Masking Dilemma

Implemented in 1996, Standard Precautions represent the minimum precautions applicable to all patients in any type of setting, and include guidelines on the use of masks.¹ Unfortunately, the speed and ease in which the COVID-19 virus spreads among people has resulted in the need for providers, staff, and patients to wear masks during clinical interactions, at least in the interim. This is certainly uncharted territory, and when you add the current critical supply shortages of masks to the mix, audiologist may find themselves experiencing a new “masking dilemma.” This post is intended to assist with making informed decisions about respirator and surgical masks use within the context of the audiology clinic.

When To Use N95 Masks:

Aerosol generating procedures (AGP) are associated with potentially higher concentrations of infectious respiratory droplets than coughing and sneezing.² AGP procedures audiologists may be associated with include (but are not limited to) activity in the surgical suite,³ cerumen management, and vestibular testing.⁴ The guidance issued by the Center for Disease Control and Prevention (CDC) recommends the use of a N95 respirator (mask) during AGP procedures because this mask is tight-fitting and designed to reduce exposure to small particle aerosols.⁵

Viable Option During N95 Respirator Shortage:

With critical shortages of N95 masks, both the CDC and the FDA have identified the use of respirators (masks) approved under standards used in other countries similar to NIOSH-approved N95 respirators is acceptable.^6,7  Given this issued interim guidance, the use of KN95 masks manufactured in China meeting GB2626-2006 or GB2626-2019 performance standards are considered suitable alternatives.⁸ NOTE: safety glasses, goggles, or a face shield are also indicated to protect the eyes from exposure to droplet nuclei during AGP.

N95 Mask vs KN95 Mask Meeting GB2626-2006 Performance Standards:

The difference between an N95 and a KN95 mask is where the product is certified. The N95 mask is evaluated, tested and approved by the National Institute for Occupational Safety and Health (NIOSH) and meets the US Standard for respirator masks.⁴ The KN95 mask meets Chinese standards for respirator masks. At the onset of the COVID-19 pandemic, heightened concerns over counterfeiting of imported respirator products resulted in NIOSH and other federal agencies to identify imported products meeting similar standards of NIOSH-approved N95 masks.^6-8 KN95 masks manufactured in China with GB2626-2006 or GB2626-2019 performance standards labeling are essentially equivalent to N95 standards as both are capable of capturing capture 95% of small airborne particles (0.3 micron).⁹

Medical Masks

Medical masks (also called surgical or procedure masks) are fluid-resistant masks cleared by the FDA that provide protection against large droplets, splashes, or sprays of bodily or other hazardous fluids, and designed to protect others from the wearer’s respiratory emissions.⁴ Surgical masks affix to the head with either ties or elastic ear hooks. These masks do not provide a seal and are not necessarily adequate for use during AGC.¹⁰

Extended Use vs Limited Reuse of Masks

In response mask shortages during COVID-19 pandemic, the CDC outlined strategies for optimizing supply including extended and limited reuse of masks. Both involve the practice of wearing the same mask for multiple encounters with different patients. Extended use involves wearing the same mask without removing the mask between patient encounters whereas limited reuse involves removing and reusing the same mask between patients.^11,12

N95 and KN95 Masks

Extended use of respirator masks (K95 and KN95 masks) is favored over reuse because it involves less touching of the respirator and therefore less risk of contact transmission.^6,12 While extended use increases the period of time the same masks can be used, respirator masks must be discarded following use during AGP; if contaminated with blood, respiratory or nasal secretions or other bodily fluids from patients; and following close contact with, or exit from, the care area of any patient co-infected with an infectious disease requiring contact precautions.¹²

If public health or institutional authorities allow reuse, respirator masks must be discarded according to extended use recommendations. Furthermore, respirator masks should be stored in a designated area when not in use and hand hygiene performed before and after touching or adjusting the respirator.¹² Currently, there is no way of determining the maximum number of safe reuses for respirator masks with data suggesting reuses to no more than five per device.¹³

Surgical Masks

Not all surgical masks are suitable for reuse. According to the CDC, extended use applies to all tie-on masks whereas masks with elastic ear hooks may be more suitable for reuse.¹¹

Face Shields

As mentioned in an earlier blog post, per the CDC, when no face masks are available, the use of a face shield that covers the entire front (extending to the chin or below) and sides of the face with no face mask is an option.¹⁴ NIOSH has also offered recommended guidance for providers to consider using a face shield when feasible.¹²

References

1. Bankaitis, A.U. (2018). Infection Control.  In: B. Taylor (Ed). Audiology Practice Management, 3^rd edition. Thieme Medical Publishers, New York: NY
2. CDC (2020). Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19_ in Healthcare Settings. Updated May 18, 2020. Available: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
3. AAA (2020). Surgical Monitoring Safety: COVID-19 and Beyond. Posted May 19, 2020. Available: https://www.audiology.org/news/surgical-monitoring-safety-covid-19-and-beyond
4. AAA (2020). Vestibular Testing Safety: COVID-19 and Beyond. posted May 19, 2020. Available: https://www.audiology.org/news/vestibular-testing-safety-covid-19-and-beyond
5. CDC Infographic. Understanding the Difference. Accessed May 28, 2020. Available: https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf
6. CDC (2020). Strategies for Optimizing the Supply of N95 Respirators. Posted April 22, 2020. Available: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html
7. FDA. Non-NIOSH Approved Respiratory Emergency Use Authorization (EUA). Available: https://www.fda.gov/media/136664/download
8. NIOSH (2020). NPPTL Respirator Assessments to Support the COVID-19 Response. Updated May 13, 2020. Available: https://www.cdc.gov/niosh/npptl/respirators/testing/ NonNIOSH.html
9. 3M (2020). Technical Bulletin: Comparison of FFP2, KN95, and N95 and Other Filternig Facepiece Respirator Classes. Accessed: May 26, 2020. Available: https://multimedia.3m.com/mws/media/1791500O/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf
10. WHO (2014). Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care. Annex A, Respiratory Protection. Available: https://www.ncbi.nlm.nh.gov/books/NBK214348/
11. CDC (2020). Strategies for Optimizing the Supply of Facemasks. Posted March 17, 2020. Available: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html
12. NIOSH (2020). Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Setting. Posted March 27, 2020. Available: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
13. Bergman, M.S., D.J. Viscusi, Z. Zhuang, A.J. Palmiero, J.B. Powell, and R.E. Shaffer (2012). Impact of multiple consecutive donnings on filtering facepiece respirator fit. American Journal of Infection Control 40(4): 375-380.
14. A.U. Bankaitis (2020). Infection Control Anxiety: Acceptable Alternatives to Critical Supplies. Posted May 4, 2020. Available: https://aubankaitis.com/infection-control-anxiety/