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In Europe, respiratory protective devices must be certified before they can be marketed. Among the parameters of interest, inward leakage (IL) characterizes the tightness between the face seal and the face, to verify that the device is well-designed. European standard EN 13274-1 (2001) and International Organization for Standardization (ISO) standard ISO 16900-1 (2019) specify that IL should be measured using sodium chloride (NaCl) aerosol or sulfur hexafluoride (SF6) gas. For reusable masks made of nonporous materials, both test agents are considered equally acceptable. However, the few studies that have compared IL values measured with various aerosols and gases have come to divergent conclusions. This work then aimed to measure IL with the test agents recommended by the standards to determine whether they are really equivalent. Since krypton (Kr) is an interesting candidate for replacing SF6 in standard tests, IL was assessed with SF6 and Kr simultaneously, and with NaCl aerosol using various calculation methods. Tests were carried out on 5 models of full-face masks donned on a headform connected to a breathing machine simulating 3 sinusoidal breathing rates of various intensities. The respirator fit on the headform was evaluated using a controlled negative pressure method to determine a manikin fit factor. Four scenarios were then tested to represent very poor, bad, good, and excellent fit. Gas concentration was measured using a mass spectrometer, and IL was calculated for SF6 and Kr. A combination of 3 devices allowed the determination of the number-based concentration of particles with diameters between 20 nm and 2 µm, and IL was calculated for each of the 33 channels, as well as using a cumulative number concentration. In addition, to comply with standards, a conversion was carried out to calculate IL using a cumulative mass concentration. The results of this work evidenced that the IL values measured with NaCl were systematically lower than those determined with gases. IL was also shown to vary with particle size, with a maximum value exceeding that calculated with cumulative concentrations (in number or mass). As part of the revision of the standards, protocols for measuring inward leakage should be redefined. On the one hand, acceptability thresholds should be re-evaluated according to the nature of the test agent (gas or aerosol), as it is clear that the 2 options do not give the same results for a given configuration. On the other hand, the aerosol leakage measurement protocol needs to be reworked to enable the measurement of a well-defined, robust, and reproducible inward leakage value., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Occupational Hygiene Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Device manufacturers who seek to market their pediatric facemasks in the United States (U.S.), as part of anthropometric data requirement, need to demonstrate their mask designs are expected to fit the intended user population. However, currently there are no well accepted test methodologies for pediatric facemasks. In addition, unlike N95 respirators, the expected maximum flow rate, and the pressure drop at that expected maximum flow rate for pediatric facemasks have not been established., Method: The objective of this article is three-fold; use a literature survey to determine the worst-case flow rate, and an acceptable breathing resistance; and come up with a bench-test based protocol for assessing fit of pediatric facemasks., Results & Discussion: The worst-case breathing flow rate for mask testing in the pediatric population is 45-60 Liters/minute (LPM), and the acceptable pressure drop at the worst-case flow rate is 2.0 mmH2O. A retrospective assessment of all the four brands of legally marketed facemasks in the U.S. that could be purchased, revealed that majority of the brands have high filtration efficiency (>95%) at low flow rate 5 LPM which reduces to ~ 80% at 45 LPM. At 5 LPM, the pressure drop ranges from 0.3-0.6 mmH2O, remaining below the 2.0 mmH2O. However, at higher flow rates, (representing strenuous activities, or older children (> 12 years)), most masks exhibited a pressure drop within the range of 2.9 to 6.0 mmH2O. Furthermore, opening the pleats of the facemasks completely results in a notable reduction in pressure drop (a 6.6-fold decrease, p = 0.03). To assess fit of these same brands of facemasks, we then updated our previous validated adult manikin fit-test method and used it in manikins in the age group of 2 to 14 years. Either poor nose-clip adherence to the manikin, low filtration efficiency of the pediatric facemasks, or off-label use (i.e. when donned on manikins representing 2 years to 14 years) contributed to low fit., Conclusions: A new bench-top tool to evaluate quantitative fit of pediatric facemasks was developed. In addition, based on the research reported here, we provide practical implications for the members of the community: users, academia and medical device manufacturers., Competing Interests: None to report., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Objective: to analyze the integrity of N95/PFF2 masks in relation to fiber morphology, porosity, cracks and micro holes, as well as identify visible damage to their structure and components, after seven- and fifteen-day reuse protocols., Method: cross-sectional study. Structural and morphological characteristics of a new N95/PFF2 mask were analyzed in comparison with N95/PFF2 masks (n=10) used in seven- and fifteen-day protocols, through visual inspection and scanning electron microscopy., Results: upon visual inspection, following the seven-day protocol, 40% and 60% of the N95/PFF2 masks showed, respectively, personal identification marks and external and internal dirt. Additionally, 20% exhibited loosening and/or tearing of the straps, while 100% showed some type of damage to the nose clips. In the fifteen-day protocol, all N95/PFF2 masks had dirt, loose straps and damaged nose clips, and 80% had folds. Electronic microscopy revealed an increase in pores and loosening in the weaves from seven days onwards, extending up to fifteen days, with the presence of micro holes and residues., Conclusion: the reuse of N95/PFF2 masks affects their structural and morphological integrity. It is crucial to carry out tests to measure the impact of this practice on the safety of health professionals.

Background: During public health emergencies, demand for N95 filtering facepiece respirators (N95 FFRs) can outpace supply. Elastomeric half-mask respirators (EHMRs) are a potential alternative that are reusable and provide the same or higher levels of protection. This study sought to examine the practical aspects of EHMR use among health care personnel (HCP)., Methods: Between September and December 2021, 183 HCPs at 2 tertiary referral centers participated in this 3-month EHMR deployment, wearing the EHMR whenever respiratory protection was required according to hospital protocols (ie, when an N95 FFR would typically be worn) and responding to surveys about their experience., Results: Participants wore EHMRs typically 1 to 3 hours per shift, reported disinfecting the respirator after 85% of the removals, and reported high confidence in using the EHMR following the study. EHMRs caused minimal interference with patient care tasks, though they did inhibit communication., Discussion: HCP who had not previously worn an EHMR were able to wear it as an alternative to an N95 FFR without much-reported interference with their job tasks and with high disinfection compliance., Conclusions: This study highlights the feasibility of the deployment of EHMRs during a public health emergency when an alternative respirator option is necessary., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Reusable elastomeric half-mask respirators (EHMR) are an alternative to address shortages of disposable respirators. While respirator discomfort has been noted as a barrier to adherence to wearing an N95 filtering facepiece respirator (FFR) among health care personnel (HCP), few have examined EHMR comfort while providing patient care, which was the purpose of this study., Method: Among a cohort of 183 HCP, we prospectively examined how HCP rated EHMR tolerability using the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI) questionnaire at Study Week 2 and Week 10. At the completion of the study (Week-12), HCP compared EHMR comfort with their prior N95 FFR use. Overall R-COMFI scores and three subscales (comfort, wear experience, and function) were examined as well as individual item scores., Findings: The HCP reported an improved overall R-COMFI score (lower score more favorable, 30.0 vs. 28.7/47, respectively) from Week 2 to Week 10. Many individual item scores improved or remained low over this period, except difficulty communicating with patients and coworkers. The overall R-COMFI scores for the EHMR were more favorable than for the N95 FFR (33.7 vs. 37.4, respectively), with a large proportion of workers indicating their perception that EHMR fit better, provided better protection, and they preferred to wear it in pandemic conditions compared with the N95 FFR., Conclusion/application to Practice: Findings suggest that the EHMR is a feasible respiratory protection device with respect to tolerance. EHMRs can be considered as a possible alternative to the N95 FFR in the health care setting. Future work is needed in the EHMR design to improve communication., Competing Interests: Conflict of InterestThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Cellulose acetate (CA) is a non-toxic, renewable, and biodegradable polymeric material that can be effectively electrospuned into bacterial filtration efficient nanofiber membrane for face mask application. However, its fragile and non-antibacterial nature influenced its scalability. In this context, natural antibacterial gum rosin (GR) additive can be explored. Therefore, the present study aimed to produce a CA/GR composite nanofibers membrane for the finest bacterial filtration, excellent antibacterial moiety, and improved tensile properties for facemask application. Hence, in this work, we have studied the effect of GR concentrations (0-15 g) on the needleless electrospinning behavior and fibers' morphology through rheology, electrical conductivity, and SEM analysis. These analyses revealed that GR significantly affects the fibers' spinning behavior, morphology, and diameter of the produced fibers. Later, ATR-FTIR spectroscopy mapped the functional changes in the produced nanofibers that affirmed the integration of GR with CA polymer. This modification resulted in a 3-fold rise in tensile strength and an 11-fold decline in elongation% in 15 g CA/GR composite nanofibers membrane than the control sample. Furthermore, it has shown 98.79 ± 0.10% bacterial filtration efficiency and ∼ 93 % reduction in Staphylococcus Aureus and Klebsiella Pneumoniae bacterial growth, elucidating a high-efficiency level for potential facemask application., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The effect of filtering face piece grade 2 (FFP2) masks for infection prevention is essential in health care systems; however, it depends on supply chains. Efficient methods to reprocess FFP2 masks may be needed in disasters. Therefore, different UV-C irradiation schemes for bacterial decontamination of used FFP2 masks were investigated.Seventy-eight masks were irradiated with UV light for durations between 3 and 120 seconds and subsequently analyzed for the presence of viable bacteria on the inside. Ten masks served as the control group. Irradiation on the inside of the masks reduced bacteria in proportion to the dose, with an almost complete decontamination after 30 seconds. Outside irradiation reduced the quantity of colonies without time-dependent effects. Both sides of irradiation for a cumulated 30 seconds or more showed almost complete decontamination.Overall, this study suggests that standardized UV irradiation schemes with treatment to both sides might be an efficient and effective method for FFP2 mask decontamination in times of insufficient supplies.

Objective: To assess the effect of different noninvasive ventilation interfaces on preventing the facial pressure injury., Methods: This network meta-analysis was conducted following the PRISMA reporting guidelines. Seven electronic databases were systematically searched for randomised controlled trials about the comparative effectiveness of different interfaces in preventing facial pressure injury with noninvasive ventilation in adults and newborns from inception to June 2023. The acronym of PICOS was used and the keywords as well as inclusion/exclusion criteria were determined. Study selection and data extraction were performed by two independent reviewers. The Cochrane risk of bias assessment tool was used to assess the methodological quality., Results: A total of 78 randomised controlled trials involving 7,291 patients were included. The results of network meta-analysis showed that the effectiveness of the eight noninvasive ventilation interfaces on the prevention of facial pressure injury was in the order of: nasal cannula > full-face mask > rotation of nasal mask with nasal prongs > helmet > nasal mask > oronasal mask > nasal prongs > face mask. The use of full-face mask in adults and nasal cannula in newborns had the best effect on preventing the incidence of facial pressure injury., Conclusions: The use of full-face mask in adults and nasal cannula in newborns had the most clinical advantage in preventing the incidence of facial pressure injury and were worthy promoting in clinical practice., Implications for Clinical Practice: This study provides a certain theoretical basis for the selection of appropriate interface for patients with noninvasive ventilation. Clinical practitioners should choose the appropriate interfaces based on the patient's specific condition to reduce the incidence of facial pressure injury, enhance patient comfort, and improve the effectiveness of respiratory therapy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Surgical masks have become critical for protecting human health against the COVID-19 pandemic, even though their environmental burden is a matter of ongoing debate. This study aimed at shedding light on the environmental impacts of single-use (i.e., MD-Type I) versus reusable (i.e., MD-Type IIR) face masks via a comparative life cycle assessment with a cradle-to-grave system boundary. We adopted a two-level analysis using the ReCiPe (H) method, considering both midpoint and endpoint categories. The results showed that reusable face masks created fewer impacts for most midpoint categories. At the endpoint level, reusable face masks were superior to single-use masks, producing scores of 16.16 and 84.20 MPt, respectively. The main environmental impacts of single-use masks were linked to raw material consumption, energy requirements and waste disposal, while the use phase and raw material consumption made the most significant contribution for reusable type. However, our results showed that lower environmental impacts of reusable face masks strongly depend on the use phase since reusable face masks lost their superior performance when the hand wash scenario was tested. Improvement of mask eco-design emerged as another key factor such as using more sustainable raw materials and designing better waste disposal scenarios could significantly lower the environmental impacts., (© 2022. The Author(s).)

Background: Health care workers (HCW) are heavily exposed to SARS-CoV-2 from the beginning of the pandemic. We aimed to analyze risk factors for SARS-CoV-2 seroconversion among HCW with a special emphasis on the respective healthcare institutions' recommendation regarding the use of FFP-2 masks., Methods: We recruited HCW from 13 health care institutions (HCI) with different mask policies (type IIR surgical face masks vs. FFP-2 masks) in Southeastern Switzerland (canton of Grisons). Sera of participants were analyzed for the presence of SARS-CoV-2 antibodies 6 months apart, after the first and during the second pandemic wave using an electro-chemiluminescence immunoassay (ECLIA, Roche Diagnostics). We captured risk factors for SARS-CoV-2 infection by using an online questionnaire at both time points. The effects of individual COVID-19 exposure, regional incidence and FFP-2 mask policy on the probability of seroconversion were evaluated with univariable and multivariable logistic regression., Results: SARS-CoV-2 antibodies were detected in 99 of 2794 (3.5%) HCW at baseline and in 376 of 2315 (16.2%) participants 6 months later. In multivariable analyses the strongest association for seroconversion was exposure to a household member with known COVID-19 (aOR: 19.82, 95% CI 8.11-48.43, p < 0.001 at baseline and aOR: 8.68, 95% CI 6.13-12.29, p < 0.001 at follow-up). Significant occupational risk factors at baseline included exposure to COVID-19 patients (aOR: 2.79, 95% CI 1.28-6.09, p = 0.010) and to SARS-CoV-2 infected co-workers (aOR: 2.50, 95% CI 1.52-4.12, p < 0.001). At follow up 6 months later, non-occupational exposure to SARS-CoV-2 infected individuals (aOR: 2.54, 95% CI 1.66-3.89 p < 0.001) and the local COVID-19 incidence of the corresponding HCI (aOR: 1.98, 95% CI 1.30-3.02, p = 0.001) were associated with seroconversion. The healthcare institutions' mask policy (surgical masks during usual exposure vs. general use of FFP-2 masks) did not affect seroconversion rates of HCW during the first and the second pandemic wave., Conclusion: Contact with SARS-CoV-2 infected household members was the most important risk factor for seroconversion among HCW. The strongest occupational risk factor was exposure to COVID-19 patients. During this pandemic, with heavy non-occupational exposure to SARS-CoV-2, the mask policy of HCIs did not affect the seroconversion rate of HCWs., (© 2022. The Author(s).)

Importance: It is not known how effective child masking is in childcare settings in preventing the transmission of SARS-CoV-2. This question is critical to inform health policy and safe childcare practices., Objective: To assess the association between masking children 2 years and older and subsequent childcare closure because of COVID-19., Design, Setting, and Participants: A prospective, 1-year, longitudinal electronic survey study of 6654 childcare professionals at home- and center-based childcare programs in all 50 states was conducted at baseline (May 22 to June 8, 2020) and follow-up (May 26 to June 23, 2021). Using a generalized linear model (log-binomial model) with robust SEs, this study evaluated the association between childcare program closure because of a confirmed or suspected COVID-19 case in either children or staff during the study period and child masking in both early adoption (endorsed at baseline) and continued masking (endorsed at baseline and follow-up), while controlling for physical distancing, other risk mitigation strategies, and program and community characteristics., Exposures: Child masking in childcare programs as reported by childcare professionals at baseline and both baseline and follow-up., Main Outcomes and Measures: Childcare program closure because of a suspected or confirmed COVID-19 case in either children or staff as reported in the May 26 to June 23, 2021, end survey., Results: This survey study of 6654 childcare professionals (mean [SD] age, 46.9 [11.3] years; 750 [11.3%] were African American, 57 [0.9%] American Indian/Alaska Native, 158 [2.4%] Asian, 860 [12.9%] Hispanic, 135 [2.0%] multiracial [anyone who selected >1 race on the survey], 18 [0.3%] Native Hawaiian/Pacific Islander, and 5020 [75.4%] White) found that early adoption (baseline) of child masking was associated with a 13% lower risk of childcare program closure because of a COVID-19 case (adjusted relative risk, 0.87; 95% CI, 0.77-0.99), and continued masking for 1 year was associated with a 14% lower risk (adjusted relative risk, 0.86; 95% CI, 0.74-1.00)., Conclusions and Relevance: This survey study of childcare professionals suggests that masking young children is associated with fewer childcare program closures, enabling in-person education. This finding has important public health policy implications for families that rely on childcare to sustain employment.

During the first wave of Covid-19 infections in Germany in April 2020, clinics reported a shortage of filtering face masks with aerosol retention> 94% (FFP2 & 3, KN95, N95). Companies all over the world increased their production capacities, but quality control of once-certified materials and masks came up short. To help identify falsely labeled masks and ensure safe protection equipment, we tested 101 different batches of masks in 993 measurements with a self-made setup based on DIN standards. An aerosol generator provided a NaCl test aerosol which was applied to the mask. A laser aerosol spectrometer measured the aerosol concentration in a range from 90 to 500 nm to quantify the masks' retention. Of 101 tested mask batches, only 31 batches kept what their label promised. Especially in the initial phase of the pandemic in Germany, we observed fluctuating mask qualities. Many batches show very high variability in aerosol retention. In addition, by measuring with a laser aerosol spectrometer, we were able to show that not all masks filter small and large particles equally well. In this study we demonstrate how important internal and independent quality controls are, especially in times of need and shortage of personal protection equipment., (© 2021. The Author(s).)

Due to the COVID-19 pandemic, people were encouraged and sometimes required to wear disposable facemasks, which then are discarded creating an environmental problem. In this study, we aim at investigating novel ideas to recycle wasted facemasks in order to lower the environmental impact. An experimental study has been carried out to investigate the possibility of using discarded masks for thermal insulation and sound absorption. The wasted masks are simulated by new masks, which stripped off the nose clips, elastic ear loops and are heated to 120 °C for one hour to kill any biological contaminants. The masks are also melted to investigate their thermal insulation and sound absorption properties. Results show that the thermal conductivity coefficients of the loose and melted masks are 0.03555 and 0.08683 W/m K, respectively, at room temperature of about 25 °C. Results show also that the sound absorption coefficient for loose masks is above 0.6 for the frequency range 600-5000 Hz. The loose facemasks are found to be thermally stable up to 295 °C, elastic ear loops at 304.7 °C, and the composite (melted) facemasks at 330.0 °C using the thermo-gravimetric analysis. Characterization of the facemask's three-layer fibers and the composite (melted) samples is obtained using scanning electron microscopy (SEM). The three-point bending test is obtained for the composite specimens showing good values of flexural stress, flexural strain, and flexural elastic modulus. These results are promising about using such discarded masks as new thermal insulation and sound-absorbing materials for buildings replacing the synthetic or petrochemical insulation materials., (© 2021. The Author(s).)

Respirators, medical masks, and barrier face coverings all filter airborne particles using similar physical principles. However, they are tested for certification using a variety of standardized test methods, creating challenges for the comparison of differently certified products. We have performed systematic experiments to quantify and understand the differences between standardized test methods for N95 respirators (NIOSH TEB-APR-STP-0059 under US 42 CFR 84), medical face masks (ASTM F2299/F2100), and COVID-19-related barrier face coverings (ASTM F3502-21). Our experiments demonstrate the role of face velocity, particle properties (mean size, size variability, electric charge, density, and shape), measurement techniques, and environmental preconditioning. The measured filtration efficiency was most sensitive to changes in face velocity and particle charge. Relative to the NIOSH method, users of the ASTM F2299/F2100 method have commonly used non-neutralized (highly charged) aerosols as well as smaller face velocities, each of which may result in approximately 10% higher measured filtration efficiencies. In the NIOSH method, environmental conditioning at elevated humidity increased filtration efficiency in some commercial samples while decreasing it in others, indicating that measurement should be performed both with and without conditioning. More generally, our results provide an experimental basis for the comparison of respirators certified under various international methods, including FFP2, KN95, P2, Korea 1st Class, and DS2., (© 2021. The Author(s).)

Background: The outbreak of Coronavirus disease 2019 (COVID-19) made imperative the use of protective devices as a source control tool. As there is no definite antiviral treatment and effective vaccine, the only efficient means of protecting and mitigating infectious contagion has been the use of personal protective equipment, especially by healthcare workers. However, masks affect the humidification process of inhaled air, possibly leading to a basal inflammatory state of the upper airways., Study Design: This is a single-center observational study conducted at the University Hospital of Catania from April 1, 2020, to June 31, 2020., Methods: We analyzed the role of protective masks on the elimination of upper airways complaints in healthcare workers of the University Hospital of Catania. We evaluated 277 subjects through a self-administered 17 item questionnaire based on respiratory, work performance and health-related quality of life domains., Results: A higher prevalence of nasal and ocular symptoms, perceived reduced work performance, difficulty in concentrating, and sleep disorders were found. After two weeks adhering to a list of good practices that we recommended, significant reversibility of the symptoms investigated and work performance enhancement were observed., Conclusions: Despite clinical complaints related to personal protective equipment, effective amelioration through usage rules is easily obtained. Given the essential use of protective masks, healthcare workers have to adhere to appropriate work and safety prevention rules.

Study Objective: To determine whether non-invasive ventilation (NIV) delivered by helmet continuous positive airway pressure (hCPAP) is non-inferior to facemask continuous positive airway pressure (fCPAP) in patients with acute respiratory failure in the emergency department (ED)., Methods: Non-inferiority randomized, clinical trial involving patients presenting with acute respiratory failure conducted in the ED of a local hospital. Participants were randomly allocated to receive either hCPAP or fCPAP as per the trial protocol. The primary endpoint was respiratory rate reduction. Secondary endpoints included discomfort, improvement in Dyspnea and Likert scales, heart rate reduction, arterial blood oxygenation, partial pressure of carbon dioxide (PaCO2), dryness of mucosa and intubation rate., Results: 224 patients were included and randomized (113 patients to hCPAP, 111 to fCPAP). Both techniques reduced respiratory rate (hCPAP: from 33.56 ± 3.07 to 25.43 ± 3.11 bpm and fCPAP: from 33.46 ± 3.35 to 27.01 ± 3.19 bpm), heart rate (hCPAP: from 114.76 ± 15.5 to 96.17 ± 16.50 bpm and fCPAP: from 115.07 ± 14.13 to 101.19 ± 16.92 bpm), and improved dyspnea measured by both the Visual Analogue Scale (hCPAP: from 16.36 ± 12.13 to 83.72 ± 12.91 and fCPAP: from 16.01 ± 11.76 to 76.62 ± 13.91) and the Likert scale. Both CPAP techniques improved arterial oxygenation (PaO 2 from 67.72 ± 8.06 mmHg to 166.38 ± 30.17 mmHg in hCPAP and 68.99 ± 7.68 mmHg to 184.49 ± 36.38 mmHg in fCPAP) and the PaO2:FiO2 (Partial pressure of arterial oxygen: Fraction of inspired oxygen) ratio from 113.6 ± 13.4 to 273.4 ± 49.5 in hCPAP and 115.0 ± 12.9 to 307.7 ± 60.9 in fCPAP. The intubation rate was lower with hCPAP (4.4% for hCPAP versus 18% for fCPAP, absolute difference -13.6%, p = 0.003). Discomfort and dryness of mucosa were also lower with hCPAP., Conclusion: In patients presenting to the ED with acute cardiogenic pulmonary edema or decompensated COPD, hCPAP was non-inferior to fCPAP and resulted in greater comfort levels and lower intubation rate., Competing Interests: Declaration of Competing Interest All authors declared no competing interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To determine leakage for two neonatal continuous positive airway pressure (CPAP) interfaces and evaluate leak-corrective manoeuvres., Design: The ToNIL (Trial of NCPAP Interface Leakage) study was a randomised, clinical, cross-over trial with data collection between August 2018 and October 2019. The primary outcome was blinded to the treating staff., Setting: One secondary, 8-bed neonatal intensive care unit (NICU) and three larger (>15 beds), academic NICU referral centres., Patients: Newborn infants with CPAP were screened (n=73), and those with stable spontaneous breathing, low oxygen requirement, postmenstrual age (PMA) over 28 weeks and no comorbidities were eligible. In total, 50 infants were included (median PMA 33 completed weeks)., Interventions: Leakage was measured for both prongs and nasal mask, before and after leak-corrective manoeuvres. Interface application was performed in a randomised order by a nurse, blinded to the measured leakage., Main Outcome Measures: 30 s average leakage, measured in litres per minute (LPM)., Results: Analyses showed a significantly lower leakage (mean difference 0.86 LPM, 95% CI 0.07 to 1.65) with prongs (median 2.01 LPM, IQR 1.00-2.80) than nasal mask (median 2.45 LPM, IQR 0.99-5.11). Leak-corrective manoeuvres reduced leakage significantly for both prongs (median 1.22 LPM, IQR 0.54-1.87) and nasal mask (median 2.35 LPM, IQR 0.76-4.75)., Conclusions: Large leakages were common for both interfaces, less with prongs. Simple care manoeuvres reduced leakage for both interfaces. This is the first report of absolute leakage for nasal interfaces and should encourage further studies on leakage during CPAP treatment., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Face coverings are a key component of preventive health measure strategies to mitigate the spread of respiratory illnesses. In this study five groups of masks were investigated that are of particular relevance to the SARS-CoV-2 pandemic: re-usable, fabric two-layer and multi-layer masks, disposable procedure/surgical masks, KN95 and N95 filtering facepiece respirators. Experimental work focussed on the particle penetration through mask materials as a function of particle diameter, and the total inward leakage protection performance of the mask system. Geometric mean fabric protection factors varied from 1.78 to 144.5 for the fabric two-layer and KN95 materials, corresponding to overall filtration efficiencies of 43.8% and 99.3% using a flow rate of 17 L/min, equivalent to a breathing expiration rate for a person in a sedentary or standing position conversing with another individual. Geometric mean total inward leakage protection factors for the 2-layer, multi-layer and procedure masks were <2.3, while 6.2 was achieved for the KN95 masks. The highest values were measured for the N95 group at 165.7. Mask performance is dominated by face seal leakage. Despite the additional filtering layers added to cloth masks, and the higher filtration efficiency of the materials used in disposable procedure and KN95 masks, the total inward leakage protection factor was only marginally improved. N95 FFRs were the only mask group investigated that provided not only high filtration efficiency but high total inward leakage protection, and remain the best option to protect individuals from exposure to aerosol in high risk settings. The Mask Quality Factor and total inward leakage performance are very useful to determine the best options for masking. However, it is highly recommended that testing is undertaken on prospective products, or guidance is sought from impartial authorities, to confirm they meet any implied standards., Competing Interests: The authors have declared that no competing interests exist.

Introduction: The COVID-19 pandemic has forced health care workers to explore alternative personal protective equipment (PPE) strategies due to traditional product shortages in the setting of increased global demand. Some physicians have chosen to use elastomeric face masks (EFMs), traditionally used in non-healthcare industries., Methods: We performed a prospective cohort study of Emergency Medicine (EM) physicians working at a Level 1 Trauma Center who chose to use self-supplied EFMs for PPE. All subjects used commercial EFMs with disposable filters (N95, P95, or P100). All subjects chose their mask size independently with no input from employee health regarding appropriate fit. Per study protocol, subjects were fit tested periodically during clinical shifts over the course of the 6-week study period. All investigators performing fit testing underwent OSHA qualitative fit testing training. Data collected included mask/filters age, subjective assessment of mask seal quality, and fit test results. The data were analyzed using descriptive statistics., Results: 105 fit tests were performed on physicians wearing EFMs over the course of 49 shifts. Physicians felt their fit was adequate for all tests performed. There were no fit test failures in any subjects., Conclusions: EFMs have an extremely low failure rate. Physicians are able to assess the adequacy of fit and accurately choose EFM size., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The ongoing worldwide outbreak of COVID-19 has set personal protective equipment in the spotlight. A significant number of countries impose the use of facemasks in public spaces and encourage it in the private sphere. Even in countries where relatively high vaccination rates are achieved at present, breakthrough infections have been frequently reported and usage of facemasks in certain settings has been recommended again. Alternative solutions, including community masks fabricated using various materials, such as cotton or jersey, have emerged alongside facemasks following long-established standards (e.g., EN 149, EN 14683). In the present work, we present a computational model to calculate the ability of different types of facemasks to reduce the exposure to virus-laden respiratory particles, with a focus on the relative importance of the filtration properties and the fitting on the wearer's face. The model considers the facemask and the associated leakage, the transport of respiratory particles and their accumulation around the emitter, as well as the fraction of the inhaled particles deposited in the respiratory system. Different levels of leakages are considered to represent the diversity of fittings likely to be found among a population of non-trained users. The leakage prevails over the filtration performance of a facemask in determining the exposure level, and the ability of a face protection to limit leakages needs to be taken into account to accurately estimate the provided protection. Filtering facepieces (FFP) provide a better protection efficiency than surgical and community masks due to their higher filtration efficiency and their ability to provide a better fit and thus reduce the leakages. However, an improperly-fitted FFP mask loses a critical fraction of its protection efficiency, which may drop below the protection level provided by properly-worn surgical and community masks., (© 2021. The Author(s).)

Global shortages of N95 respirators have led to an urgent need of N95 decontamination and reuse methods that are scientifically validated and available world-wide. Although several large scale decontamination methods have been proposed (hydrogen peroxide vapor, UV-C); many of them are not applicable in remote and low-resource settings. Heat with humidity has been demonstrated as a promising decontamination approach, but care must be taken when implementing this method at a grassroots level. Here we present a simple, scalable method to provide controlled humidity and temperature for individual N95 respirators which is easily applicable in low-resource settings. N95 respirators were subjected to moist heat (>50% relative humidity, 65-80°C temperature) for over 30 minutes by placing them in a sealed container immersed in water that had been brought to a rolling boil and removed from heat, and then allowing the containers to sit for over 45 minutes. Filtration efficiency of 0.3-4.99 μm incense particles remained above 97% after 5 treatment cycles across all particle size sub-ranges. This method was then repeated at a higher ambient temperature and humidity in Mumbai, using standard utensils commonly found in South Asia. Similar temperature and humidity profiles were achieved with no degradation in filtration efficiencies after 6 cycles. Higher temperatures (>70°C) and longer treatment times (>40 minutes) were obtained by insulating the outer vessel. We also showed that the same method can be applied for the decontamination of surgical masks. This simple yet reliable method can be performed even without electricity access using any heat source to boil water, from open-flame stoves to solar heating, and provides a low-cost route for N95 decontamination globally applicable in resource-constrained settings., Competing Interests: The authors have declared that no competing interests exist.

Background: Face masks, also referred to as half masks, are essential to protect healthcare professionals working in close contact with patients with COVID-19-related symptoms. Because of the Corona material shortages, healthcare institutions sought an approach to reuse face masks or to purchase new, imported masks. The filter quality of these masks remained unclear. Therefore, the aim of this study was to assess the quality of sterilized and imported FFP2/KN95 face masks., Methods: A 48-minute steam sterilization process of single-use FFP2/KN95 face masks with a 15 minute holding time at 121°C was developed, validated and implemented in the Central Sterilization Departments (CSSD) of 19 different hospitals. Masks sterilized by steam and H2O2 plasma as well as new, imported masks were tested for particle filtration efficiency (PFE) and pressure drop in a custom-made test setup., Results: The results of 84 masks tested on the PFE dry particle test setup showed differences of 2.3±2% (mean±SD). Test data showed that the mean PFE values of 444 sterilized FFP2 face masks from the 19 CSSDs were 90±11% (mean±SD), and those of 474 new, imported KN95/FFP2 face masks were 83±16% (mean±SD). Differences in PFE of masks received from different sterilization departments were found., Conclusion: Face masks can be reprocessed with 121 °C steam or H2O2 plasma sterilization with a minimal reduction in PFE. PFE comparison between filter material of sterilized masks and new, imported masks indicates that the filter material of most reprocessed masks of high quality brands can outperform new, imported face masks of unknown brands. Although the PFE of tested face masks from different sterilization departments remained efficient, using different types of sterilization equipment, can result in different PFE outcomes., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Investigation of potential erroneous behavior in the general public's use of face masks during the COVID-19 pandemic., Design: We conducted a naturalistic observational study in the period from April to June 2020., Sample: In two western Austrian provinces, a total of 2080 persons were observed in front of 24 grocery stores., Measurement: The frequencies and types of erroneous behavior in the use of face masks were collected using a standardized observation form., Results: A total of 2080 persons were observed. Almost one-third of all observations (n = 648; 31.2%) showed erroneous behavior before positioning the face masks. Another 935 (45.0%) persons touched the face mask front during the adjustment via mouth and nose, 501 (24.1%) persons touched the face mask front in the period after the adjustment. A total of 116 (5.6%) persons showed erroneous behavior in each sequence of the observation unit. Overall, almost half of all people observed showed at least one erroneous behavior within the observation period., Conclusions: The behavior of the general public in handling face masks is highly error-prone. Decision makers must increasingly provide accompanying information and educational measures in order to encourage the population at risk to use face masks correctly., (© 2021 Wiley Periodicals, Inc.)

Introduction: The coronavirus 2019 (COVID-19) pandemic has reinforced the importance of facial protection against droplet transmission of diseases. Healthcare workers wear personal protection equipment (PPE), including face shields and masks. Plastic face shields may have advantages over regular medical masks. Although many designs of face shields exist, there is a paucity of evidence regarding the efficacy of shield designs against droplet transmissions. There is even less published evidence comparing various face shields. Due to the urgency of the pandemic and the health and safety of healthcare workers, we aimed to study the efficacy of various face shields against droplet transmission., Methods: We simulated droplet transmission via coughing using a heavy-duty chemical spray bottle filled with fluorescein. A standard-adult sized mannequin head was used. The mannequin head wore various face shields and was positioned to face the spray bottle at either a 0°, 45°, or 90° angle. The spray bottle was positioned at and sprayed from 30 centimeters (cm), 60 cm, or 90 cm away from the head. These steps were repeated for all face shields used. Control was a mannequin that wore no PPE. A basic mask was also tested. We collected data for particle count, total area of particle distribution, average particle size, and percentage area covered by particles. We analyzed percent covered by particles using a repeated measures mixed-model regression with Tukey-Kramer pairwise comparison., Results: We used least square means to estimate the percentage area covered by particles. Wearing PPE regardless of the design reduced particle transmission to the mannequin compared to the control. The LCG mask had the lowest square means of 0.06 of all face-shield designs analyzed. Tukey-Kramer pairwise comparison showed that all PPEs had a decrease in particle contamination compared to the control. LCG shield was found to have the least contamination compared to all other masks (P < 0.05)., Conclusion: Results suggest the importance of wearing a protective covering against droplet transmission. The LCG shield was found to decrease facial contamination by droplets the most of any tested protective equipment.

The use of close-fitting PPE is essential to prevent exposure to dispersed airborne matter, including the COVID-19 virus. The current pandemic has increased pressure on healthcare systems around the world, leading to medical professionals using high-grade PPE for prolonged durations, resulting in device-induced skin injuries. This study focuses on computationally improving the interaction between skin and PPE to reduce the likelihood of discomfort and tissue damage. A finite element model is developed to simulate the movement of PPE against the face during day-to-day tasks. Due to limited available data on skin characteristics and how these vary interpersonally between sexes, races and ages, the main objective of this study was to establish the effects and trends that mask modifications have on the resulting subsurface strain energy density distribution in the skin. These modifications include the material, geometric and interfacial properties. Overall, the results show that skin injury can be reduced by using softer mask materials, whilst friction against the skin should be minimised, e.g. through use of micro-textures, humidity control and topical creams. Furthermore, the contact area between the mask and skin should be maximised, whilst the use of soft materials with incompressible behaviour (e.g. many elastomers) should be avoided., (© 2021. The Author(s).)

In Italy, as well as in almost all countries, the use of masks in public with several other measures has been an important health measure during the ongoing COVID-19 pandemic. The correct use of masks is essential, as a wrong use and disposal may increase the rate of contagious. Herein, we report a descriptive study evaluating the knowledge and use, reuse and disposal of masks in community settings. An anonymous questionnaire called MaSK (Mask uSe and Knowledge) questionnaire was developed and offered to patients referring at our dermatologic outpatient clinic. A total of 2562 full complete patients' questionnaires were considered for the study. Our results showed that awareness and information campaigns aimed at the general population are urgently needed in order to implement a correct use of masks and limit as much as possible the infection rate., (© 2020. The Author(s).)

Background: Public Health England guidance stipulates the use of filtering facepiece (FFP3) masks for healthcare workers engaged in aerosol-generating procedures. Mask fit-testing of respiratory protective equipment is essential to protect healthcare workers from aerosolized particles., Aim: To analyse the outcome of mask fit-testing across National Health Service (NHS) hospitals in the UK during the first wave of the coronavirus disease 2019 (COVID-19) pandemic., Methods: Using the Freedom of Information Act, 137 NHS hospitals were approached on May 26 th , 2020 by an independent researcher to provide data on the outcome of fit-testing at each site., Findings: Ninety-six hospitals responded to the request between May 26 th , 2020 to October 29 th , 2020. There was a total of 86 mask types used across 56 hospitals, 13 of which were used in at least 10% of these hospitals; the most frequently used was the FFP3M1863, used by 92.86% of hospitals. Overall fit-testing pass rates were provided by 32 hospitals with mean pass rate of 80.74%. The most successful masks, in terms of fit-test failure rates, were the Alpha Solway 3030V and the Alpha Solway S-3V (both reporting mean fit-test failures of 2%). Male- and female-specific pass and failure rates were provided by seven hospitals. Across the seven hospitals, 20.1% of men tested failed the fit-test for all masks used, whereas 19.9% of women tested failed the fit-test for all masks used. Failure rates were significantly higher in staff from Black, Asian, and Minority Ethnic (BAME) backgrounds 644/2507 (25.69%) across four hospitals., Conclusion: Twenty percent of healthcare workers tested during the first response to the pandemic failed fit-testing for masks. A small sample revealed that this was most prominent in staff from BAME backgrounds., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Health authorities and organizations consider non-medical face masks as an additional passive means to prevent virus diffusion. Communication strategies disseminate information among the population that such masks are essential for mitigating virus diffusion. However, scientific studies are not conclusive in showing the undisputed filtration efficiency of fabric/cloth facial masks (both commercial and homemade)., Objectives: This study examines scientific data about the effectiveness of face masks before and during the COVID-19 emergency. Present trends in the making of commercial and homemade fabric/cloth face masks are also examined., Methods: Statistical data of published studies are analyzed and compared. Main considerations and sugge-stions are also extracted and discussed. Current approaches are examined for assessing the characteristics and effectiveness of fabric/cloth commercial and homemade face masks intended for the population., Results: Conflicting data exist as to whether non-medical masks have a protective effect from the spread of respiratory viruses. Both medical masks (MDs) and respiratory personal protection equipment (PPE) show a given effectiveness value., Conclusion: Concerning commercial and homemade fabric/cloth masks, giving general indications on the choice of materials and their assemblage is difficult as it is not possible to assess the effectiveness of the filter media with respect to the kind of multiphase fluid that may be emitted upon breathing, sneezing, or coughing under different environmental conditions. This is particularly important because airflow rate, temperature, humidity, and duration of use will affect the performance of filter media. Moreover, while a mask may have excellent filter media, droplets may leak into the face-piece unless there is an adequate facial seal. In the presence of leaks, any type of mask may actually offer less protection independently of its nominal filtering effìciency.

Homemade cloth masks and other improvised face coverings have become widespread during the COVID-19 pandemic driven by severe shortages of personal protective equipment. In this study, various alternative (mostly common household) materials, which have not traditionally been used in respiratory protective devices, were tested for particle filtration performance and breathability. Most of these materials were found of some-but rather limited-utility in facemasks. At a breathing flow rate of 30 L min -1 , 17 out of 19 tested materials demonstrated collection efficiency below 50%; at 85 L min -1 , only one material featured particle collection efficiency above 50%. Pressure drop values were mostly below 4 mm w.g. (observed in 89% of cases for the two flow rates), which provides comfortable breathing. Only for one fabric material (silk) tested at 85 L min -1 did the pressure drop reach 11 mm w.g. Based on these results, a three-layer facemask prototype was designed and fabricated comprised of the best performing materials. Additional tests were conducted to examine possible particle detachment/shedding from the materials used in the newly developed facemask, but no such phenomenon was observed. The prototype was evaluated on 10 human subjects using the standard OSHA-approved quantitative fit testing protocol. The mask protection level, determined as an adopted fit factor, was found to lie between that of the two commercial surgical/medical masks tested for comparison. A 10-cycle washing of the mask prototype lowered its collection efficiency across the particle size range; however, washing did not substantially affect mask breathability. The study revealed that although homemade masks offer a certain level of protection to a wearer, one should not expect them to provide the same respiratory protection as high-end commercial surgical/medical masks or-by any means-NIOSH-certified N95 filtering facepieces.

The use of face masks by the general population during viral outbreaks such as the COVID-19 pandemic, although at times controversial, has been effective in slowing down the spread of the virus. The extent to which face masks mitigate the transmission is highly dependent on how well the mask fits each individual. The fit of simple cloth masks on the face, as well as the resulting perimeter leakage and face mask efficacy, are expected to be highly dependent on the type of mask and facial topology. However, this effect has, to date, not been adequately examined and quantified. Here, we propose a framework to study the efficacy of different mask designs based on a quasi-static mechanical model of the deployment of face masks onto a wide range of faces. To illustrate the capabilities of the proposed framework, we explore a simple rectangular cloth mask on a large virtual population of subjects generated from a 3D morphable face model. The effect of weight, age, gender, and height on the mask fit is studied. The Centers for Disease Control and Prevention (CDC) recommended homemade cloth mask design was used as a basis for comparison and was found not to be the most effective design for all subjects. We highlight the importance of designing masks accounting for the widely varying population of faces. Metrics based on aerodynamic principles were used to determine that thin, feminine, and young faces were shown to benefit from mask sizes smaller than that recommended by the CDC. Besides mask size, side-edge tuck-in, or pleating, of the masks as a design parameter was also studied and found to have the potential to cause a larger localized gap opening., Competing Interests: The authors have declared that no competing interests exist.

Coronavirus disease 2019 (CoViD-19), with the fatality rate in elder (60 years old or more) being much higher than young (60 years old or less) patients, was declared a pandemic by the World Health Organization on March 11, 2020. A mathematical model considering young and elder subpopulations under different fatality rates was formulated based on the natural history of CoViD-19 to study the transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The model considered susceptible, exposed, asymptomatic, pre-symptomatic, mild CoViD-19, severe CoViD-19, and recovered compartments, besides compartments of isolated individuals and those who were caught by test. This model was applied to study the epidemiological scenario resulting from the adoption of quarantine (isolation or lockdown) in many countries to control the rapid propagation of CoViD-19. We chose as examples the isolation adopted in São Paulo State (Brazil) in the early phase but not at the beginning of the epidemic, and the lockdown implemented in Spain when the number of severe CoViD-19 cases was increasing rapidly. Based on the data collected from São Paulo State and Spain, the model parameters were evaluated, and we obtained a higher estimation for the basic reproduction number R0 (9.24 for São Paulo State, and 8 for Spain) compared to the currently accepted estimation of R0 around 2 using the SEIR (susceptible, exposed, infectious, and recovered compartments) model. In comparison with the lockdown in Spain, the relatively early adoption of the isolation in São Paulo State resulted in enlarging the period of the first wave of the epidemic and delaying its peak. The model allowed to explain the flattening of the epidemic curves by quarantine when associated with the protective measures (face mask, washing hands with alcohol and gel, and social distancing) adopted by the population. The description of the epidemic under quarantine and protections can be a background to foreseen the epidemiological scenarios from the release strategies, which can help guide public health policies by decision-makers., Competing Interests: The authors have declared that no competing interests exist.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for the novel coronavirus disease 2019 (COVID-19), has caused a global pandemic on a scale not seen for over a century. Increasing evidence suggests that respiratory droplets and aerosols are likely the most common route of transmission for SARS-CoV-2. Since the virus can be spread by presymptomatic and asymptomatic individuals, universal face masking has been recommended as a straightforward and low-cost strategy to mitigate virus transmission. Numerous governments and public health agencies around the world have advocated for or mandated the wearing of masks in public settings, especially in situations where social distancing is not possible. However, the efficacy of wearing a mask remains controversial. This interdisciplinary review summarizes the current, state-of-the-art understanding of mask usage against COVID-19. It covers three main aspects of mask usage amid the pandemic: quality standards for various face masks and their fundamental filtration mechanisms, empirical methods for quantitatively determining mask integrity and particle filtration efficiency, and decontamination methods that allow for the reuse of traditionally disposable N95 and surgical masks. The focus is given to the fundamental physicochemical and engineering sciences behind each aspect covered in this review, providing novel insights into the current understanding of mask usage to curb COVID-19 spread., Competing Interests: Declaration of Competing Interest The authors declare no competing financial interests., (Copyright © 2021 Elsevier B.V. All rights reserved.)

In the absence of fit-testing, leakage of aerosolized pathogens through the gaps between the face and N95 respirators could compromise the effectiveness of the device and increase the risk of infection for the exposed population. To address this issue, we have developed a model to estimate the increase in risk of infection resulting from aerosols leaking through gaps between the face and N95 respirators. The gaps between anthropometric face-geometry and N95 respirators were scanned using computed tomography. The gap profiles were subsequently input into CFD models. The amount of aerosol leakage was predicted by the CFD simulations. Leakage levels were validated using experimental data obtained using manikins. The computed amounts of aerosol transmitted to the respiratory system, with and without leaks, were then linked to a risk-assessment model to predict the infection risk for a sample population. An influenza outbreak in which 50% of the population deployed respirators was considered for risk assessment. Our results showed that the leakage predicted by the CFD model matched the experimental data within about 13%. Depending upon the fit between the headform and the respirator, the inward leakage for the aerosols ranged between 30 and 95%. In addition, the non-fit-tested respirator lowered the infection rate from 97% (for no protection) to between 42 and 80%, but not to the same level as the fit-tested respirators (12%). The CFD-based leakage model, combined with the risk-assessment model, can be useful in optimizing protection strategies for a given population exposed to a pathogenic aerosol.

Objective: The objective of this article is to review the quality  equirements and recommended uses of the different types of face masks  with a view to helping optimize their use and facilitating identification of  nonconforming products., Method: A literature search was conducted in PubMed, the Spanish Official State Gazette and Eudralex. The websites of the Ministry of Industry, Commerce and Tourism and of the Ministry of Health, as well as  the relevant UNE standards were also reviewed., Results: The different types of face masks available on the market meet different regulatory requirements. Community masks are not  considered medical devices or personal protective equipment and do not  require marketing authorization. They do not carry a CE mark and need  not comply with the general regulations applicable to consumer products.  Surgical masks, for their part, must meet the quality criteria defined in  UNE-EN standard 14683: 2019. According to Regulation (EU) 745/2017  they are class I devices, subject to an EU declaration of conformity, and  must bear a CE mark. Filtering masks are considered category III personal protective equipment, regulated by Regulation (EU) 2016/425, and must  also bear a CE mark. In spite the abundant regulations in place, market  control instruments have detected counterfeit face masks, which means  that public authorities and users should ask manufacturers or suppliers for  additional information in case of doubt., Conclusions: The legal and quality requirements of the masks are  sufficient for their safe use. It is necessary for the general public to know  these requirements to avoid the fraudulent use of high consumption  products., (Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.)

Background: Due to regional shortages some health services have proposed using surgical masks manufactured from sterilisation wrap. However, there has been little assessment of the safety of this practice. Therefore, we developed our own prototypes and evaluated whether they met regulatory standards., Methods: Surgical mask prototypes were manufactured from two thickness grades of commercial sterilisation wrap. Safety was assessed in the context of regulatory standards. As it was not previously reported, we developed and performed differential pressure and synthetic blood penetration resistance experiments in accordance with official methodology., Results: Bacterial filtration efficiency was comparable between sterilisation wrap and commercial surgical masks. Both prototypes met regulatory standards for synthetic blood resistance, whilst only our thinner mask fulfilled acceptable differential pressure ('breathability') thresholds., Conclusion: Acceptable barrier and breathability properties can be achieved with surgical masks produced from sterilisation wrap. Therefore, this may be a reasonable method to supplement stock if required. Unless there are shortages mandating alternatives, health-care workers should always use approved personal protective equipment., (Copyright © 2020 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.)

Disposable N95 respirator masks are the current standard for healthcare worker respiratory protection in the COVID-19 pandemic. In addition to shortages, qualitative fit testing can have low sensitivity for detecting poor fit, leading to inconsistent protection. Multiple groups have developed alternative solutions such as modified snorkel masks to overcome these limitations, but validation of these solutions has been lacking. We sought to determine if N95s and snorkel masks with attached high-efficiency filters provide consistent protection levels in healthcare workers and if the addition of positive pressure via an inexpensive powered-air purifying respirator to the snorkel mask would provide enhanced protection. Fifty-one healthcare workers who were qualitatively fitted with N95 masks underwent quantitative mask fit testing according to a simulated workplace exercise protocol. N95, snorkel masks with high-efficiency filters and snorkel masks with powered-air purifying respirators were tested. Respiratory filtration ratios were collected for each step and averaged to obtain an overall workplace protocol fit factor. Failure was defined as either an individual filtration ratio or an overall fit factor below 100. N95s and snorkel masks with high-efficiency filters failed one or more testing steps in 59% and 20% of participants, respectively, and 24% and 12% failed overall fit factors, respectively. The snorkel masks with powered-air purifying respirators had zero individual or overall failures. N95 and snorkel masks with high-efficiency filter respirators were found to provide inconsistent respiratory protection in healthcare workers., (© 2021 Association of Anaesthetists.)

Snorkel masks have become an option for personal protective equipment (PPE) due to the shortage of air filtration at least 95% of airborne particle (N95) masks as a result of the coronavirus disease 2019 (COVID-19) pandemic. We developed a 3D design of a triheaded adapter that connects a snorkel mask to 3 different National Institute for Occupational Safety and Health (NIOSH)-approved air filtration at least 99% of airborne particles (N99) filters with the aim of improving wearer comfort. We measured the resistance of the new triheaded adapter to be one-third the resistance of the single adapter. Interdepartmental survey of anesthesiologists showed an improvement in perceived comfort when using the triheaded adapter as compared to the single adapter., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 International Anesthesia Research Society.)

Importance: During the COVID-19 pandemic, wearing masks has become necessary, especially within health care. However, to our knowledge, the consequences of mask wearing on communication between surgeons and patients have not been studied., Objective: To evaluate the effects of clear vs standard covered masks on communication during surgical clinic encounters., Design: This randomized clinical trial examined communication between surgeons and their patients when surgeons wore clear vs covered masks in surgical outpatient clinics at a single academic medical center. New patients were recruited from participating surgeons' clinic schedules., Interventions: Surgeons wore either clear masks or covered masks for each clinic visit with a new patient, based on a per-visit randomization plan., Main Outcomes and Measures: The primary outcome measures included patient perceptions of (1) surgeon communication and (2) trust in surgeons, as well as (3) quantitative assessments and (4) qualitative assessments regarding patient impressions of the surgeon's mask. After the clinic encounter, patients completed a verbal survey including validated Clinician and Group Consumer Assessment of Healthcare Providers and Systems questions. Additional questions involved surgeon empathy, trust, and the patient's impression of the surgeon's mask. Data were analyzed by comparing patient data in the clear vs covered groups using Cochran-Mantel-Haenszel tests, and comments were analyzed for themes., Results: Two hundred patients were enrolled from 15 surgeons' clinics spanning 7 subspecialties. When surgeons wore a clear mask, patients rated their surgeons higher for providing understandable explanations (clear, 95 of 100 [95%] vs covered, 78 of 100 [78%]; P < .001), demonstrating empathy (clear, 99 [99%] vs covered, 85 [85%]; P < .001), and building trust (clear, 94 [94%] vs covered, 72 [72%]; P < .001). Patients preferred clear masks (clear, 100 [100%] vs covered, 72 [72%]; P < .001), citing improved surgeon communication and appreciation for visualization of the face. Conversely, 8 of 15 surgeons (53%) were unlikely to choose the clear mask over their standard covered mask., Conclusions and Relevance: This randomized clinical trial demonstrates that patients prefer to see their surgeon's face. Surgeons who wore clear masks were perceived by patients to be better communicators, have more empathy, and elicit greater trust. Because masks will remain part of the health care landscape for some time, deliberate attention to preserving communication within the surgeon-patient relationship is warranted., Trial Registration: ClinicalTrials.gov Identifier: NCT04595695.

Background: During the recent COVID-19 outbreak, masks became mandatory and shortages frequent, therefore the prevalence of non-CE (European Conformity Mark) approved masks increased in the general population. We aimed to quantify the prevalence of mask-related cutaneous side effects and the differences between CE and non-CE approved masks., Methods: In this multicenter prospective observational study conducted from March 20, 2020 to May 12, 2020(during and after quarantine), patients attending emergency departments for a dermatological consult were clinically assessed and their masks were inspected to detect CE marks and UNI (Italian National Unification Entity) norms. Patients with history of facial dermatoses or under current treatment for facial dermatoses were excluded., Results: We enrolled 412 patients (318 during quarantine and 94 after quarantine). CE-approved masks were observed 52.8% vs. 24.5%, whilst subsets of non-CE approved masks were 9.7% vs. 14.9% (Personal protective equipment (PPE)-masks), 16.4% vs. 12.8% (surgical masks [SM]), and 21.1% vs. 47.9%(non-PPE) and (non-SM masks), respectively during and after quarantine. Remarkably, non-CE-approved masks resulted in patients displaying a statistically significant higher incidence of facial dermatoses and irritant contact dermatitis compared to CE-approved masks, and these differences were mainly driven by non-PPE non-SM masks. Comparing quarantine and after quarantine periods, no statistically significant differences were found for CE-approved masks, whilst differences were detected in non-CE-approved masks regarding incidence of facial dermatoses (P<0.0001)and irritant contact dermatitis (P=0.0041)., Conclusions: Masks are essential to prevent COVID-19 but at the same time higher awareness regarding mask specifications should be promoted in the general population. Non-PPE and non-SM masks should undergo more rigorous testing to prevent the occurrence of cutaneous side effects and future patients' lawsuit damages.

Introduction: Community face mask use during the coronavirus disease 2019 (COVID-19) pandemic has considerably differed worldwide. Generally, Asians are more inclined to wear face masks during disease outbreaks. Hong Kong has emerged relatively unscathed during the initial outbreak of COVID-19, despite its dense population. Previous infectious disease outbreaks influenced the local masking behaviour and response to public health measures. Thus, local behavioural insights are important for the successful implementation of infection control measures. This study explored the behaviour and attitudes of wearing face masks in the community during the initial spread of COVID-19 in Hong Kong., Methods: We observed the masking behaviour of 10 211 pedestrians in several regions across Hong Kong from 1 to 29 February 2020. We supplemented the data with an online survey of 3199 respondents' views on face mask use., Results: Among pedestrians, the masking rate was 94.8%; 83.7% wore disposable surgical masks. However, 13.0% wore surgical masks incorrectly with 42.5% worn too low, exposing the nostrils or mouth; 35.5% worn 'inside-out' or 'upside-down'. Most online respondents believed in the efficacy of wearing face mask for protection (94.6%) and prevention of community spread (96.6%). Surprisingly, 78.9% reused their mask; more respondents obtained information from social media (65.9%) than from government websites (23.2%)., Conclusions: In Hong Kong, members of the population are motivated to wear masks and believe in the effectiveness of face masks against disease spread. However, a high mask reuse rate and errors in masking techniques were observed. Information on government websites should be enhanced and their accessibility should be improved., Competing Interests: All authors have disclosed no conflicts of interest.