Health systems have been thrust into this position largely because of a global shortage of N95 masks. In the U.S., the Strategic National Stockpile was depleted during the 2009 H1N1 influenza pandemic when 85 million respirators were distributed. Public health experts have lamented that the reserves were never replenished. For their part, health systems are trying to be diligent about the new solutions they are trying, but this is unfamiliar terrain.
Beaumont Health for instance is only allowing masks to be reused up to three times. Evidence supports that N95s can withstand ultraviolet light for more cycles without deteriorating in functionality, Flanders said, but the system is being cautious.
Furthermore, the system has gone the extra step of ensuring all caregivers get the same mask back from cleaning.
“We weren’t comfortable giving back a mask from a different person,” Flanders said. “The fit might be different and … in the unlikely event anything was left on there, the person knows it’s theirs.”
There are still risks with using ultraviolet light, though, said Karen Hoffmann, immediate past president of the Association for Professionals in Infection Control and Epidemiology. Because ultraviolet light is a precise beam of light, it runs the risk of missing some parts of the mask because it’s not a smooth straight shape.
Beaumont has tried to combat that concern by building eight walls in the OR space that reflect the UV light, hitting all parts of the mask, as well as putting the mask through a heating process afterward just to be sure.
“The ultraviolet light should be sufficient but we decided to add the heat as an extra measure,” Flanders said.
Another method backed by evidence that it can clean N95 masks is vaporized hydrogen peroxide, which is also recommended by the CDC.
OhioHealth struck up a partnership with the research and technology company Battelle to use its vaporized hydrogen peroxide process to reuse its N95 masks.
Battelle has been researching the use of vaporized hydrogen peroxide to decontaminate N95 respirator masks since 2015 when it received funding from the U.S. Food and Drug Administration to conduct tests after the SARS outbreak.
“We know that vaporized hydrogen peroxide works for N95 because of our three years of research on N95 masks,” said Matt Vaughan, president of contract research at Battelle. In late March, the FDA approved Battelle’s process for reusing N95 masks up to 20 times. Its process has since been deployed in New York City.
OhioHealth sends its used N95 masks to Battelle’s nearby facility where they are cleaned. The 12-hospital system is relying on Battelle to ensure the masks are decontaminated, said Chris Clinton, vice president of shared services at the system.
Battelle uses a multistep process that involves inspecting the masks before and after they are soaked. Any mask with blood or makeup isn’t eligible for reuse and is disposed of. The process takes 8 to 12 hours.
While Battelle has studied the use of vaporized hydrogen peroxide on N95 masks, Chu said there are areas of concern. For one, Battelle’s research didn’t involve the novel coronavirus, known as SARS-CoV-2, but bacteria that cause anthrax.
Vaughan said while that’s true, he argues the bacteria that causes anthrax is harder to remove than SARS-CoV-2.
“This is not the hardest of viruses and if you challenge it, it’s pretty easy to kill,” he said.
Battelle also tested for proper mask fit by using mannequins, which Chu criticized.
“Quantified fit testing on humans involves moving our heads left to right, up or down; these are things that people do in real life that determine if the mask passes or fails the fit test,” he said.
Similar uncertainties are present for the use of heat or ultraviolet light. In its recent guidance on N95 reuse, the CDC admits that it doesn’t evaluate how respirator filters are impacted as part of performance requirements.
Given the uncertainty around the data, it’s a risk health systems are taking when their clinicians use decontaminated N95 masks and it should be a last-resort decision only, said Dr. Marcus Schabacker, CEO of ECRI and an intensive-care specialist.
“It’s not a good situation and it’s very worrisome that the people at the front lines are not equipped properly,” he said. “It’s like if we sent our soldiers into a fight with bayonets instead of machine guns. That’s essentially what we are doing.”
And because wearing personal protective equipment including N95 respirators routinely is new territory for caregivers, it’s especially important health systems have protocols in place to monitor how the equipment is put on and removed, a process called donning and doffing, APIC’s Hoffmann said.
Infection-control specialists in health systems should be called on to help train and oversee staff to ensure equipment is properly handled, she said.
“There is a lot of concern among infection preventionists that healthcare workers understand putting on and taking off and managing their mask correctly so they aren’t infecting themselves,” she added.