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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 36  |  Issue : 3  |  Page : 410-411

Are the users of Valved N95 masks 'innocent spreaders' of COVID-19?


1 Department of Surgery, Dayanand Medical College & Hospital, Ludhiana, Punjab, India
2 Department of Cardiology, Hero DMC Heart Institute, Ludhiana, Punjab, India
3 Department of Gastroenterology, Dayanand Medical College & Hospital, Ludhiana, Punjab, India

Date of Submission30-Jun-2020
Date of Acceptance22-Jul-2020
Date of Web Publication15-Sep-2020

Correspondence Address:
Dr. Ashvind Bawa
Department of Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_387_20

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How to cite this article:
Bawa A, Wander GS, Mahajan R. Are the users of Valved N95 masks 'innocent spreaders' of COVID-19?. J Anaesthesiol Clin Pharmacol 2020;36:410-1

How to cite this URL:
Bawa A, Wander GS, Mahajan R. Are the users of Valved N95 masks 'innocent spreaders' of COVID-19?. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2020 Oct 25];36:410-1. Available from: https://www.joacp.org/text.asp?2020/36/3/410/295107

Dear Editor,

The N95 respirators (and equivalent FFP-2 respirators) also called as filtering facepiece respirators provide the best protection against particles up to 0.3 microns, including the SARS-CoV-2.[1] These masks are better than surgical masks for self-protection and are recommended for health care workers. These respirators come in various shapes and types such as cone and cup shape and-some of them are the valved variety [Figure 1]a.[2] The respirator has to fix snuggly on the skin and should not allow air to pass from the sides after the usual fit check and seal check is performed. A poorly fit respirator can cause harm to the wearer in terms of inhalation of air from the sides thus exposing him to the risk of infection.[3]
Figure 1: (a) The Valved N95 Respirator (b) Air coming out of the Valved N95 Respirator, with Venturi effect, worrisome in an asymptomatic carrier

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The valved variety is more comfortable for the wearers for long term use since exhalation is less labored and air can flow out in one direction, which is outwards.[2] This fulfills the purpose of the wearer as no unfiltered air flows in and exhalation is more comfortable. However, we feel that the valve of N95 mask puts the accompanying healthcare worker at greater risk than with the non-valved N95 mask.

It is known that high pressure nebulization and use of non-invasive positive pressure ventilation can generate aerosols which can travel longer distance and are hazardous for the bystanders.[4] For this reason, their use is avoided in diagnosed and suspected COVID patients, especially in closed areas like the wards and ICUs. The valved masks can be considered as similar mini aerosol generators in the hospital setting as can be seen in [Video 1] on how the valve is opening up to allow exhaled air to gush out. There is also growing awareness about airborne transmission of SARS-CoV-2 via aerosolized droplets, especially in a hospital setting.[5] The valve in N95 mask causes a possible Venturi effect of the exhaled air since it passes through a small outlet and so causes greater aerosolization in case the wearer talks, coughs or sneezes [Figure 1]b. If this wearer is a COVID carrier, at times asymptomatic, it will result in much greater risk to others in that work environment.[6]




It is therefore, recommended that the valved N95 masks should not be used and only non-valved masks should be used. These go against the principle of “my mask protects you and your mask protects me” , which is the basis of the recommendation that all need to wear masks. Even in general public, one sees valved respirators being used which can be harmful to the surrounding persons. The Hippocratic principle of “AtFirst, Do No Harm” is defeated with these valved N95 masks which are good and comfortable for the wearer but can be more harmful for those around.

We have known of healthcare workers getting infected by COVID-19 despite taking utmost precautions. No disease in the realm of mankind has caused more morbidity and mortality of healthcare workers than SARS-CoV-2.

These valved masks need to be banned for this reason and only the non-valved N95 masks should be used during the pandemic. In case of shortage of supplies, a simple 3-ply surgical mask may be used to cover the valved mask.

The authors want to put on record a YouTube video made by the first author (link: https://youtu.be/DcgY9iZN-xw) dated May 4th, 2020, in which he demonstrates in detail about the problem with the valved respirator mask and talks about potential aerosolized spread by the asymptomatic carrier. This has become more relevant now as the Director General Health Services, Government of India has warned against used of valved masks calling them detrimental to the measures adopted in preventing the spread of SARS-CoV-2.[7]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Qian Y, Willeke K, Grinshpun SA, Donnelly J, Coffey CC. Performance of N95 respirators: Filtration efficiency for airborne microbial and inert particles. Am Ind Hyg Assoc J 1998;59:128-32.  Back to cited text no. 1
    
2.
Ippolito M, Vitale F, Accurso G, Iozzo P, Gregoretti C, Giarratano A, et al. Medical masks and respirators for the protection of healthcare workers from SARS-CoV-2 and other viruses. Pulmonology 2020;26:204-12.  Back to cited text no. 2
    
3.
MacIntyre CR, Chughtai AA. A rapid systematic review of the efficacy of face masks and respirators against coronaviruses and other respiratory transmissible viruses for the community, healthcare workers and sick patients. Int J Nurs Stud 2020;108:103629. doi: 10.1016/j.ijnurstu. 2020.103629.  Back to cited text no. 3
    
4.
Whittle JS, Pavlov I, Sachetti A, et al. Respiratory support for adult patients with COVID-19. JACEP Open. 2020;1:95-101. https://doi.org/10.1002/emp2.12071.  Back to cited text no. 4
    
5.
Morawska L, Milton DK. It is time to address airborne transmission of COVID-19. Clin Infect Dis 2020;ciaa939. doi: 10.1093/cid/ciaa939.  Back to cited text no. 5
    
6.
Gandhi M, Yokoe DS, Havlir DV. Asymptomatic transmission, the Achilles' heel of current strategies to control Covid-19. N Engl J Med 2020. doi: 10.1056/NEJMe2009758.  Back to cited text no. 6
    
7.


    Figures

  [Figure 1]



 

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