REUSABILITY OF FACEMASKS DURING AN INFLUENZA PANDEMIC

FACING THE FLU

Committee on the Development of Reusable Facemasks for Use During an Influenza Pandemic

Board on Health Sciences Policy

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu REUSABILITY OF FACEMASKS DURING AN INFLUENZA PANDEMIC FACING THE FLU Committee on the Development of Reusable Facemasks for Use During an Influenza Pandemic Board on Health Sciences Policy INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 200-2005-10881 between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-10182-4 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu COMMITTEE ON THE DEVELOPMENT OF REUSABLE FACEMASKS FOR USE DURING AN INFLUENZA PANDEMIC JOHN C. BAILAR III (Co-Chair), The University of Chicago, Illinois DONALD S. BURKE (Co-Chair), The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland LISA M. BROSSEAU, University of Minnesota, Minneapolis HOWARD J. COHEN, University of New Haven, West Haven, Connecticut E. JOHN GALLAGHER, Albert Einstein College of Medicine, New York KATHLEEN F. GENSHEIMER, Maine Centers for Disease Control, Department of Human Services, Augusta ALAN L. HACK, Consultant, Los Alamos, New Mexico SUNDARESAN JAYARAMAN, Georgia Institute of Technology, Atlanta FRANK E. KARASZ, University of Massachusetts, Amherst YOUCHENG LIU, Yale University School of Medicine, New Haven, Connecticut ALLISON MCGEER, Mount Sinai Hospital, Toronto, Ontario, Canada MICHAEL T. OSTERHOLM, University of Minnesota, Minneapolis IOM Staff EMILY ANN MEYER, Study Director ANDREW M. POPE, Board Director LYLA HERNANDEZ, Senior Program Officer ANDREA SCHULTZ, Research Assistant AMY HAAS, Board Assistant LORA TAYLOR, Senior Project Assistant ELEANORE EDSON, Fellow JULIA SOUTHERTON, Intern

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu BOARD ON HEALTH SCIENCES POLICY1 FRED H. GAGE (Chair), The Salk Institute for Biological Studies, La Jolla, California GAIL H. CASSELL, Eli Lilly and Company, Indianapolis, Indiana JAMES F. CHILDRESS, University of Virginia, Charlottesville ELLEN WRIGHT CLAYTON, Vanderbilt University Medical School, Nashville, Tennessee DAVID R. COX, Perlegen Sciences, Mountain View, California LYNN R. GOLDMAN, The Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland BERNARD D. GOLDSTEIN, University of Pittsburgh, Pennsylvania MARTHA N. HILL, The Johns Hopkins University School of Nursing, Baltimore, Maryland ALAN LESHNER, American Association for the Advancement of Science, Washington, D.C. DANIEL MASYS, Vanderbilt University Medical Center, Nashville, Tennessee JONATHAN D. MORENO, University of Virginia, Charlottesville E. ALBERT REECE, University of Arkansas, Little Rock MYRL WEINBERG, National Health Council, Washington, D.C. MICHAEL J. WELCH, Washington University School of Medicine, St. Louis, Missouri OWEN N. WITTE, University of California, Los Angeles MARY WOOLLEY, Research!America, Alexandria, Virginia IOM Staff ANDREW M. POPE, Director AMY HAAS, Board Assistant DAVID CODREA, Financial Associate 1 IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution.

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu Independent Report Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Virginia M. Dato, Pennsylvania Department of Health, Bureau of Epidemiology Seto Wing Hong, Queen Mary Hospital, Hong Kong, China Robert A. Lamb, Department of Biochemistry, Northwestern University Mark Nicas, School of Public Health, University of California, Berkeley Trish M. Perl, Johns Hopkins Medical Institutions, The Johns Hopkins University Aaron Richardson, Battelle, Columbus, Ohio

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu William Schaffner, Department of Preventive Medicine, Vanderbilt University Julie Tremblay, Aearo Technologies, Southbridge, Massachusetts Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Kristine M. Gebbie, associate professor of nursing, Columbia University. Appointed by the National Research Council and Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu Foreword Any strategy to cope with an influenza pandemic must be based on the knowledge and tools that are available at the time an epidemic may occur. In the near term, when we lack an adequate supply of vaccine and antiviral medication, strategies that rely on social distancing and physical barriers will be relatively more prominent as means to prevent spread of disease. The use of respirators and facemasks is one key part of a larger strategy to establish barriers and increase distance between infected and uninfected individuals. Respirators and facemasks may have a role in both clinical care and community settings. This report answers a specific question about the role of respirators and facemasks to reduce the spread of flu: Can respirators and facemasks that are designed to be disposable be reused safely and effectively? The committee—assisted by outstanding staff—worked intensively to review the pertinent literature; consult with manufacturers, researchers, and medical specialists; and apply their expert judgment. This report offers findings and recommendations based on the evidence, pointing to actions that are appropriate now and to lines of research that can better inform future decisions. Unlike the scientist who has the luxury of suspending judgment about the presence or absence of an effect when data are ambiguous, the policy maker must make choices. Choices under conditions of uncertainty will be most sound if they are based on the best available evidence, even when the evidence may leave many questions yet to be answered. The evidence and

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu conclusions assembled here can inform policy choices that may need to be made soon about the role of respirators and facemasks in influenza preparedness, and this report thereby represents a real contribution to protecting the public’s health. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu Preface The Committee on the Development of Reusable Facemasks for Use During an Influenza Pandemic was given a herculean task—how to make the disposable reusable—and completed it in less than three months. Our first meeting was on January 23–24, 2006, and our second on March 6–8, and the completed report was delivered to the sponsor on April 13, 2006. Given the threat of pandemic influenza, the committee understood and responded to the urgency of the request. Although the committee felt constrained by the narrowness of its task on reuse, rather than proper initial use, we kept a sharp focus on the questions asked. Urgency notwithstanding, all of the findings and recommendations presented herein underscore the importance of adequate pandemic planning and preparedness, including the acquisition and stockpiling of facemasks and respirators. The task was difficult because most of the data on the utility of either N95 respirators or medical (i.e., surgical or procedural) masks against viruses—and specifically influenza—are inconclusive. In part because of this, many occupational health and infection control professionals regard masks as a supplement to other infection control measures or a defense of last resort, to be used only when other public health or medical controls are not available or do not work. Although “more research is needed to answer the questions” is often regarded as a scientist’s way of dodging an answer, in this case it is the only

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu rational response. More research is needed. The research needs set out in this report are specific to the design and development of respirators and medical masks and to understanding the modes of transmission of influenza. However, as a part of any pandemic preparedness effort, research into vaccine and drug development and the stockpiling of those that are found to work is also needed. Although the committee found circumstances in which respirators can be reused, we emphasize that reuse should be considered an option only in circumstances in which adequate supplies simply cannot be obtained. Ensuring adequate stockpiles and acquisition mechanisms will offer more protection than attempts to reuse facemasks that were not designed for that purpose. Indeed, it might be preferable to stockpile respirators that are already known to be reusable, such as elastomeric facepieces with replaceable filters or powered air-purifying respirators. However, these were not the questions that were asked of the committee, and in order to accomplish our task rapidly, it was necessary to adhere to it strictly. We are grateful for the hard work and dedication of the Institute of Medicine staff: Judith Estep, Amy Haas, Lyla Hernandez, Emily Ann Meyer, Andrew Pope, Andrea Schultz, Lora Taylor, and Vilija Teel. We deeply appreciate the efforts of Elizabeth Lee Daugherty, a consultant; Eleanore Edson, a winter National Academies fellow; and Julia Southerton, a winter intern. As chairs, we also thank the committee members for their extensive and effective participation within a very short timeframe. John C. Bailar and Donald S. Burke, Co-Chairs Committee on the Development of Reusable Facemasks for Use During an Influenza Pandemic

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu Contents     SUMMARY   1 1   INTRODUCTION AND BACKGROUND   11      Influenza Transmission,   13      Respirator or Medical Mask Use as a Nonpharmacological Intervention,   15      Charge to the Committee,   17      References,   20 2   CHARACTERISTICS OF RESPIRATORS AND MEDICAL MASKS   22      Filtration Theory of Airborne Particles,   23      Properties of Respirators,   26      Properties of Medical Masks,   31      Behavioral Compliance Issues Related to Respiratory Protection,   38      Summary and Conclusions,   38      References,   39 3   USE AND REUSE OF RESPIRATORY PROTECTIVE DEVICES FOR INFLUENZA CONTROL   42      Existing Recommendations and Guidance Regarding Respirator or Medical Mask Use,   43      Contamination and Reuse of Medical Masks and Respirators,   47

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Reusability of Facemasks During an Influenza Pandemic: Facing the Flu                 Respirator and Medical Mask Use in Combating SARS,   50      Summary and Conclusions,   53      References,   54 4   FINDINGS AND RECOMMENDATIONS   57      Respirators,   59      Medical Masks and Improvised Protection,   61      Research Agenda,   63      Conclusion,   66      References,   67     APPENDIXES     A   STUDY PROCESS   69 B   ACRONYMS   79 C   GLOSSARY   81 D   BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS   88