EXPERT REACTION: Concerns over lack of masks and PPE for those treating COVID19

What PPE is needed to treat a coronavirus patient? 

A. There are two types of masks; surgical and N95. The design of the surgical mask is tested in a lab to ensure it effectively resist at least 98% of particles that are droplet size and are resistant to blood. The surgical masks provides protection against droplet spread for all healthcare workers providing routine care to COVID-19 patents. N95 masks resist smaller particle sizes tan surgical masks. N95 are required when healthcare workers perform an aerosol-generating procedure (causing small particles to be be expelled by the patient such as placing a breathing tube into a patient)

What issues do we currently have with PPE supply? 

A. The Australian guidelines stipulate that healthcare workers must use a new mask with each new patient, when the mask becomes moist during caring for the patient, and the healthcare worker must remove the mask when leaving the patient’s room so a new mask must to used for the next patient care episode. This means the number of masks used will be very high. Prior to the pandemic the number of patients who required care from a healthcare worker needing to wear a mask was lower than during a pandemic because of the surge in patients who can infect healthcare workers. All countries that have a high number of COVID-19 patients are concerned that the supply will not meet the required number of these essential equipment.

Can people safely reuse masks? (writing name in them to use for the whole day etc) 

A. During SARS 2003 outbreak healthcare workers reused their own masks because of the high number of SARS patients and the high number of procedures that required the healthcare worker to wear a mask. They placed their N95 mask into a labelled bag and re-use it the following day until the mask was moist or damp and then they replaced it with a new one. This is not ideal safety standards, this is an emergency response to severe disruption to the supply chain.

There is a new publication that tested the equipment of 13 healthcare workers, including their masks, to determine whether these were contamination after they provided care to COVID-19 patients. They found no virus on the masks. If we find that we have a sever supply problem the findings that no virus contaminated the masks might help us to identify a safe method of reuse ones own mask. However, the study had limitations (1) the care provided by the 13 healthcare workers did not include an aerosol generating procedure. (2) the authors acknowledged they used an inferior method, swabbing of the outside of the masks, to test for virus and this method may have a reduced ability to identify the presence of the virus.  We can’t safety, yet, reprocess N95 masks because it degrades  the strands within the mask. The World Health Organization (WHO) is right now work with global experts to identify the safety method of extending the use of masks.

What are the guidelines around masks and are these already being broken? 

A. See the first response. To my knowledge, at presence the guidelines are complied.

Can people make their own safely?

A. No.  The production of masks is complex, for example some masks are made up of polypropylene central layers that are charged to prevent penetration of particles and designed to fit the face to provide a seal to prevent small particles from entering the mask. Both N95 and surgical masks are lab tested to ensure they filter at least 98% of a lab particles (referred to as the ‘most penetrating particle')

With global shortages reported, what are our options for increasing supply?

A. Longer term could be to locally produce masks.

The Personal Protective Equipment that is needed to treat people with Coronavirus depends on the situation, but essentially it is that for which any contagious agent that is spread by respiratory droplets.  I refer you to the recommendations of the Australian Government:

https://www.health.gov.au/sites/default/files/documents/2020/03/interim-recommendations-for-the-use-of-personal-protective-equipment-ppe-during-hospital-care-of-people-with-coronavirus-disease-2019-covid-19.pdf

• What issues do we currently have with PPE supply?

"The main problem is surge demand, and the ability of both manufacturers and the logistics to get the supplies to where they are needed. These are compounded by a number of factors including inappropriate use (potential demand for use by people not having direct patient care), hoarding, and the move in recent years to hospitals progressively reducing the amount of capital sitting on shelves.

Since the 1990s there has been a movement towards a 'just in time' supply practice that replaced a 'just in case' practice, where hospitals held vast quantities of supplies that often went out of date. The 'just in time' practice has served the system well, but was always predicated on the ability for the manufacture and medical supply chain to respond nimbly to changes in demand.

In response to rising consumable prices that were not able to be addressed by hospitals individually, most states established mechanisms by which collective purchasing arrangements could be entered into for the secure supply of goods and services. In NSW for example, this function was provided by the Peak Purchasing Council, In Victoria by Health Purchasing Victoria. 

Tenders (and the resultant contracts) for the supply of goods and services always had clauses that addressed the need for suppliers to meet demand; but this was never envisaged at the extent we currently find ourselves in. In addition, there has been a movement offshore of many manufacturing processes to countries where labour costs are more competitive; including China.

Those manufacturing processes that have the capacity for creating PPE are also often are associated with the manufacture of domestic toilet paper, and due to the panic hoarding by the public they may have been pressured to meet that demand at the expense of PPE production.

People cannot really safely reuse masks. Most masks do not provide the protection that the lay person thinks – they don’t filter out viruses. The provide a physical barrier to droplets being projected into the mouths and respiratory passages of people nearby. That said, there are some types of masks that will provide effective filtration, but they are few and far between and frankly, unnecessary if standard universal droplet precautions are taken.

Can people make their own masks safely? They can waste their time doing so, but it would only provide psychological comfort, so it might be worthwhile for some. Macramé, crotched and knitted masks will no doubt appear, but will be as useful as a chocolate teapot. People are far better off staying away from each other and maintaining a physical separation and washing their hands frequently. It’s not sexy or sophisticated, so people doubt its effectiveness.

Our options for addressing the supply issues are: simply to reduce the demand by avoiding passing on the infection, to understand that supply chains will be disrupted, to immediately forbid the general public to purchase hospital intensive barrier PPE for household use, to encourage local producers to consider ways in which their production facilities could be modified to respond to need, and to suspend elective surgery in the short term. All hospitals and healthcare facilities should review practices and current holdings and area health management must monitor and identify areas of true need.

The type of RPE (Respiratory protective equipment) that medical professionals ideally need is the dual purpose surgical mask and P2 (N95 in the US) respirator (mask). This type is designed to seal well around the face so it protects both the wearer and the patient.

I cannot comment on current supplies, however it is easy to believe they are in short supply. There are two companies I am aware of the manufacture surgical/industrial masks and respirators in Australia, however the issue is that we have no companies manufacturing the non-woven filter media they are composed of. Most filter media manufacture is in the USA/Europe/China and they appear only able to meet current needs at present.

It would be possible to disinfect and reuse the flat surgical type masks, however for a P2/N95 rated respirator (mask), they usually rely on an electrostatic charge to enhance the filter performance. This would be removed during disinfection, plus there is a high likelihood of damaging the filter media. A disinfected mask would be better than none at all. Reuse without disinfection would not be a good idea as the mask could aerosolise collected droplets which may contain virus.

Surgical masks work as a physical barrier for large droplets. When a health care worker wears one it provides protection for the both the health care worker and the patient. The health care worker is protecting their mucosa (mouth and nose) from large droplets from the patient and similarly the patient is protected from the droplets from the health care worker, generally this would be in the surgical setting where the patient has an open surgical wound. Surgical masks do not contain special filters, they are generally made of mats of nonwoven fibrous materials such as fiberglass paper or polypropylene. It is the tightness of the material within the mask that defines the difference between a surgical mask and an respirator. Surgical masks do not create a seal around the face.

Homemade masks potentially pose a risk to the wearer. Not only would a home-made mask not work as consistently, or as well, as a TGA-approved one would, wearing a mask encourages people to touch their face which in turn increases the risk of transferring microorganisms from the environment to their mucosa. Doffing (taking off) PPE is a particular skill and is a point where people do get infected. It requires practice and meticulous attention to detail, home-made masks often increase this risk. Potentially wearing a mask could give someone a false sense of security. This may lead them to be less likely to remain at home if unwell as they may think they have been protected my wearing the mask.

I would recommend that people do not make their own masks. Using appropriate social distancing, staying at home if unwell, strict adherence to hand hygiene and not touching your face is more effective. For those promoting the use of home-made masks they need to fully consider the risks. The CDC in America does talk about the use of home-made masks which includes the statement that home-made masks are not considered PPE and that they should be used in combination with a full face shield.

Australia has had decades of offshoring and outsourcing manufacturing to countries where labour is cheap, especially China. That has worked for us because we have had continuous supply of cheaper products – especially for small and light items like face masks that are easy to ship. But the consequence is that we are not prepared for emergencies and supply chain disasters like what we face today.

We cannot produce our vital health care supplies in Australia. It won’t be surprising if hospitals will soon rely on public donations of face masks for health workers. Building new production capacity in Australia where we have spent decades economising through offshoring is not easy.  Even if it is possible to force local production today, it is very unlikely to keep pace with this current pandemic-spurred demand. The coronavirus pandemic is an opportunity for Australia to rethink the idea that offshoring is the best way to operate.

• What PPE is needed to treat a coronavirus patient? 

"PPE is really needed to protect clinical staff from the patients with COVID-19, this includes masks, gowns, and hairnets."  
 

• What issues do we currently have with PPE supply?

"This is hard to answer as the hospitals still have PPE, but the average person on the street can’t buy PPE.  The government has stockpiles but has not said how much which is causing the anxiety. "
 

• Can people safely reuse masks? (writing name in them to use for the whole day etc) 

"The current evidence is that they can not be safely sterilised for reuse,  The masks mostly have a plastic fibre filter and it is damaged by heat and alcohol."
 

• What are the guidelines around masks and are these already being broken? 

"Each mask manufacture would have guidelines for how long a mask can be worn, and each hospital has a policy around when the masks have to be changed.  The issues is that there might be different rules from one hospital to the next."
 

• Can people make their own safely? 

"No – there is no evidence that homemade masks work.  However a simple face shield made from a sheet of Perspex would protect people from direct contact with someone that is coughing in front of them. "
 

• With global shortages reported, what are our options for increasing supply? 

"The best option for any country is to locally produce masks.  Supplies are low globally so you can’t simply order more from overseas."