Many Masking Problems Can’t be Masked

As of early October 2021, there have been over 233 million cases of COVID-19 and 4.7 million associated deaths worldwide.¹ These numbers likely represent a significant undercounting due to asymptomatic and presymptomatic cases as well as access to testing, roadblocks to care, and the amplification of existing social and racial inequities. The COVID-19 pandemic has revealed many vulnerabilities in our health care and public health systems, but also in our ability to prepare for and respond to infectious disease outbreaks and pandemics.

Fundamentally, this has been a painful lesson in situations we thought we were better equipped to handle and weaknesses we had been ignoring. For so many of us working in infectious disease, public health, and infection prevention, many failures we saw were not unexpected. In fact, it seemed many were issues and red flags we had been raising for years, from inadequate pandemic planning in hospitals and other health care facilities to challenges in fit-testing large numbers of health care workers emergently and hurdles to getting enough isolation room.

Saskia v. Popescu, PhD, MPH, MA, CIC

These are things we knew would be problematic during a pandemic; they do not include the obvious factors like hurdles in quarantine/isolation in the community, science communication, health care and essential worker burnout, etc. Fundamentally, this pandemic has held a large mirror up to the world—but will we remember these lessons?

For infection preventionists (IPs), one of the biggest roadblocks was access to personal protective equipment (PPE), specifically masks, during the first year of the pandemic.² We always expected supply chain hurdles but nothing could have prepared us for how chaotic and worrisome this experience has been.

Role of IPs

Although IPs are not responsible for procurement of PPE, we work closely with the supply chain and procurement departments within health care facilities to ensure adequate supplies and review new ones to discuss quality, product availability, needs, etc. There is an intrinsic relationship between these 2 departments that was amplified during the COVID-19 pandemic.

When supplies—specifically of masks like N95s—began to dwindle, the realization hit: We will have to move to an emergency process and reuse or extend use of the masks we have been telling individuals for years to dispose of after caring for a patient. Soon, these shortages pushed us to evaluate the use of KN95 masks,³ which were not previously allowed in the United States because of a lack of quality assurance.

Following this, gowns and in some cases disinfectants become the hot commodity. While there were toilet paper shortages across the United States, we were increasingly just trying to buy what we could. As part of the problem, hoarding became an issue. To implement reprocessing of masks through disinfecting measures like UV radiation C (UV-C) or to enable extended use, we had to centralize many supplies because of such shortages.

For many health care professionals, this gave the impression that masks were being withheld, which added stress, frustration, and distrust during an already complex, exhausting situation. This was perhaps one of the more challenging times, as IPs worked to communicate that masks were available or that there existed a process for obtaining them. Therein lies our role—a bridge between the patients or health care workers and ensuring safety through supplies, processes, etc. In this case, many of us felt helpless.

Like so many, we turned to alternatives that opened the door to more supplies or at least extended use. Disinfection and extended use became more common, with processes shared by organizations and agencies like the CDC. Another option was reusable elastomeric particulate respirators,⁴ which were made of rubber material and could be repeatedly cleaned, disinfected, stored, and reused. Per the CDC, “They are available as alternatives to disposable half-mask filtering facepiece respirators (FFRs), such as N95 FFRs, for augmenting the total supply of respirators available for use by HCP [health care practitioners]. [Although] elastomeric respirators are not cleared by FDA for fluid resistance, based on their NIOSH [National Institute for Occupational Safety and Health] approval, they can provide at least equivalent protection to N95 FFRs. Some types of elastomeric respirators can offer higher assigned protection factors than N95 FFRs.”

While we were addressing the other needs of PPE, the use of elastomeric respiratory opened the door to what the future may look like for infection prevention and masks in general. The hard part is whether we feel comfortable moving the needle when it comes to what we have always seen PPE as—a disposable mask and gown, etc.

What We’ve Learned

The lessons learned from COVID-19 will likely take years to truly understand. Perhaps one of the most telling comes from the front lines of health care in terms of masks and PPE. The issue is 2-fold—we need stronger supply chains for essential workers (and the public) to ensure adequate protection during emergent times, but we also need to start shifting how we approach PPE for health care workers. It’s worrisome when we must discourage the public from buying masks, specifically medical masks, to ensure adequate supplies for health care workers. As noted in the Washington Post: “Both the market for N95 masks and the national stockpile were small before the pandemic. The US imported at least half of its PPE, including medical masks, from China, where exports shrank for months because of the outbreak, said Scott Paul, president of the Alliance for American Manufacturing, a nonprofit organization that advocates for public policies to benefit US manufacturers.”⁵

What We Need

Ultimately, we need PPE that can be reprocessed both within a health care setting and at home—this issue speaks to bigger needs outside the hospitals and patient care areas. PPE that is single use can and does serve an important purpose, but one of the greatest hurdles we’ve had has been through continuously having to refit-test people when new masks come in that haven’t been used before. We need masks that can easily be fit-tested or are more moldable to ensure a good seal. Health care has such a significant waste problem and single-use PPE, like masks, is a prime example. To design more PPE like elastomeric respirators⁶ that can be reused and appropriately reprocessed would give us a significant advantage in times of stressed supplies but also ensure that we have higher levels of respiratory protection that are readily available and can be used by multiple health care workers.

Moreover, such masks should be more moldable to make fit-testing easier and more efficient. Having to redo fit-testing for health care workers when we ran out of one kind of N95 and got another brand in was extremely time consuming. There is a desperate need for us to think outside the box when it comes to PPE and to incorporate IPs and frontline responders into these conversations as well as conversations about research and development. Our approach to PPE and masks is a bit antiquated and now is the time to invest in innovation and pragmatic solutions, but we need to call upon the individuals who have experienced the hurdles of working in a pandemic.

SASKIA V. POPESCU, PHD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. In her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University in Fairfax, Virginia, where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in pediatric and adult acute care facilities.

References:

1. WHO coronavirus (COVID-19) dashboard. World Health Organization. Accessed October 7, 2021. https://covid19.who.int/
2. McKenna M. Amid coronavirus fears, a mask shortage could spread globally. Wired. February 4, 2020. Accessed October 7, 2021. https://www.wired.com/story/amid-coronavirus-fears-a-mask-shortage-could-spread-globally/
3. FAQs on shortages of surgical masks and gowns during the COVID-19 pandemic. FDA. Updated June 19, 2020. Accessed October 7, 2021. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns-during-covid-19-pandemic
4. Elastomeric respirators: strategies during conventional and surge demand situations. CDC. Updated October 13, 2020. Accessed October 7, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/elastomeric-respirators-strategy/index.html
5. Iati M. More experts now recommend medical masks. Good ones are hard to find. Washington Post. February 2, 2021. Accessed October 7, 2021. https://www.washingtonpost.com/health/2021/02/02/medical-mask-shortage/
6. Ngo H. How do you fix healthcare’s medical waste problem? BBC. August 13, 2020. Accessed October 7, 2021. https://www.bbc.com/future/article/20200813-the-hidden-harm-of-medical-plastic-waste-and-pollution