As the novel coronavirus COVID-19 continues its logarithmic leaps from person to people, across borders and oceans, trailing jokey and terrifying viral memes, it has triggered an odd assortment of hoarding behaviors in the panicky public: toilet paper, hand sanitizer, soap … and surgical face masks.

Early-and indeed, ongoing-lack of information about the virus’ etiology and pathology meant face masks have become a precious commodity. In early March, health authorities from Washington state (which by that time had announced the first COVID-19–related death in the US) sent an urgent request to the federal Strategic National Stockpile for 233,000 respirators and 200,000 surgical masks.  

They received an answer-but not the one they hoped for. They would get less than half the amount they requested: 93,600 N95 respirators and 100,200 surgical masks.¹

In late February, when US Department of Health and Human Services Secretary Alex Azar said the US needed at least 300 million N95 respirators for healthcare workers, the US had only 30 million.² As of March 5, Prestige Ameritech, one of the few manufacturers still making face masks and respirators in the US, had received requests for 1.5 billion masks.³ As of March 10, the US had a national stockpile of 12 million N95 masks and 30 million surgical masks for a healthcare workforce of about 18 million, according to an article in STAT, which notes “[i]f only 6 million of them are working on any given day (certainly an underestimate) they would burn through the national N95 stockpile in two days if each worker only got one mask per day, which is neither sanitary nor pragmatic.”⁴

The US Centers for Disease Control and Prevention (CDC) in mid-March posted new guidelines, saying surgical masks are now an acceptable alternative for N95 respirators because “the supply chain of respirators cannot meet demand.”⁵

The mismatch between demand and supply has opened questions about what actually is the best way to protect against infections like COVID-19, and who will benefit most from them. The World Health Organization (WHO) has said wearing masks may create a false sense of security among the general public.⁶ US Surgeon General Jerome Adams, MD, tweeted in exasperation: “Seriously people-STOP BUYING MASKS! They are NOT effective in preventing 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!” 

Shortfalls in protective masks have put a spotlight on 2 concerns in particular: utility and compliance. Experts agree that not every situation requires a face mask, even in this world of drug-resistant bacteria-although it isn’t always definitively clear which situations do. 

In an interview with BBC News, David Carrington, MD, of the University of London, said although routine surgical masks could help lower the risk of contracting a virus via the “splash” from a sneeze or cough, and provide some protection against hand-to-mouth transmission, they aren’t effective against airborne viruses or bacteria because they’re too loose, have no air filter, and leave the eyes exposed.⁷

Face masks have come a long way since the 1800s, when they were basically gauze strips placed over the mouth. Originally developed to minimize the risk of transmitting microorganisms from clinician to patient, they’re now intended to protect both patients and clinicians from drug-resistant pathogens transmitted by blood or other body fluids. 

Masks come in different shapes, with different features, intended for different purposes: flat-fold tie-on, duckbill with or without shield, cone shaped, flat-fold with shields…theoretically, there should be something for everyone. But they’re only effective when worn properly, and not everyone can-or does-wear them properly. Most guidelines suggest changing a surgical mask any time it becomes wet. A mask wet with exhaled moisture has increased resistance to airflow, is less efficient at filtering bacteria, and vents more.⁸ It’s not uncommon, though, says Dianne Rawson, RN, MA, in The Basics of Surgical Mask Selection, to see masks poorly fitted, placed below the nose, or wet with blood or body fluids.⁹

Even the correct mask can put clinicians at risk if not worn correctly: with nose and mouth completely covered to create a seal and prevent gaps. But fit can be an issue for anyone whose face doesn’t follow the median contours, or someone who has a beard or mustache. A 2000 study found that bacterial shedding from people with beards was increased (although an analysis of that study called it “an example of contamination being extrapolated to infection without measuring the endpoint of infection”).¹⁰

One National Health Service hospital in England has responded to the coronavirus pandemic by asking staff to “consider” shaving their beards. “I recognize,” Derek Sandeman, MD, the medical director, said, “for some this is a big ask, that beards are so popular at present. However, I do believe it is the right thing to do.” He added that alternative types of respiratory equipment are available for people who have a good reason to keep their beards, including for religious reasons.¹¹

The CDC has helpfully published a visual aid for the kinds of facial hair that work, or don’t work, with mask use.¹² Some styles, such as soul patches, pencil mustaches, and “the Zappa” made the cut. 

The current health emergency (like other pandemics) has also put a new spotlight on compliance, a complicated subject. Studies have demonstrated that healthcare workers are generally poorly compliant with respiratory guidelines.¹³ But compliance studies often run into the Hawthorne effect: Knowing they’re being observed, staff tend to improve their adherence. 

Interestingly, a 2019 study found that following hospital protocol for using N95 respirators was a given-until it wasn’t. Discussions with focus groups of nurses and nursing assistants at 4 Veterans Administration and academic medical centers revealed that discomfort was not the main issue. People wanted to follow respiratory protective equipment (RPE) protocol, the investigators said, but RPE misuse was driven by “personal” protocols, such as when people did not trust the protocol and instead relied on their experience. Generally, the misuse amounted to overuse-staff didn’t trust the safety protocols and wanted to protect themselves and patients. The overuse, of course, is a factor in supply shortages.¹⁴

Moreover, according to researchers who reviewed studies on facial protection, healthcare workers may view standard precautions as adversely affecting job performance and their relationships with patients: They cite insufficient time, interference with job duties, reduced dexterity, and discomfort.¹⁵ But the investigators also found peer pressure and attitudes of family members who were afraid of contracting infection influenced the actions of the healthcare workers, making them more likely to adhere to safety procedures.¹⁶ One health professional said, “I think the fear of contracting the disease was palpable, very real. Nobody was trying to cut corners.”¹⁷

The CDC has issued interim recommendations, tempered with reality: When possible-given the current shortages-patients with confirmed or possible infection should wear surgical masks, and healthcare workers treating potentially infected patients should wear N95 respirator masks and goggles. N95 respirators are more protective, reducing exposure to small particles, filtering out at least 95% of airborne particles, and, because of the tight fit, allowing minimal leaking¹⁸ (the National Institute for Occupational Safety and Health recommends fit assessment during the initial selection of a respirator and periodically as part of a respiratory protection program.)¹⁹  

But the tight fit that makes respirators safer than masks also makes them uncomfortable, especially when worn for long stretches. Julie Feuer, an oncology nurse practitioner in a large county hospital in Westchester County, New York, says she wears a mask for about half the day, depending on how many of her patients are on droplet isolation. Although she prefers the N95 for safety reasons, especially during this pandemic, “it’s pretty tight on my face, leaving marks-and it’s hot under there!” It’s a little claustrophobic, she says. “Regular surgical masks are easier to deal with and looser fitting.” 

Kathy Manelis, RN, agrees. Recently retired after 37 years, she worked with critically ill patients and usually wore a mask for 20 to 30 minutes at a time. She, too, found the masks claustrophobia-inducing-and they steamed up her glasses.

Alessia Bonari, a young nurse in Italy, posted a photo of the chafe marks from the respirator, saying, “I’m afraid because the mask might not stick properly to the face…I’m physically tired because the protective devices hurt…”²⁰

Respirators have also been associated with mild adverse effects, including acne, skin rashes, dehydration, and headaches. About one third of healthcare providers in one study reported headaches, which could be due to hypoxemia, hypercapnia, or stress, the researchers say.²¹ It’s also possible, they note, that the pressure from the strap on the neck over the superficial nerves might aggravate neck strain. 

Researchers who surveyed healthcare workers about respirator use said the respondents were looking for respirators that are more comfortable, interfere less with breathing, diminish heat buildup, are disposable, and permit the user to have facial hair.²² Healthcare workers have also said time constraints related to donning, doffing, and changing masks frequently are very real: “…In triage, you change your goggles, gloves, mask and gown between every patient and it’s 100% not feasible,” said one. “Patients would be dying waiting at the triage desk.”²³

The CDC offers alternatives to N95 respirators, such as other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air-purifying respirators (which can be repeatedly disinfected, cleaned, and reused), all of which provide equivalent or higher protection than N95 respirators (“when properly worn,” the CDC cautions).²⁴ Crisis strategies also include using respirators beyond the manufacturer-designated shelf life, and “limited” re-use.²⁵

Health authorities have a double-pronged problem to tackle: The pandemic-driven urgency for enough protection and the daily-use desire for more comfortable protection. The CDC has come under fire for not planning for a shortfall during the current crisis, and for not acting quickly and forcefully enough when the crisis began to expand. The result? Workers are not sure day to day whether they’ll have the supplies they need, leading to a breakdown in a crucial bond of trust. 

“…[I]f workers had more confidence in their employers’ commitment to worker health and safety,” Yassi notes, “employees would have more confidence in the messages and directives they received during a crisis.”²⁶

Jan Dyer is a writer and editor specializing in clinical topics. She lives in Suffern, NY.

References:

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2.    Secon H. People are racing to buy face masks amid the coronavirus outbreak, but they probably won't protect you from illness. Business Insider. 02-26-20. Businessinsider.com. https://www.businessinsider.com/wuhan-coronavirus-face-masks-not-entirely-effective-2020-1Accessed Mar. 14, 2020.

3.    Not enough face masks are made In America to deal with coronavirus. NPR Morning Edition. 03-03-20. https://www.npr.org/sections/health-shots/2020/03/05/811387424/face-masks-not-enough-are-made-in-america-to-deal-with-coronavirusAccessed March 14, 2020.

4.    Specht L. What does the coronavirus mean for the U.S. health care system? Some simple math offers alarming answers. STAT. 03-10-20. statnews.com. https://www.statnews.com/2020/03/10/simple-math-alarming-answers-covid-19/Accessed March 14, 2020.

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15.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. J Occup Environ Med. 2005 Jan; 47(1): 41–50. 

16.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. J Occup Environ Med. 2005 Jan; 47(1): 41–50. 

17.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. J Occup Environ Med. 2005 Jan; 47(1): 41–50. 

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23.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. J Occup Environ Med. 2005 Jan; 47(1): 75. 

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26.Yassi A, Moore D, FitzGerald JM, Bigelow P, Hon C-Y, Bryce E and other members of The BC Interdisciplinary Respiratory Protection Study Group. Protecting the faces of health care workers: knowledge gaps and research priorities for effective protection against occupationally-acquired respiratory infectious diseases. J Occup Environ Med. 2005 Jan; 47(1): 80.