Respiratory Protection During Outbreaks: Respirators versus Surgical Masks

Respirators versus Surgical Masks

Consistent use of respirators improves protection against respiratory illness

In these times of the Corona pandemic, one of the foremost strategies are to protect medical professionals from getting infected by patients. One can achieve it by consistent use of respirators that block the infectious particles and viruses, thereby reducing respiratory infections. 

In a healthcare environment, N95 filtering facepiece respirators (FFRs) and surgical masks are the two most commonly used devices. As there is a shortage of N95 respirators now, it becomes imperative to understand the difference between surgical masks and the N95 respirators to have access to proper protection. 

FFRs are designed to protect the healthcare professional and surgical masks are designed for patient

N95 respirators

When we talk about the healthcare environment, respirators have been designed to protect the medical professionals, and surgical masks have been designed to protect the patients. N95 respirators block at least 95% of particles from inhaled air. The filtering facepiece respirators (FFRs) are regulated by the National Institute for Occupational Safety and Health (NIOSH), which is a part of the Centers for Disease Control and Prevention (CDC) within the U.S. Department of Health and Human Services. NIOSH has laid down stringent test conditions to measure the minimum filtration efficiency based on which the FFRs are categorized. To provide the expected protection levels, the FFRs must seal the wearer's face preventing air leaks. FFR acts as a physical barrier between the wearer's face and contaminated hands or gloves.

Surgical masks

On the contrary, surgical masks have not been designed to protect the wearer from airborne hazards. At best, they can only limit the spread of infectious particles expelled by the wearer. Surgical masks can protect a sterile area surrounding a surgical incision from contamination by particles expelled by the wearer that can be in the form of sneezes or coughs. Surgical masks act as a physical barrier to protect the wearer from sprays, splashes, or contact with contaminated hands. Surgical masks are not governed by stringent conditions on minimum filtration efficiency and they are loose fitting in nature.

N95 respirators offer greater protection than surgical masks if worn properly - Scientific studies 

The current COVID-19 pandemic has restarted the debate on which device should be the minimum level protection in the healthcare facilities - N95 FFRs or surgical masks. One should keep this fact in mind that respirators have been designed so as to reduce the wearer’s exposure to airborne particles. Respirators do not make any claims with respect to disease prevention. Properly fitted and worn N95 masks have a minimum filtration efficiency of 95%. Greater protection against aerosols is achieved by FFRs in comparison with surgical masks in the laboratory studies, however, the clinical studies have been inconclusive.

Thus during the time of crisis and mask shortage, it becomes very important to prioritize the distribution of N95 masks and limit their usage for protection against aerosols. Once the shortage ceases and the supply chain is back to normal, facilities with a respiratory protection program must follow the CDC and Occupational Safety and Health Administration (OSHA) guidelines. These guidelines and procedures have been described in detail in the Hospital Respiratory Protection Program Toolkit.

 

surgical masks v/s N95 respirators

There have been discussions on the comparative the ability of respirators against surgical masks to protect medical professionals against influenza virus that was published in the Journal of the American Medical Association’s article, “N95 Respirators versus Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial (ResPECT)”. No significant difference was reported, when a number of incidence of laboratory-confirmed influenza was compared among outpatient health care personnel, participants on trial with surgical masks v/s N95 respirators. ResPECT was conducted at a randomly selected 137 outpatient study sites at seven U.S. medical centers between September 2011 and May 2015, followed by a final follow-up in June 2016. The aim of ResPECT was to measure the effectiveness of an intervention under routine clinical conditions. One limitation of the study was that although the FDA has cleared 500 N95 FFR models and 200 surgical masks, ResPECT studied only two  N95 respirators and medical mask models. It would not be correct to generalize about the protectiveness of other models on the basis of these two models. Due to the absence of performance requirements for surgical masks regarding environmental aerosol filtration capability and no requirement of fit testing, less than 1% of surgical masks were cleared by the FDA. 

Personal protective equipment worn inconsistently by healthcare professionals reduces protection

There has been a constant debate over the use of respirators versus surgical masks by healthcare professionals. The main bone of contention in this debate is that the PPEs including the respiratory protection cannot protect the users effectively if they are not used consistently in a proper manner. 

Healthcare professionals have been reported to be inconsistently using personal protective equipment, substantially leading to reduced protection. More than 12 observational studies have proved that healthcare professionals are not using protective equipment frequently and are not removing the respirators correctly. They have been seen to take off their respirators when they should be wearing them or have been observed not to wear them at all when required. 

Authors conducting trials in ResPECT found that only 35% of medical professionals either never used surgical masks or respirators or used sometimes. This led to the conclusion that this incomplete adherence to the use of surgical masks or respirators had caused unprotected exposures, thereby leading to an increase in the probability of discovering no differences.

Adherence to infection control can be increased with observation, metrics, training, and reinforcing safety culture

The ResPECT study conducted among healthcare professionals could not definitively prove whether there was any practical difference in the protection provided by surgical masks v/s N95 respirators. However, the study emphasized an important opportunity for prevention.  This was the enhancement of the safety culture, which would improve adherence to infection control recommendations. 

One must realize that understanding and addressing the core reasons for non-compliance will go a long way to improve the safety culture. The compliance of proper PPE usage improves depending on the level of health risk the worker perceives, such as exposure to influenza v/s tuberculosis (TB) or the Ebola virus. Hence, to ensure consistent compliance, a safety culture emphasizing daily worker safety and training must be established. The behavior leading to non-compliance can be corrected with training, making observations, collecting metrics, and reinforcing the safety culture. The Hospital Respiratory Protection Program Toolkit issued by NIOSH details this belief that routine compliance increases preparedness during a public health emergency.  

Healthcare professionals will have to follow the two main steps when they are formulating and implementing respiratory protection program policies. Firstly, they have to be aware of the best practices and secondly, strike the right balance between their own safety and factors associated with patient care. 

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