COVID 19 – PPE for clinicians
Introduction and disclaimer
Hi, all. Thanks for visiting. This is little bit of the subject of the project of EndlessMedical, but since I own and operate this website, I decided to publish PPE info here. I am a nephrologist working in various clinical settings. I am not claiming to be a front line hero, or any kind of here. As a matter of fact , most of patient encounters are telehealth at this point. I also realize there is many people out there with more experience and knowledge with PPE and COVID-19. However, when I first started learning about PPE i felt lost, and quickly realized there I was missing one good source of information on PPE for clinicians. This would help me avoid buying less useful, or overpriced (after I found out later) masks, coveralls and face shields.
During this COVID-19 pandemic, I was able to accumulate some knowledge and practical experience about PPE, masks, coveralls, PAPRs, and others, that may be useful for clinicians. I want to share this. I am not advising you what PPE is adequate to a given clinical scenario or setting. I am purely sharing knowledge about various kinds of PPE out there, so you can better orient yourself in this complex matter. This is not the complete guide, and it is NOT a substitute of your employer safety policies. It may even have errors, and please if you see any point them out to me so I can correct them: firstname.lastname@example.org. I want to share some educational information for clinicians, who would like to better understand and learn more about personal protective equipment use or availability. I hope this will safe you some time, money and missed purchases. Trust me, there are people out there who are taking advantage of us clinicians and will sell overpriced, and less usefull PPE, if you don’t know any better. Please use this advice at your own risk and always check with your on-site safety officer, safety policies and occupational health department if you are allowed to and if you are safe to use any information provided here. I will also share some links to deals, safety online stores, online sellers and listings to some PPE, and will try to keep them updated. I will try to include valuable deals, and yes I may be getting paid or benefit otherwise by sharing some here.
1. Respiratory protection.
1a. Surgical (procedural) face masks used in healthcare.
Medical grade “face masks” are usually different from face masks used in hair or nail places. Medical grade face masks have the rating per ASTM of 1-3 levels resistance to fluids and barrier. As per https://www.halyardhealth.com/industry-news/2019/july/choosing-the-right-face-mask-3-things-to-know.aspx and other sources, generally the higher level gives the wearer and people around higher protection from bacterial penetration and fluid splashes. For a mask to be medical, you need at least ASTM level 1.
Use facemasks according to product labeling and local, state, and federal requirements.
- FDA-cleared surgical masks are designed to protect against splashes
and sprays and are prioritized for use when such exposures are
anticipated, including surgical procedures.
- Facemasks that are not regulated by FDA, such as some procedure
masks, which are typically used for isolation purposes, may not provide
protection against splashes and sprays.
So when you are buying masks, make sure they are at least ASTM level 1, forget about using these with no ASTM level. Of coursed FDA clearance in nice to have. Other important things you may consider, is that some are latex and glass fiber free and some are not. Of course these masks provide minimal protection to wearer. Overall they are worn to protect others. You should be still able to find some FDA cleared masks in large outlets like McKesson (although they rarely ship it to new customers), grainger.com, ebay or amazon.
1b. Disposable respirators, so called “n95” masks, but also n99, n100, p95, p99, r100, FFP2, FFP3, KN95 etc..
These are worn to protect mostly the wearer, and somewhat to protect others around the wearer as well. NIOSH regulates and approves the N, P and R masks. These are USA grades. The FFP1-3 are European. The KN95 are Chinese standards.
Let’s focus on NIOSH markings: N masks, can be usually worn for several hours in non-oily environments (hospitals/offices). P can be used for much longer, in both oily and non-ily environments (usually are slightly more expensive). R can be used for short times than N masks – hence rarely even considered. The number essentially means the grade of filtration. The higher, the higher the filtration standards met.
N95 would mean that the mask can only by used in non-oily environments, and when properly fitted should hold at least 95% of small particles with each breath. Technically they can let through almost 5% of dangerous particles with each breath. Usually they should not be used for more than several hours.
The P100 would mean, that mask can be used both in oily and non-oily environment, and that it filtrates at least 99.97%, letting pass through only 0.03% of particles. So this is much much better filtration than N95. This usually comes with price (not only $) but also, these masks are usually somewhat harder to breath through.
The FFP2 is somewhat comparable to 95, and FFP3 100 filatration grades, however they are not NIOSH approved. During the pandemic the governing agencies issued various wavers, but this changes, so you need to check FDA/CDC websites regularly. For example read here: https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/personal-protective-equipment-euas
Also, there is question of valves. The CDC does not prohibit use valved respirators, as long as these are not used in sterile field. It would be probably wise to put fluid resistant (think ASTM Level at least 1) on top these valved respirators, to protect others.
An N95 respirator with an exhalation valve does provide the same level of protection to the wearer as one that does not have a valve. The presence of an exhalation valve reduces exhalation resistance, which makes it easier to breathe (exhale). Some users feel that a respirator with an exhalation valve keeps the face cooler and reduces moisture build up inside the facepiece. However, respirators with exhalation valves should not be used in situations where a sterile field must be maintained (e.g., during an invasive procedure in an operating or procedure room) because the exhalation valve may allow unfiltered exhaled air to escape into the sterile field.
Respirators with exhalation valves protect the wearer from SARS-CoV-2, the virus that causes COVID-19, but may not prevent the virus spreading from the wearer to others (that is, they may not be effective for source control). Until data are available to describe how effective respirators with exhalation valves are in preventing the spread of SARS-CoV-2 from the wearer to others:
- Wear a respirator without an exhalation valve when both source control and respiratory protection are required.
- If only a respirator with an exhalation valve is available and source control is needed, cover the exhalation valve with a surgical mask, procedure mask, or a cloth face covering that does not interfere with the respirator fit.
Last but not least is the so called Assigned Protection Factor (APF). Generally NIOSH assigns a number to a various respiratory protection system to help us understand the level of protection. The fitted N95 provides a wearer APF of 10.
1c. Elastomeric, respirators, half-face masks with filters or cartridges.
These are worn to protect only the wearer. You can buy various cartridges for them, N95, P99, P100. They require fitting (just like disposable respirators), and when they are fitted they provide a wearer APF of 10.
1d. PAPRs (powered air purifying respirators)
These are worn to protect only the wearer. It actually blows the exhaled air all over the wearer. Some employers make the wearers wears N95s underneath the PAPR to protect others around the wearer as well. These don’t need fitting, but require batteries to operate. There are issues with decontamination afterwards. They can either worn as helmets (covering the neck, head) and they would provide APF of 1000 then. When they just have face seal (not covering the neck) they provide APF of 25 then.