposable filter, which seem to be more available than disposable masks.
Cloth masks rated poorly in our study, but perhaps this was because people did not wash the cloth masks well enough, or that the particular fabric was poor quality. Importantly, we we do not have data on this, except that HCWs reported self-washing the masks almost on a daily basis. In addition, some people in the control arm used disposable surgical masks - which may be why the cloth arm looked worse. If using a cloth mask, have several and wash and dry them daily. A hot wash with soap in the washing machine should do. Cloth masks can be hung in the sun to dry, as UV light is germicidal. Ultimately, however, a cloth mask is not suitable protection for a health worker.
Seek methods to clean, sterilise and extend use of PPE
If cloth masks are all you can get or make, I suggest that people choosing to use cloth masks have at least 2 and cycle them, so that each one can be washed and dried after daily use. Sanitizer spray or UV light disinfection boxes can be used to clean them during breaks in a single day. Importantly, this advice is driven by informed common-sense, not research.
To help galvanise creative thinking, JAMA put out a call for novel PPE solutions, which has some useful suggestions such as use of plastic bottles to make face shields. Protocols for cleaning is attached below. Duke university has a cleaning protocol with hydrogen peroxide vapour and UV light. The University of Nebraska protocol is attached at the bottom of the page. However, recent research shows that infectious SASR-CoV-2 virus can persist on the outer surface of a disposable mask for 7 days. So beware of re-using single use products. Note that decontamination of disposable respirators is not an approved practice by NIOSH or OSHA, which set the standards for respiratory protection. A consortium of decontamination of N95s also provides guidance. A summary of evidence for cleaning methods and re-use/extended use can be found here.
Procure your own PPE
If your hospital cannot provide you PPE, procure your own. I have checked online, and most disposable products are out of stock, but a range of re-usable masks, including industrial respirators are available online. Look for products that have certified respirator status. The benefit of re-usable products is they can be cleaned according to the manufacturer’s instructions, although some have a disposable filter cartridge. Procure your own gloves, gowns, hoods, coveralls and whatever you can get, because shortages will worsen as the pandemic grows. Procure your own UV light steriliser and other disinfecting and cleaning products.
What else can we do?
As well as scaling up procurement or production of PPE, we should be actively looking at re-use strategies for disposable masks which will need stringent guidelines, cleaning methods for re-usable masks and mobilising all industrial supplies of respirators. Manufacturers do not recommend disinfection and re-use of disposable products (guidance attached). The medical research community should mobilise and donate their PPE to clinical health workers. Today I gave my stock of 40 respirators, 80 gowns, 3 eye shields and a box of gloves (used for an influenza research study) to frontline clinicians in need.
We should also look at design and planning solutions to reduce exposure to virus for health workers. Ultraviolet light should be used to reduce aerosolised and surface viral load in high transmission settings such as ICU. Modifying any spatial design elements of wards which could improve ventilation should also be considered. Rostering to expose as few health workers as possible to infection should also be reviewed. We could have an active plan to mobilise recovered COVID-19 patients, both skilled and unskilled, to help with the hospital surge capacity (including working as porters, attendants and other roles) and public health contact tracing capacity.
We should also ensure we put the occupational health and safety of our precious health workers at the top of the priority list. It's heartening to see the creative thinking of Australian manufacturers and the Australian Defence Force rising to the task of solving such problems. When we return to the world we knew before COVID-19 we need to realistically reassess our strategies for stockpiling and our domestic capacity to manufacture PPE for health workers.
Selected research publications on masks and PPE from our research group
Randomised clinical trials
- MacIntyre CR, Chughtai AA, Rahman B, Peng Y, Zhang Y, Seale H, et al. The efficacy of medical masks and respirators against respiratory infection in health workers. Influenza and Other Respiratory Viruses, 11 Aug 2017. doi:10.1111/irv.12474
- *MacIntyre CR, Zhang Y, Chughtai AA, Seale H, Zhang D, Chu Y, Zhang H, Rahman B, Wang Q. Cluster randomised controlled trial to examine medical mask use as source control for people with respiratory illness. BMJ Open 2016;6:e012330.
- *MacIntyre CR, Seale H, Dung TC, Nguyen Tran Hien NT, Nga PT, Chughtai AA, Rahman B, Dwyer DE, Wang Q. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015;5:e006577 doi:10.1136/bmjopen-2014-006577 0.1093/annhyg/mew008.
- *MacIntyre CR, Wang Q, Seale H, Peng Y, Shi W, Gao Z, Rahman B, Zhang Y, Wang X, Newall AT, Heywood A, Dwyer D. A randomised clinical trial of three options for N95 respirators and medical masks in health workers. American Journal of Respiratory and Critical Care Medicine 2013; 187(9): 960-966.
- MacIntyre CR, Wang Q, Cauchemez S, Seale H, Dwyer D E, Yang P, Shi W, Gao Z, Pang X, Zhang Y, Wang X, Duan W, Rahman B, Ferguson N. A cluster randomized clinical trial comparing fit tested and non-fit tested N95 respirators to medical masks to prevent respiratory virus infection in healthcare workers. Influenza and Other respiratory Viruses. 2011; 5(3):170-9, 2011 May.
- MacIntyre CR, Cauchemez S, Dwyer DE, Seale H, Cheung P, Browne G, Fasher M, Wood J, Gao Z, Booy R, Ferguson N, Effectiveness of face mask use to control respiratory virus transmission in households, Emerging Infectious Diseases. Vol. 15, No. Pg 233-41. 2 February 2009
- *MacIntyre CR, Wang Q, Rahman B, Seale H, Ridda I, Gao Z, Yang P, Shi W, Pang X, Zhang Y, Moa A, Dwyer DE. Efficacy of face masks and respirators in preventing upper respiratory tract bacterial colonization and co-infection in hospital healthcare workers. Preventive Medicine 2014; 62: p. 1-7.
Other face mask and PPE research
- Chughtai AA, Stelzer-Braid S, Rawlinson W, Pontivivo G, Wang Q, Pan Y, Zhang D, Zhang Y, Li L, MacIntyre CR. Contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers. BMC Infect Dis. 2019 Jun 3;19(1):491.
- Chughtai AA, Chen X, Macintyre CR. Risk of self-contamination during doffing of personal protective equipment. American journal of infection control. 2018 Jul 17.
- Bhattacharjee, Shovon; Joshi, Rakesh; Chughtai, Abrar Ahmad; Macintyre, Chandini Raina. Graphene Modified Multifunctional Personal Protective Clothing. Advanced Materials Interfaces, 20 Aug 2019. doi: 10.1002/admi.201900622
- Chughtai AA, Seale H, Islam MS, Owais M, Macintyre CR. Policies on the use of respiratory protection for hospital health workers to protect from coronavirus disease (COVID-19). Int J Nurs Stud. 2020 Mar 13;105:103567. doi: 10.1016/j.ijnurstu.2020.103567. [Epub ahead of print] No abstract available.
- Mukerji S, MacIntyre CR, Seale H, et al. Cost-effectiveness analysis of N95 respirators and medical masks to protect healthcare workers in China from respiratory infections. BMC Infectious Diseases 2017; 17(1): 464.
- Mukerji S, MacIntyre CR, Newall AT. Review of economic evaluations of mask and respirator use for protection against respiratory infection transmission. BMC Infect Dis. 2015 Oct 13;15:413. doi: 10.1186/s12879-015-1167-6. Review.
- Chughtai AA, Seale H, Dung TC, Hayen A, Rahman B, MacIntyre CR. Compliance with the Use of Medical and Cloth Masks Among Healthcare Workers in Vietnam. Ann Occup Hyg. 2016; 60(5):619-30. doi:
- Chughtai AA, *MacIntyre CR, Ashraf MO, Zheng Y, Yang P, Wang Q, et al. Practices around the use of masks and respirators among hospital health care workers in 3 diverse populations. American Journal of Infection Control, 2015; 43(10):1116-8. doi: 10.1016/j.ajic.2015.05.041. Epub 2015 Jul 13.
- *MacIntyre CR, Chughtai AA. Face masks for the prevention of infection in healthcare and community settings. BMJ 2015;350:h694. doi: 10.1136/bmj.h694.
- 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 hospital-based health care workers in Vietnam. Am J Infect Control. 2015 Jan 1;43(1):72-7.
- Seale H, Leem JS, Gallard J, Kaur R, Chughtai AA, Tashani M, MacIntyre CR. “The cookie monster muffler”: Perceptions and behaviours of hospital healthcare workers around the use of masks and respirators in the hospital setting. The Int J Infect Control, 2014; v11:i1.page 1-8.
- Chughtai, A. A., MacIntyre, C. R., Zheng, Y., Wang, Q., Toor, Z. I., Dung, T. C., et al. (2014). Examining the policies and guidelines around the use of masks and respirators by healthcare workers in China, Pakistan and Vietnam. Journal of Infection Prevention, 2015; 16(2):68-74. doi: 10.1177/1757177414560251.
- MacIntyre CR, Chughtai AA, Seale H, Richards GA, Davidson PM. Response to Martin-Moreno et al. (2014) Surgical mask or no mask for health workers not a defensible position for Ebola. Int J Nurs Stud. 2014 Dec;51(12):1694-5.
- *MacIntyre, C.R., Chughtai, A.A., Seale, H., Richards, G.A., Davidson, P.M. Respiratory protection for healthcare workers treating Ebola virus disease: are facemasks sufficient to meet occupational health and safety obligations? International Journal of Nursing Studies (2014), 51(11):1421-1426.
- *Chughtai AA, Seale H, MacIntyre CR. Use of cloth masks in the practice of infection control – evidence and policy gaps. International Journal of Infection Control. 2013; 9(3): 12 pages
- *Chughtai AA, Seale H, MacIntyre CR. Availability, consistency and evidence-base of policies and guidelines on the use of mask and respirator to protect hospital health care workers: a global analysis. BMC Research Notes 2013;6:216.
- Yang P, Seale H, MacIntyre CR, Zhang H, Zhang Z, Zhang Y, Wang X, Li X, Pang X, Wang Q. Mask-wearing and respiratory infection in healthcare workers in Beijing, China. Braz J Infect Dis. 2011;15(2):102-8.
- *Macintyre CR. Hand hygiene and face mask use within 36 hours of index patient symptom onset reduces flu transmission to household contacts. Evidence Based Medicine. 15(2):48-9, 2010 Apr.
- *Seale H, Dwyer DE, Cowling BJ, Wang Q, Yang P, Macintyre CR. A review of medical masks and respirators for use during an influenza pandemic. Influenza Other Respi Viruses. 2009 Sep;3(5):205-6.
- Chen X, Chughtai AA, MacIntyre CR. Herd protection effect of N95 respirators in healthcare workers. J Int Med Res, first published online, 26 Oct 2016. 1-8. doi: 10.1177/0300060516665491