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Use of N95, Surgical, and Cloth Masks to Prevent COVID-19 in Health Care and Community Settings: Living Practice Points From the American College of Physicians (Version 1)
other
Author(s):
Amir Qaseem , MD, PhD, MHA,
Itziar Etxeandia-Ikobaltzeta , PharmD, PhD,
Jennifer Yost , RN, PhD,
Matthew C. Miller , MD,
George M. Abraham , MD, MPH,
Adam J. Obley , MD,
Mary Ann Forciea , MD,
Janet A. Jokela , MD, MPH,
Linda L. Humphrey , MD, MPH,
for the Scientific Medical Policy Committee of the American College of Physicians
*
Publication date (Electronic):
18 June 2020
Journal:
Annals of Internal Medicine
Publisher:
American College of Physicians
There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
Controversy exists around the appropriate types of masks and the situations in which they should be used in community and health care settings for the prevention of SARS-CoV-2 infection. In this article, the American College of Physicians (ACP) provides recommendations based on the best available evidence through 14 April 2020 on the effectiveness of N95 respirators, surgical masks, and cloth masks in reducing transmission of infection. The ACP plans periodic updates of these recommendations on the basis of ongoing surveillance of the literature for 1 year from the initial search date.
Related collections
Most cited references34
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Transmission of COVID-19 to Health Care Personnel During Exposures to a Hospitalized Patient — Solano County, California, February 2020
Amy Heinzerling, Matthew J. Stuckey, Tara Scheuer … (2020)
On February 26, 2020, the first U.S. case of community-acquired coronavirus disease 2019 (COVID-19) was confirmed in a patient hospitalized in Solano County, California ( 1 ). The patient was initially evaluated at hospital A on February 15; at that time, COVID-19 was not suspected, as the patient denied travel or contact with symptomatic persons. During a 4-day hospitalization, the patient was managed with standard precautions and underwent multiple aerosol-generating procedures (AGPs), including nebulizer treatments, bilevel positive airway pressure (BiPAP) ventilation, endotracheal intubation, and bronchoscopy. Several days after the patient’s transfer to hospital B, a real-time reverse transcription–polymerase chain reaction (real-time RT-PCR) test for SARS-CoV-2 returned positive. Among 121 hospital A health care personnel (HCP) who were exposed to the patient, 43 (35.5%) developed symptoms during the 14 days after exposure and were tested for SARS-CoV-2; three had positive test results and were among the first known cases of probable occupational transmission of SARS-CoV-2 to HCP in the United States. Little is known about specific risk factors for SARS-CoV-2 transmission in health care settings. To better characterize and compare exposures among HCP who did and did not develop COVID-19, standardized interviews were conducted with 37 hospital A HCP who were tested for SARS-CoV-2, including the three who had positive test results. Performing physical examinations and exposure to the patient during nebulizer treatments were more common among HCP with laboratory-confirmed COVID-19 than among those without COVID-19; HCP with COVID-19 also had exposures of longer duration to the patient. Because transmission-based precautions were not in use, no HCP wore personal protective equipment (PPE) recommended for COVID-19 patient care during contact with the index patient. Health care facilities should emphasize early recognition and isolation of patients with possible COVID-19 and use of recommended PPE to minimize unprotected, high-risk HCP exposures and protect the health care workforce. HCP with potential exposures to the index patient at hospital A were identified through medical record review. Hospital and health department staff members contacted HCP for initial risk stratification and classified HCP into categories of high, medium, low, and no identifiable risk, according to CDC guidance.* HCP at high or medium risk were furloughed and actively monitored; those at low risk were asked to self-monitor for symptoms for 14 days from their last exposure. † Nasopharyngeal and oropharyngeal specimens were collected once from HCP who developed symptoms consistent with COVID-19 § during their 14-day monitoring period, and specimens were tested for SARS-CoV-2 using real-time RT-PCR at the California Department of Public Health. Serologic testing and testing for other respiratory viruses was not performed. The investigation team, including hospital, local and state health departments, and CDC staff members, attempted to contact all 43 tested HCP by phone to conducted interviews regarding index patient exposures using a standardized exposure assessment tool. Two-sided p-values were calculated using Fisher’s exact test for categorical variables and Wilcoxon rank-sum test for continuous variables; p-values 60 1/3 (33) 3/34 (9) Median (IQR) total estimated time in patient room, mins 120 (120–420) 25 (10–50) 0.06 Median (IQR) total estimated time in patient room during AGPs, mins¶ 95 (0–160) 0 (0–3) 0.13 Came within 6 ft of index patient 3/3 (100) 30/34 (91) 1.00 Reported direct skin-to-skin contact with index patient 0/3 (0) 8/34 (24) 1.00 Index patient either masked or on closed-system ventilator when contact occurred Always 0/3 (0) 7/34 (23) 0.58 Sometimes 2/3 (67) 10/34 (32) Never 1/3 (33) 14/34 (45) Abbreviations: AGPs = aerosol-generating procedures; COVID-19 = coronavirus disease 2019; IQR = interquartile range. * Versus sometimes or never. † No HCP reported use of gowns, N95 respirators, powered air-purifying respirators (PAPRs), or eye protection during any patient care activities for index patient. § Denominators for PPE use during AGPs are numbers of HCP exposed to AGPs. ¶ This was estimated by asking each interviewed staff member to report the number and average duration of each exposure to the patient during AGPs. Total estimated duration for each AGP was calculated by multiplying the number of exposures by average duration of exposure during that AGP. Total estimated exposure time for all AGPs was calculated by adding total duration of exposures across all AGPs. Discussion HCP are at high risk for acquiring infections during novel disease outbreaks, especially before transmission dynamics are fully characterized. The cases reported here are among the first known reports of occupational transmission of SARS-CoV-2 to HCP in the United States, although more cases have since been identified ( 2 ). Little is known to date about SARS-CoV-2 transmission in health care settings. Reports from Illinois, Singapore, and Hong Kong have described cohorts of HCP exposed to patients with COVID-19 without any documented HCP transmission ( 3 – 5 ); most HCP exposures in these cases occurred with patients while HCP were using contact, droplet, or airborne precautions. §§ As community transmission of COVID-19 increases, determining whether HCP infections are acquired in the workplace or in the community becomes more difficult. This investigation presented a unique opportunity to analyze exposures associated with COVID-19 transmission in a health care setting without recognized community exposures. Describing exposures among HCP who did and did not develop COVID-19 can inform guidance on how to best protect HCP. Among a cohort of 121 exposed HCP, 43 of whom were symptomatic and tested, three developed confirmed COVID-19, despite multiple unprotected exposures among HCP. HCP who developed COVID-19 had longer durations of exposure to the index patient; exposures during nebulizer treatments and BiPAP were also more common among HCP who developed COVID-19. These findings underscore the heightened COVID-19 transmission risk associated with prolonged, unprotected patient contact and the importance of ensuring that HCP exposed to patients with confirmed or suspected COVID-19 are protected. CDC recommends use of N95 or higher-level respirators and airborne infection isolation rooms when performing AGPs for patients with suspected or confirmed COVID-19; for care that does not include AGPs, CDC recommends use of respirators where available. ¶¶ In California, the Division of Occupational Safety and Health Aerosol Transmissible Diseases standard requires respirators for HCP exposed to potentially airborne pathogens such as SARS-CoV-2; PAPRs are required during AGPs.*** Studies of other respiratory pathogens have documented increased transmission risk associated with AGPs, many of which can generate large droplets as well as small particle aerosols ( 6 ). A recent study found that SARS-CoV-2 generated through nebulization can remain viable in aerosols <5 μm for hours, suggesting that SARS-CoV-2 could be transmitted at least in part through small particle aerosols ( 7 ). Among the three HCP with COVID-19 at hospital A, two had index patient exposures during AGPs; one did not and reported wearing a facemask but no eye protection for most of the contact time with the patient. Given multiple unprotected exposures among HCP in this investigation, separating risks associated with specific procedures from those associated with duration of exposure and lack of recommended PPE is difficult. More research to determine the risks associated with specific procedures and the protectiveness of different types of PPE, as well as the extent of short-range aerosol transmission of SARS-CoV-2, is needed. Patient source control (e.g., patient wearing a mask or connected to a closed-system ventilator during HCP exposures) might also reduce risk of SARS-CoV-2 transmission. Although the index patient was not masked or ventilated for the majority of hospital A admission, at hospital B, where the patient remained on a closed system ventilator from arrival to receiving a positive test result, none of the 146 HCP identified as exposed developed known COVID-19 infection ( 8 ). Source control strategies, such as masking of patients, visitors, and HCP, should be considered by health care facilities to reduce risk of SARS-CoV-2 transmission. This findings in this report are subject to at least three limitations. First, exposures among HCP were self-reported and are subject to recall bias. Second, the low number of cases limits the ability to detect statistically significant differences in exposures and does not allow for multivariable analyses to adjust for potential confounding. Finally, additional infections might have occurred among asymptomatic exposed HCP who were not tested, or among HCP who were tested as a result of timing and limitations of nasopharyngeal and oropharyngeal specimen testing; serologic testing was not performed. To protect HCP caring for patients with suspected or confirmed COVID-19, health care facilities should continue to follow CDC, state, and local infection control and PPE guidance. Early recognition and prompt isolation, including source control, for patients with possible infection can help minimize unprotected and high-risk HCP exposures. These measures are crucial to protect HCP and preserve the health care workforce in the face of an outbreak already straining the U.S. health care system. Summary What is already known about this topic? Health care personnel (HCP) are at heightened risk of acquiring COVID-19 infection, but limited information exists about transmission in health care settings. What is added by this report? Among 121 HCP exposed to a patient with unrecognized COVID-19, 43 became symptomatic and were tested for SARS-CoV-2, of whom three had positive test results; all three had unprotected patient contact. Exposures while performing physical examinations or during nebulizer treatments were more common among HCP with COVID-19. What are the implications for public health practice? Unprotected, prolonged patient contact, as well as certain exposures, including some aerosol-generating procedures, were associated with SARS-CoV-2 infection in HCP. Early recognition and isolation of patients with possible infection and recommended PPE use can help minimize unprotected, high-risk HCP exposures and protect the health care workforce.
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Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial.
Benjamin Cowling, Kwok-Hung Chan, Vicky J. Fang … (2009)
Few data are available about the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. To investigate whether hand hygiene and use of facemasks prevents household transmission of influenza. Cluster randomized, controlled trial. Randomization was computer generated; allocation was concealed from treating physicians and clinics and implemented by study nurses at the time of the initial household visit. Participants and personnel administering the interventions were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00425893) Households in Hong Kong. 407 people presenting to outpatient clinics with influenza-like illness who were positive for influenza A or B virus by rapid testing (index patients) and 794 household members (contacts) in 259 households. Lifestyle education (control) (134 households), hand hygiene (136 households), or surgical facemasks plus hand hygiene (137 households) for all household members. Influenza virus infection in contacts, as confirmed by reverse-transcription polymerase chain reaction (RT-PCR) or diagnosed clinically after 7 days. Sixty (8%) contacts in the 259 households had RT-PCR-confirmed influenza virus infection in the 7 days after intervention. Hand hygiene with or without facemasks seemed to reduce influenza transmission, but the differences compared with the control group were not significant. In 154 households in which interventions were implemented within 36 hours of symptom onset in the index patient, transmission of RT-PCR-confirmed infection seemed reduced, an effect attributable to fewer infections among participants using facemasks plus hand hygiene (adjusted odds ratio, 0.33 [95% CI, 0.13 to 0.87]). Adherence to interventions varied. The delay from index patient symptom onset to intervention and variable adherence may have mitigated intervention effectiveness. Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset. These findings suggest that nonpharmaceutical interventions are important for mitigation of pandemic and interpandemic influenza. Centers for Disease Control and Prevention.
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N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel
Clinical studies have been inconclusive about the effectiveness of N95 respirators and medical masks in preventing health care personnel (HCP) from acquiring workplace viral respiratory infections.
Author and article information
Journal
Journal ID (nlm-ta): Ann Intern Med
Journal ID (iso-abbrev): Ann. Intern. Med
Journal ID (publisher-id): aim
Title:
Annals of Internal Medicine
Publisher:
American College of Physicians
ISSN
(Print):
0003-4819
ISSN
(Electronic):
1539-3704
Publication date
(Electronic):
18
June
2020
Publication date PMC-release: 18
June
2020
Electronic Location Identifier: M20-3234
Affiliations
[2
]American College of Physicians, Philadelphia, and Villanova University, Villanova,
Pennsylvania (J.Y.)
[4
]University of Massachusetts Medical School and Saint Vincent Hospital, Worcester,
Massachusetts (G.M.A.)
Author notes
Note: The Practice Points are developed by the Scientific Medical Policy Committee of the
American College of Physicians. The Practice Points are “guides” only and may not
apply to all patients and all clinical situations. All Practice Points are considered
automatically withdrawn or invalid 5 years after publication, or once an update has
been issued.
Financial Support: Financial support for the development of the Practice Points comes exclusively from
the ACP operating budget.
Disclosures: All financial and intellectual disclosures of interest were declared and potential conflicts were discussed and managed. Dr. Akl participated in discussion of the Practice Points but was recused from authorship and voting due to a moderate-level conflict of interest (author of recent relevant systematic review). A record of disclosures of interest and management of conflicts of interest is kept for each Scientific Medical Policy Committee meeting and conference call and can be viewed at https://www.acponline.org/about-acp/who-we-are/leadership/boards-committees-councils/scientific-medical-policy-committee/disclosure-of-interests-and-conflict-of-interest-management-summary-for-scientific-medical-policy. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-3234.
Corresponding Author: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall
West, Philadelphia, PA 19106; e-mail,
aqaseem@
123456acponline.org
.
Current Author Addresses: Dr. Qaseem: American College of Physicians, 190 N Independence Mall West, Philadelphia,
PA 19106.
Dr. Etxeandia-Ikobaltzeta: 1, Santa Margarita Hospital Street, Ground Floor 2, Office
1, Room 2, 20303 Irun, Gipuzkoa, Spain.
Author Contributions: Conception and design: A. Qaseem, I. Etxeandia-Ikobaltzeta, J. Yost, J.A. Jokela,
A.J. Obley, M. Marcucci.
Analysis and interpretation of the data: A. Qaseem, I. Etxeandia-Ikobaltzeta, J. Yost,
M.C. Miller, A.J. Obley, M.A. Forciea, J.A. Jokela, L.L. Humphrey, E.A. Akl.
Critical revision for important intellectual content: A. Qaseem, I. Etxeandia-Ikobaltzeta,
J. Yost, M.C. Miller, A.J. Obley, J.A. Jokela, L.L. Humphrey, E.A. Akl, R. Andrews,
R.A. Haeme, D. Kansagara, M. Marcucci.
Author information
Amir Qaseem
http://orcid.org/0000-0001-6866-7985
Itziar Etxeandia-Ikobaltzeta
http://orcid.org/0000-0001-6606-649X
Jennifer Yost
http://orcid.org/0000-0002-3170-1956
Matthew C. Miller
http://orcid.org/0000-0001-7267-4897
George M. Abraham
http://orcid.org/0000-0003-4296-8362
Mary Ann Forciea
http://orcid.org/0000-0002-1999-1145
Article
Publisher ID: aim-olf-M203234DOI: 10.7326/M20-3234
PMC ID: 7357230
PubMed ID: 32551813
SO-VID: f1f4fff4-88c6-4529-9043-17c277d98c73
Copyright statement:
Copyright @
2020
License:
This article is made available via the PMC Open Access Subset for unrestricted re-use for research, analyses, and text and data mining through PubMed Central. Acknowledgement of the original source shall include a notice similar to the following: "© 2020 American College of Physicians. Some rights reserved. This work permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited." These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.
History
Related
Categories
Subject:
Special Articles
Compound subject:
coronavirus, Coronavirus Disease 2019 (COVID-19)
Compound subject:
7426, Respirators
Compound subject:
11279, SARS coronavirus
Compound subject:
6354, Upper respiratory tract infections
Compound subject:
3122457, COVID-19
Compound subject:
3006, Prevention, policy, and public health
Compound subject:
1939, Health services research
Compound subject:
924, Health care quality
Compound subject:
8509, Hygiene
Compound subject:
6499, Breathing
Compound subject:
1541398, Pulmonary diseases
Compound subject:
3122457, COVID-19
Compound subject:
2357, Health care providers
Compound subject:
11279, SARS coronavirus
Compound subject:
9715, Patients
Compound subject:
6354, Upper respiratory tract infections
Compound subject:
1541398, Pulmonary diseases
Compound subject:
3282, Infectious diseases
Compound subject:
8910, Epidemiology
Compound subject:
7245, Lungs
Data availability: