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Table of Contents
EXPERT COMMENTARY
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 53-55

Novel coronavirus (COVID-19): N95 mask hysteria


American College of Academic International Medicine; World Academic Council of Emergency Medicine, Bethlehem, Pennsylvania, USA

Date of Submission27-May-2020
Date of Acceptance28-May-2020
Date of Web Publication8-Jun-2020

Correspondence Address:
Dr. Manish Garg
439 East 51st Street Apartment 9F, New York, NY 10022
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_78_20

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How to cite this article:
Garg M, Garg SM. Novel coronavirus (COVID-19): N95 mask hysteria. Int J Crit Illn Inj Sci 2020;10:53-5

How to cite this URL:
Garg M, Garg SM. Novel coronavirus (COVID-19): N95 mask hysteria. Int J Crit Illn Inj Sci [serial online] 2020 [cited 2020 Sep 25];10:53-5. Available from: http://www.ijciis.org/text.asp?2020/10/2/53/286201




   Why Is This Critical? Top


The novel coronavirus COVID-19 was officially declared a pandemic on March 11, 2020, by the World Health Organization (WHO).

[1] Physicians, particularly on the front lines in the emergency department (ED), may have to care for critically ill patients during this pandemic without sufficient personal protective equipment (PPE) because of increasing international concern for contracting illness. This mass, or “mask,” hysteria can have significant implications on the lives of these physicians and their future patients.


   Where Do Masks Come From? Top


Most of the world's face masks come from China.[2] As we know, this is particularly troubling as China was the source country for COVID-19. Impacts in supply chain or media reports of PPE hoarding have serious ramifications for the rest of the world.[3] At the time of this commentary, China went from making approximately 100,000 face masks in February to 200 million daily.[2] Of this 200 million, approximately 600,000 are N95 masks used by health-care workers for respiratory protection.[2]


   How Do the N95 Masks Work? Top


For airborne protection, physicians typically have access to wear N95 face masks. N95 gets its name from blocking 95% of very small (0.3 μ) particles during testing.[4] The virus that causes COVID-19 is approximately 0.125 μ,[5] thus making the N95 an imperfect strategy if the virus was completely airborne. Thankfully, only when respiratory droplets are coughed or sneezed, do they become aerosolized. Furthermore, the international physician community who has gone through this pandemic has communicated to the Joint World Academic Council of Emergency Medicine/American College of Academic International Medicine Task Force that N95 masks are adequate protection when worn during aerosolizing procedures. The virions, from a sneeze or cough, can float up to 6 feet which is why this is the physical distancing recommendation from experts.[6]


   How Are N95 Masks Made? Top


The process of making the N95 mask is technically complicated.[2] In addition to creating the packaging, elastic ear loops, and the complicated metal strip that can bend at the nose, they have to create the respirator piece. This requires a once rare material called melt-blown fabric which is an extremely fine mesh of synthetic polymer fibers.[2] This is what creates the ability of N95 mask wearers to be able to breathe while reducing the intake of infectious pathogens. As would be expected, opportunistic sources that make this melt-blown fabric have significantly increased their costs causing a ripple effect in the supply chain.[7] Once created, price gouging middle suppliers have further amplified costs due to scarce availability to desperate hospitals. This has created significant difficulty in N95 mask acquisition for physicians.


   What Have International Leaders Declared About Masks? Top


The WHO and the United States (US) Centers for Disease Control and Prevention (CDC) have gone on record advising the international community to reserve N95 face masks for health-care workers.[1],[4] The US surgeon general famously tweeted “Seriously people-STOP BUYING MASKS!” He went on to say, “They are NOT effective in preventing the general public from catching #Coronavirus, but if healthcare providers can't get them to care for sick patients, it puts them and our communities at risk!”[8] If our frontline ED/specialist physicians become infected, it will impair everyone's health regardless if they have COVID-19 or another health condition. This was reinforced by the WHO director general who was quoted, “We can't stop COVID-19 without protecting health workers firsts.”[9]


   Does the General Public Need N95 Masks? Top


According to the WHO, CDC, and the US surgeon general, the answer for N95 masks is an emphatic “no.” Rather, the general public can practice handwashing, physical distancing, and not touching one's face as COVID-19 transmits mostly by droplet and contact. The general public should be wearing non-N95 face masks that cover their nose and mouth and ideally some eye protection as this is also an entry point for the virus. The N95 mask and PPE hoarding by the public are making it impossible for physicians to protect themselves from a respiratory standpoint. There has been a recent scientific report that COVID-19 can stay alive on surfaces for extended periods of time or in the air for longer than previously thought.[10] The authors aerosolized the virus, and these findings are predictable. Importantly, it does not speak to the virulence or transmission as the virus decays out of a human body. Originally, the transmission characteristics of the disease strongly favored contact and droplet transmission compared to a respiratory transmission based on R naught data of 1 person infecting approximately 2.2 people.[11] One of the challenges if the general public wears N95 masks is that many people could have a false sense of security to interact with one another and not maintain good droplet and contact precautions, especially since their eyes are still vulnerable. This has the potential to worsen or reignite the spread.


   Why Do Physicians Need N95 Masks? Top


Physicians need N95 masks because they are exposed to the sickest of patients. At present, we do not fully understand why or which patients will go onto severe hypoxemic respiratory failure/acute respiratory distress syndrome.[12] It is hypothesized that the sickest patients carry the highest amounts of viral loads. When these patients require emergent respiratory therapies (i.e., nebulized breathing treatments, high-flow oxygen, noninvasive positive pressure ventilation, intubation, and tracheostomy care), it aerosolizes COVID-19 and that is why the respiratory N95 masks are needed. These scenarios will not be encountered by the general public.


   How Do We Preserve N95 Masks? Top


Physicians are being asked to keep N95 masks for days and either clean or disinfect the masks after working. Recently, the CDC released guidance on the decontamination processes for reuse of N95 masks. Some of the methods proposed include ultraviolet germicidal irradiation, vaporous hydrogen peroxide, moist heat, and microwave-generated steam.[13] At present, it is unclear if these processes render the masks vulnerable and new research will address questions related to filtration efficiency and mask deformation.


   What Happens When There Are No N95 Masks Available? Top


Physicians on the front lines are contracting the illness, and many have been quarantined. Some are in critical care units intubated hanging on to life. Some have died. Physicians have relayed stories on social media about not having masks available or being forced to share masks with one another. Under crisis capacity strategies, where face masks are available, the CDC has recommended:[14]

  1. Using face masks beyond manufacturer-designated shelf life
  2. Reusing face masks unless soiled or damaged
  3. Prioritizing face masks for selected activities (procedures or sick patients).


Under crisis capacity strategies, where face masks are not available, the CDC has recommended:

  1. Excluding physicians at higher risk for severe illness from COVID patient contact
  2. Designating clinically recovered physicians to care for COVID patients although protective immunity has not yet been confirmed
  3. Use of homemade masks (e.g., bandana and scarf) as a last resort with knowledge that this is not PPE.



   How Do Hospitals Know If They Are Running Out of N95 Masks? Top


It is necessary for health systems to be fully aware of fluctuating and critical N95 supplies. Health systems must predict the inflow number of patients, levels of patient sickness that require N95 mask utilization, and essential personnel numbers required to safely care for patients. The CDC has created a mathematical spreadsheet with a PPE burn rate calculator to help health systems for these purposes.[15] In addition, the European CDC has created recommendations for minimum amounts of PPE for staff (nursing, medical, cleaning, and assistants) and numbers of PPE sets required for suspected and confirmed cases (mild versus severe symptoms).[16] Creating internal policies for N95 conservation must be carefully balanced to prioritize physician safety.


   What Can We Do? Top


We cannot afford to sacrifice our frontline ED physicians with irresponsible fear by falling victim to N95 mask hysteria. We must enact policies to safeguard our precious resources and protect our most vulnerable patients and the physicians who valiantly serve to watch over our communities.



 
   References Top

1.
World Health Organization. Who Characterizes COVID-19 as a Pandemic. World Health Organization; 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen. [Last accessed on 2020 Mar 21].  Back to cited text no. 1
    
2.
Feng E, Cheng A. COVID-19 has caused a Shortage of Face Masks. They're Surprisingly Hard to Make; 2020. Available from: https://www.npr.org/sections/goatsandsoda/2020/03/16/814929294/covid-19-has-caused-a-shortage-of-face-masks-but-theyre -surprisingly-hard-to-mak. [Last accessed on 2020 Mar 21].  Back to cited text no. 2
    
3.
Bradsher K, Alderman L. The World Needs Masks. China Makes them-but has Been Hoarding them; 2020. Available from: https://www.nytimes.com/2020/03/13/business/ma sks-china-coronavirus.html. [Last accessed on 2020 Mar 21].  Back to cited text no. 3
    
4.
Food and Drug Administration. N95 Respirators and Surgical Masks (Face Masks). Food and Drug Administration; 2020. Available from: https://www.fda.gov/medical-devices/personal-prote ctive-equipment-infection-control/n95-respirators-and-surgical-masks-face-masks. [Last accessed on 2020 Mar 21].  Back to cited text no. 4
    
5.
Heffman T. Can HEPA Air Purifiers Capture the Coronavirus? Yes and No; 2020. Available from: https://thewirecutter.com/blog/can-hep a-air-purifiers-capture-coronavirus/. [Last accessed on 2020 Mar 21].  Back to cited text no. 5
    
6.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) What Healthcare Personnel Should Know. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/caring-for-patients.html. [Last accessed on 2020 Mar 21].  Back to cited text no. 6
    
7.
Andrew S, Yeung J. Masks Can't Stop the Coronavirus in the US, but Hysteria has Led to Bulk-Buying, Price-Gouging and Serious Fear for the Future; 2020. Available from: https://www.cnn.com/2020/02/29/health/coronavirus-mask-hysteria-us-trnd/index.html. [Last accessed on 2020 Apr 06].  Back to cited text no. 7
    
8.
9.
World Health Organization. Shortage of Personal Protective Equipment Endangering Health Workers Worldwide. World Health Organization; 2020. Available from: https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective- equipment-endangering-health-workers-worldwide. [Last accessed on 2020 Mar 21].  Back to cited text no. 9
    
10.
van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020;382:1564-7.  Back to cited text no. 10
    
11.
Cascella M, Rajnik M, Cuomo A, Dulebohn S, Napoli RD. Features, Evaluation and Treatment Coronavirus (COVID-19). Treasure Island (FL): StatPearls [Internet]; 2020.  Back to cited text no. 11
    
12.
Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020:e200994.  Back to cited text no. 12
    
13.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Healthcare Professionals Optimize PPE Supply N95 Respirators. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html. [Last accessed on 2020 May 26].  Back to cited text no. 13
    
14.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Healthcare Professionals Optimize PPE Supply. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html. [Last accessed on 2020 Mar 21].  Back to cited text no. 14
    
15.
Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Healthcare Professionals Optimize PPE Supply. Centers for Disease Control and Prevention; 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html. [Last accessed on 2020 May 26].  Back to cited text no. 15
    
16.
European Centre for Disease Prevention and Control. Personal Protective Equipment (PPE) Needs in Healthcare Settings for the Care of Patients with Suspected or Confirmed Novel Coronavirus (2019-nCoV). European Centre for Disease Prevention and Control; 2020. Available from: https://www.ecdc.europa.eu/sites/default/files/documents/novel-coronavirus- personal-protective-equipment-needs-healthcare-settings.pdf. [Last accessed on 2020 May 26].  Back to cited text no. 16
    




 

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