In the Pandemic Times: All About Those Masks

Written by: Smiler and Amber

04.04.2020

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The coronavirus COVID-19 has been around shutting down cities and taking over 60,000 lives on planet Earth since this January.  Now with over 1,130,000 confirmed cases and still increasing everyday, regardless of where you are we all have one same mission: to protect ourselves from THE VIRUS.  But to do that, we have to do it the right way.  This article sifts through the loads of information circulating on the internet and provides you with the trusted information from scientific publications, guidelines from medical experts, research institutes, hospitals and international CDCs in combat with the coronavirus.  In other words, here you would be informed of the proper, if not the best, ways to protect yourselves from the virus.

Before going through the measures general public could take in prevention of being infected, the most important thing one should know is the common symptoms of the COVID-19.  Helping realise infected cases as soon as possible through more tests and refraining them from being in close contact with more people to reduce potential spread — that’s how social distancing works.

 

Common Symptoms

The most common early symptoms are fever and dry cough, found in over 65% of the confirmed patients.  Shortness of breath, phlegm production, fatigue, pain in muscle and joints, headache and loss of smell & taste were found in approximately 15-40% of the patients.

If you find yourself developing the mentioned symptoms, especially respiratory symptoms with a risk of having contact with COVID-19 patients, reach out to respective medical organisations in your area to get yourself tested as soon as possible.  Prior to seeking medical advice, Pantai Hospitals suggested 7 crucial steps to be taken to avoid further spreading the virus as you are out in the public:
1. Wear a surgical mask immediately.
2. Avoid any direct contacts with others.
3. Avoid travelling in public transports.
4. Seek immediate medical advice. Inform them about your recent travel and symptoms.
5. Cover your mouth and nose with tissue when coughing or sneezing. Dispose tissue after use.
6. Clean hands with soap and water or hand sanitisers regularly.
7. You will be placed in isolation where doctors or nurses will then advice you on the necessary test and steps to be taken.
More information on how symptoms developed is provided in this video:

In this post and the next, we will be covering what you could do in different scenarios with the selection and disinfection of masks, household items, also in changing your routine and boosting your immune system to reduce the risk of being infected and infecting others.  First we will be comparing different types of masks, informing you of the effective ways to put on and take off masks and gloves, how to reuse masks and alternatives when you cannot get hold of made masks.

 

Types of Masks

Whether masks could protect one from catching the virus is still under debate, but there is consensus among healthcare and medical experts that they could avoid spreading of the virus by masking the virus in.  Masks are useful in avoiding droplet spread, the most immediate spread from coughing and sneezing of a patient, and therefore has been recommended by authorities as one of the protective gears in this fight.  In many Asian countries, the use of masks in general public has been promoted by the governments since the beginning of the outbreak.  Seeing their success, more recently governments in other regions are also following.  In Austria, the Czech Republic and Slovakia, covering one’s face in public is already made mandatory.  Even the director of the Centres for Disease Control and Prevention (CDC), who earlier expressed that people should not wear masks, was saying that the CDC is reviewing its previous guidelines and may recommend mask use in the general public to prevent community infection.

 

Masks also protects healthy people from catching the virus when someone nearby sneezes or coughs by spreading air droplets.  Recently the U.S. National Academies of Science, Engineering and Medicine and CDC stated that the virus is contagious through breathing and conversation as well, recommending at least 6 feet social distance needs to be maintained. In order to protect besides social distance a good mask would be protective. Wearing masks would reduce the risk of spreading the virus since many infected people are asymptomatic or presymptomatic before the pandemic starts to show symptoms. Masks prevent people from touching their facial area which is the most vulnerable part in human body to catch the virus during social interaction or touching infected surfaces. However they are only effective as long as the social distance is maintained.

 

There is a great range of masks out there, including surgical masks, N95 masks and industrial masks that are widely used against the COVID-19.  To choose the suitable masks, depending on the risks you would foresee of yourself exposed to the virus and the amount of time of the exposure, different choices are recommended.
Generally there are 2 criteria for a mask to be effective against the coronavirsus:
1. the ability to filter the virus        2. the coverage of the mask

 

In filtering the virus, all surgical masks, N95 masks and industrial masks were capable of performing well, however among them only N95 and 3M industrial masks were reliable with consistent test results.  3M industrial masks were made to block micro particles and dust particles to begin with, therefore having no problem filtering the coronavirus considering its size.  In an experiment, 95% of the particles were filtered out, including particles that were down to 0.007 micron, smaller than 1/10 of the size of the coronavirus COVID-19 (0.1 microns = 100 nanometers).

 

N95 masks are as reliable since they were studied with actual viruses.  In a previous study where researchers shot virus particles (10-80 nanometers) that were smaller than the coronavirus at N95 masks, the masks were able to capture over 95% of the virus particles.  In the same experiment, although surgical masks could filter 84.5% at the best case, the rate could also be as low as 20.5% in another.  In certain scenarios if put on correctly, surgical masks even though not as good as the others, could still be effective against the coronavirus.  But bear in mind that this kind of masks are not as reliable as N95 or 3M industrial masks.

 

One of the main reasons contributing to the unstable rate in capturing particles is the consistency in the coverage of the masks.  The N95 and 3M industrial masks are more reliable with their seal fit design that ensures maximal protection with the best fit under seal check while surgical masks do not.  Looser fitting surgical masks are less ideal in coverage as they leave gaps at the sides that are prone to leakage and the gaps could vary in size when wearers move their heads or speak.
coronavirus: 0.1 micron = 100 nanometers (nm)

 

Choosing Your Masks

If you are a healthcare personnel or would be exposed to higher risks of contacting with a potential patient, you are suggested to get respirators comparable to N95 standards, which the standards should have a Particle Filtration Efficiency (PFE) of 99.9% @ 0.1 micron.  These respirators are especially listed by the US CDC as recommended models for heathcare personnel.
  • 3M 1860
  • 3M 1870
  • 3M 8210
  • 3M 9010
  • 3M 8000
  • Gerson 1730
  • Medline/Alpha Protech NON27501
  • Moldex 1512
  • Moldex 2201

Below are some of the comparable performance standards and product classification, a longer list could be referred to in https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html.

  • Australia
    performance standard: AS/NZS 1716:2012
    product classifications: P2, P3
  • China
    performance standard: GB 2626-2006
    product classifications: KN100, KP100, KN95, KP95, KP99
  • Europe
    performance standard: EN 149-2001
    product classifications: FFP2, FFP3
  • US NIOSH
    performance standard: US NIOSH RequirementsNIOSH approved 42 CFR 84
    product classifications: N100, P100, R100, N99, P99, R99, N95, P95, R95

If you are not a healthcare personnel or someone with a higher risk of exposure to potential patients, you can consider other alternatives according to your risks, budget and supply.  To solve the fitting problem in typical surgical masks without paying so much for a N95 or industrial respirators, there are still plenty better fitting masks as affordable alternatives that are economical and accessible.  When choosing your alternatives, look for those of Particle Filtration Efficiency (PFE) and Virus Filtration Efficiency (VFE) standard and keep an eye on the ASTM levels to target the particular size of 0.1 microns of this coronavirus (FFP2 would stand for filters specifically against viruses).  The masks should have at least 95% filtration efficiency of PFE @ 0.1 micron, or of ASTM level 1.

 

  • Nelson Laboratory Standards
    Bacteria Filtration Efficiency(BFE): 3 microns particles
    Particle Filtration Efficiency(PFE): 0.1 microns particles
    Virus Filtration Efficiency   (VFE): 0.1-5 microns particles
  • ASTM Levels
    Level 1:   >=95% BFE, >=95% PFE
    Level 2:   >=98% BFE, >=98% PFE
    Level 3:   >=98% BFE, >=98% PFE

 

When buying your next masks, check whether the model was declared a defect batch previously, buy from official stores if possible and refrain from buying via unknown source before handing out your cash (or clicking the “pay” button).  Don’t forget to keep them in dry and clean storage space after you get those precious resources.

 

Putting On, Taking Off and Disposing Of Masks and Gloves

It is equally crucial to use your masks and gloves the correct way to avoid touching the virus particles filtered on the surface when you take them off.  A publication based on lab experiment found that the coronavirus COVID-19 could remain infectious on the outer layer of surgical masks for at least 7 days, making responsible disposal of masks crucial in keeping the virus away.

 

When Putting On surgical-level masks, 5 steps are advised in guidelines from medical authorities to the public:
  1.     Wash your hands with soap or santise with hand sanitisers or alcohol.
  2.     Check that the mask is clean and not damaged.
  3.     Check that the nose strip is facing upwards and the outer layer of the mask is facing outward.
  4.     Put on the mask with ear loops or bands, to covering mouth, nose and chin.
  5.     Mould or adjust nose strip to fit wearer’s nose shape.

 

For N95 or industrial respirators, one more step of seal check has to be done.
  • Positive Pressure Seal Check(for non-valvued respirators)
    Place both hands completely over the mask and exhale.  If the mask bulge slightly, the test is passed.
  • Negative Pressure Seal Check(for valvued respirators)
    Place both hands completely over the mask and inhale.  If the respirator collapse slightly, the test is passed.

 

Links to detailed info:
Put on masks: https://www.pantai.com.my/assets/public/images/coronavirus-infographic-2-en.jpg
Put on N95 seal check: https://www.uwsp.edu/rmgt/Pages/ehs/environmental/respiratory-protection.aspx

 

When Removing disposable masks, 5 other steps are advised:
  1.     Wash your hands with soap or santise with hand sanitisers or alcohol.
  2.     Hold ONLY the ear loops/ ties/ bands, avoid touching inner or outer surface of the mask.
  3.     Lift the mask away from your face.
  4.     Dispose of the mask in a rubbish bin with a lid.
  5.     Immediately wash your hands with soap or sanitise with hand sanitisers or alcohol.

Links to Videos Demos
N95 masks:

 


Masks in general:

 

When Removing gloves, 8 steps are advised:
  1.     Pinch and hold the outside of the glove near the wrist but not touching the wrist.
  2.     Peel downwards and away from the wrist, turning the glove inside-out.
  3.     Pull the glove away to completely take it off, hold it in the hand you took it off with.
  4.     Slide fingers of the un-gloved hand into the other glove in gaps under the wrist, without touching the outer surface.
  5.     Peel downwards and away from the wrist, turning the glove inside-out.
  6.     Pull the glove away to completely take it off, hold inner surface of the glove as a pocket with the other glove inside the pocket.
  7.     Dispose of the gloves in a rubbish bin with a lid.
  8.     Immediately wash your hands with soap or santise with hand sanitisers or alcohol.

Link to Videos Demos
Removing gloves:

Extended Use and Reuse of Masks

Because of the scarce resources available, extending beyond the regular recommended using time of masks or reusing them might be a better option than to go out with no protection at all. SARS-CoV-2, the virus causing COVID-19, survives in the environment, including on surfaces of various materials such as iron, cardboard and tissue. This explains that there is a risk that the outer surface of respirators and surgical masks used in patient care can quickly become contaminated. Contamination of the surface of respirators and surgical masks entails a risk for infection when reusing a mask or respirator.

 

Decontamination and reuse of masks is not a new idea. Researchers have tested a variety of methods — ultraviolet light, bleach, ethylene oxide gas, moist heat — and have concluded in published papers that decontamination can work. However please always have in mind that many masks were NOT made or designed to be reused at first place, also that reusing masks would lower their effectiveness in filtering.  Among the two options, extended use is always preferred over reusing, since keeping the mask on longer could still maintain minimal touching of the mask and could reduce the risks of virus slipping into the inner layer of masks.  Reuse on the other hand should be kept in as minimal number of times as possible.

 

Bathroom breaks, meal times or contamination concerns etc could cause masks to be removed so that reuse would be necessary in a proper way, which is the determining factor in how long a mask should be used. If a time length is to be suggested, N95 respirators are generally good for 8 hours and surgical masks are good for 4 hours of uninterrupted use.

 

Storing Masks before Decontamination
The facemask should be removed and discarded if soiled, damaged or hard to breathe through. If the mask is undamaged and reusable, it should be stored for later use after properly sterilised according to its type. Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean sealable paper bag, sealable brown paper bag or breathable container (brown paper lunch bagsproviding they are new and unused, but these bags may not be reused. A new bag must be used each time it is stored). When a facemask is carried back home when used outside of the house it could be folded the same way and put in a ziplock bag till it is properly stored at home.

 

Decontamination of Masks

For the decontamination of N95 masks, multiple publications have suggested 3 main methods with heat & humidity, UV-C and Hydrogen Peroxide Vapor & Hydrogen Peroxide Gas Plasma. Beware that all methods require very specific monitoring in intensities and timing to ensure proper decontamination while not damaging the masks.

 

Heat and humidity may be the most available option to disinfect them at home and this method could disinfect both inner and outer layers of the mask thoroughly.  Based on the facts that 70°C at 85% humidity for 30 minutes did inactivate H1N1 and H5N1 on N95 masks, the COVID-19 was found not infectious in 70°C after 5 minutes, and N95 maintains filter performance at 5 cycles of 60°C heat and 80% humidity, it is advised that N95 masks should only be reused for no more than 6 times with this decontamination method used.  Wearers should also check the mask’s seal every use.

 

Steam sterilisation is a routinely used procedure in hospitals. Mask deformation or failing fit test after steam sterilisation at 134 °C has been reported in a study performed in the Netherlands, depending on the type of FFP2 mask used. Steam sterilisation at lower temperatures is under study.

 

University of Nebraska Medical Center’s chief of infectious diseases Dr.Mark Rupp: “The data is very clear that you can kill and inactivate viruses with UV germicidal irradiation. It is also very clear that you will not damage the respirators.”  With UV-C decontamintaion, stronger UV-C requires designated devices which sunlight may not be able to fulfill.  Based on the facts  that ≥1 J/cm of UV-C was found useful in inactivating viruses similar to SARS-CoV-2 on N95 masks and that the masks maintains filter performance after 10-20 cycles of 1–1.2 J/cm-square UV-C-square, it is advised that N95 masks should only be reused for no more than 10 times with this decontamination method used.  When disinfecting with UV-C rays each time two cycles has to be done.  One cycle should be facing the outer layer of the mask, and the other should be reaching the inner layer.  Wearers should also check the mask’s seal every use.

 

Procedure of applying UV light on masks

Masks conform somewhat to the health care worker’s face, and a tight seal is necessary. So each health care worker’s mask is returned to its user after decontamination. Health care workers write their names on their masks before they first use them. After they remove the masks for decontamination, they are placed in brown bags labelled with their names. The bags are transported to a special room covered in a beige paint that reflects UV light. After the masks are treated, each one goes into a white bag with the health care worker’s name on it.

 

The procedure is experimental, and there are uncertainties.  For instance: How many times can a mask be reused? For now, staff members will use each mask for a week before disposing of it. But the medical centre may decide to keep using the masks for 10 days, or even two weeks, University of Nebraska Medical Centee’s chief of infectious diseases Dr Mark Rupp said.

 

John Lowe of the University of Nebraska Medical Center, who designed the mask decontamination program said: “there are really good data that it can decontaminate and that it doesn’t degrade the masks a significant amount.”

 

A study by the US Food and Drug Administration (FDA) showed that hydrogen peroxide vapour (HPV) was effective in decontaminating N95 respirators. According to a pilot study in the Netherlands the method is effective for two decontamination cycles without deformation while retaining filtration capacity. The experiment showed that the tested FFP2 masks (models without cellulose) can be re-used up to two times. A possible problem with this method is that harmful concentrations of hydrogen peroxide may remain on the mask for days after decontamination.

 

Even though it is not recommended, even healthcare workers at the Miami VA hospital are being told to reuse one surgical mask for a week at a time, therefore disinfecting and reusing facial masks is a necessary subject to work on. It is possible to decontaminate masks through UV lights and an experimental procedure is ongoing about it.   To prevent the contamination of surgical masks and extend the use of them without needing to increase the contamination risk by reuse, transparent shields could be worn on the entire face on surgical masks.

 

To decontaminate cloth or cotton masks, the same method using heat and humidity mentioned in the above for N95 could be used.  Based on the findings that the COVID-19 was found not infectious in 70°C after 5 minutes, and in 56°C after 30 minutes, it is advised to soak cloth masks in hot water idealy at 70°C and then wash with your choice of disinfectants.

Alternative When There Is NO MASK

When you could not get hold of any store-bought masks, there are still things that could be done to at least have some protection.  At least you could make your own masks.  Just like store-bought masks, homemade masks also come in many designs and levels of filters.  Here we suggest 3 types with different materials.  The two prototypes developed by The University of Florida Health’s Department of Anesthesiology are like the homemade version of N95, meant to be made with heavy duty fabric readily available in medical facilities.  The cotton mask with pocket for filter designed by an alum in University of Minnesota could be more flexible depending on the available household materials as filters.  The filters could be changed from time to time as well.  The Patricia Mask designed by the West Virginia Mask Army uses furnace filters, one of the popular household filters.

 

Two Mask Prototypes for HALYARD H600 Medical Fabric, developed by The University of Florida Health’s Department of Anesthesiology

The prototypes were to be made with HALYARD H600 Medical Fabric, heavy duty fabric of industry standard for sterile processing teams in hospitals.  Prototype 1 looks like a surgical mask, with a three-pleat design that covers the face from below the eyes to below the chin.  It is easier to make and masks over a larger area of the face.  Prototype 2 is cone-like, masking over a circled area around the nose and mouth.  It is more complicated with the 3D shape and the wire inserted.

 

Cotton Mask with Pocket for Filter, designed by University of Minnesota alum Shannon Williamson

The two-layered mask is more complicated than most DIY designs as it provides a more secure fit to faces and includes a filter pocket.  It could be made with household items, namely cotton fabric, ties , wire, thread and filter material of your choice.  Furnace filters and vacuum cleaner bags were recommended as filters to be inserted into the filter pocket.

 

 

Patricia Mask, desgined by West Virginia Mask Army

The mask is another one having a similar shape as surgical masks, but does not use cloth.  The mask is directly made out of furnace filter with elastic ear loops.

 

Besides making homemade masks, other measures such as making ventilated headboards with 3D printing, social distancing, disinfecting household items and sanitising hands regularly are all viable options.  The new habits and routines to be adopted in the pandemic times will be covered in detail in the next post.

 

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References

  1. Information about Masks Generally
  2. Types of Masks
  3. Recommended Procedures in Putting On, Taking Off and Disposing Of Masks and Gloves
  4. Extended Use and Reuse of Masks
  5. Alternative homemade masks
    https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html
    https://www.pantai.com.my/Coronavirus

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