key: cord-0714719-4mx9t5td authors: Lepelletier, Didier; Grandbastien, Bruno; Romano-Bertrand, Sara; Aho, Serge; Chidiac, Christian; Géhanno, Jean-François; Chauvin, Franck title: What face mask for what use in the context of COVID-19 pandemic? The French guidelines date: 2020-04-26 journal: J Hosp Infect DOI: 10.1016/j.jhin.2020.04.036 sha: 30240cee556ecbb6ddce108e661256aee8200eb0 doc_id: 714719 cord_uid: 4mx9t5td Summary In the context of the COVID-19 pandemic, wearing a face mask has become usual and ubiquitous, in both hospitals and community. However, the general public is consuming surgical or filtering face piece (FFP) masks irrespective of their specificity, leading to global supply shortage for the most exposed persons, which are healthcare workers. This underlines the urgent need to clarify the indications of the different categories of mask, in order to rationalize their use. The study herein specifies the French position for the rational use of respiratory protective equipment for healthcare workers. In the context of the COVID-19 pandemic, healthcare workers (HCWs) protection from a contamination is based on the wearing of personal protective equipments (PPE) [1, 2] . Transmission routes of SARS-Cov-2 include direct transmission (droplet, e.g. cough, sneeze) and contact transmission (contact with oral, nasal, and eye mucous membranes). The presence of SARS-CoV-2 in the environment of COVID-19 patients therefore reinforces the belief that fomites play a role in transmission of SARS-CoV-2; however, the relative importance of this route of transmission compared to direct exposure to respiratory droplets is still unclear. The wearing of face masks has become usual and ubiquitous, obviously in hospitals, but also in community [3] . Even without necessarily needing them, the general public is over-consuming surgical or filtering face piece (FFP) masks irrespective of their specificity [4, 5] . This can lead to supply shortages for HCWs that are in the frontline to take care for patients, as already reported in several countries [5] . In order to rationalize the use of masks and to prevent from their shortage, we present the French guidelines on the indications of the anti-projection or surgical masks and FFP masks. The rational use of face masks is reinforced by the update of the WHO published on 19 February 2020 [1] that specifies indications for wearing masks as follows: in the context of stage 3 of an epidemic (active circulation of the virus) and in a period of difficulty in supplying masks, or even a shortage of masks, a prioritization of the distribution of respiratory masks (surgical masks in particular) may be envisaged in order to prioritize the protection of health professionals and other personnel ensuring the continuity of patient care in health and social care facilities and in cities. As defined in the "influenza pandemic" plan by the ECDC, this rationalization of mask distribution and use requires: In France, the anti-projection mask or surgical mask is a medical device with an official wording of the EN 14683 standard of "A medical face mask" (Table I) . It is indicated for the protection of the wearer's environment, as it is intended to avoid, when the wearer exhales, the projection of secretions from the upper airways or saliva that may contain infectious agents transmissible by "droplet" or "air" routes. A surgical mask is designed for a single use only. It should be changed as soon as it becomes wet and at least every 4 hours at the most, taking into account the conditions of use and integrity. Surgical masks must bear on their packaging: the CE marking, the dated reference of standard EN 14683, and the type of mask (type I, II, IIR). This last information characterizes the performances of bacterial filtration, differential pressure and resistance pressure to splash, according to EN14683, the last being required only for IIR masks. A medical face mask with an appropriate microbial barrier can also be effective in reducing the emission of infective agents from the nose and mouth of an asymptomatic carrier or a patient with clinical symptoms. On the other hand, respiratory protection devices (RPE) or filtering face piece (FFP) type respiratory protection masks (or N95 respirator mask) are indicated for the protection of the wearer (Table I) . They must bear the following indications on the masks and packaging: CE marking (CE symbol followed by the number of the notified body responsible for monitoring the quality of manufacture), the number and year of the standard corresponding to the type of equipment (EN 149), the efficiency class (FFP1, FFP2 or FFP3) [6] . Wearing this type of mask is more restrictive (thermal discomfort, respiratory resistance) than wearing a surgical mask. There are three categories of FFP masks, according to their efficiency (estimated based on filter efficiency and leakage to the face). A distinction is made between: -FFP1 masks filtering at least 80% of aerosols (total inward leakage <22%) -FFP2 masks filtering at least 94% of aerosols (total inward leakage <8%) -FFP3 masks filtering at least 99% of aerosols (total inward leakage <2%) The wearing time must be in accordance with the instructions for use [7] . In any case, it should be less than 8 hours in a single day, subject to the conditions of use and type of respiratory protection equipment, and a removed FFP mask should not be reused. FFP masks are subject to natural ageing and therefore have an expiry date beyond which their effectiveness cannot be guaranteed. From a legal point of view, once the expiry date has passed, respiratory protection masks cannot be resold, made available, sold or used, even free of charge. However, in the context of COVID-19 pandemic, the French Ministry of Work changed the rule in the period of shortage supply with the possibility to use FFP masks less than two years expiry. The indications of face mask for HCWs consider that: -Wearing an anti-projection or surgical mask reduces the diffusion of potentially infectious particles and protects people and the environment. Furthermore, surgical masks limit the exposure of caregivers to potentially infectious droplets from patient. Transmission of fluidborne agents from patients to staff may occur via splashes -Wearing a FFP mask protects caregivers from the airborne spread of very small infectious agents, provided it fits snugly. This type of respiratory protection is usually recommended for healthcare workers caring for patients with infection as measles, tuberculosis, pandemic flu. It may also be recommended in situations involving the management of other respiratory infectious diseases where there is a risk of aerosolization, such as when performing invasive procedures or airway manoeuvres that may generate an aerosol or provoke the patient cough. The use of any other kind of barrier masks, such as tissue masks, is not recommended for HCWs during cares [8] . In the context of COVID-19 pandemic, the wearing of a surgical mask must be reserved for: The non-ill population should not wear surgical masks, in order to preserve their use for the indications stated above in healthcare settings. Taking into account the pandemic evolution and an exit from a confinement period of people, the wearing of a face mask for the general public can be a complementary measure to the classical measures of physical distance, barrier measures and hand hygiene. In this context a standard make cloth mask is indicated and should be preferred. -Wearing masks by asymptomatic wearers, when used properly, greatly reduces virus transmission by essentially protecting the wearer's environment. However, this type of mask may not prevent a healthy person from becoming infected if he or she does not follow barrier precautions and is in close contact with a person with respiratory symptoms. (Table II) The FFP2-type protective filtering masks must be reserved exclusively for HCWs when performing invasive medical procedures or manoeuvres on the respiratory sphere that may generate an aerosol: intubation/extubation/laryngeal mask, invasive ventilation with openexpiratory circuit, non-invasive ventilation, endotracheal aspiration, bronchial fibroscopy, aerosol therapy, aerosol-generating chest physiotherapy (bronchial decongestion, induced sputum..), nasopharyngeal sampling, functional respiratory explorations, cares of dental surgery, autopsy or other cares at risk of aerosol. Both surgical and FFP masks are single-use devices, which means to be used for carrying for one patient and to be changed between patients. However, in the context of a supply shortage, prolonged use may be envisaged [9] but with the strict respect of conditions described below: tolerance and accessibility for HCWs according to the duration of wearing; Sealing and integrity during the wearing, especially in case of proved exposure to infective droplets; No re-use of mask since it has been manipulated or removed with increased risk of contamination for HCWs and their environment. It is important to note that, even by considering the conditions above, the duration of wearing may not exceed 4 hours for surgical masks and 8 hours for FFP masks, according to the supplier's recommendations. Simple barrier measures of hand hygiene and respiratory measures through the use of antiprojection or surgical masks are effective measures for the prevention of transmission of SARS-CoV-2. Wearing FFP masks is strictly reserved for HCWs exposed to aerosol during invasive or specific cares for patients suspected or confirmed to be COVID-19, although airborn transmission cannot completely be excluded. Hand hygiene is a key additional barrier measure to control the SRAS-CoV-2 The WHO continues to recommend droplet and contact precautions for those people caring for COVID-19, airborne precautions for circumstances and settings in which aerosol generating procedures and support treatment are performed, according to risk assessment [10] . Apply this strategy aims to mitigate the effects of the epidemic wave and limit its health impact on the population by acting upon the transmissibility and clinical impact of SARS-CoV-2; the vulnerability of the population (immunity, the elderly, etc.); the morbidity (number of sick people in the population) and the mortality (number of deaths in the population) and the disorganization of the health system due to saturation of the health care system. World Health Organization (WHO). 2020. Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19) Infection prevention and control for COVID-19 in healthcare settings Mass masking in the COVID-19 epidemic: people need guidance Potential utilities of mask wearing and instant hand hygiene for fighting SARS-CoV-2 World Health Organization (WHO). 2020. Coronavirus disease (COVID-19) advice for the public: When and how to use masks Standard NF EN 149 + A1 «Respiratory protective devices Particle filter masks, requirements, tests, marking», AFNOR Grandbastien B for the French society of Hospital Hygiene working group. Respiratory protective equipment at work: good practices for filtering facepiece (FFP) mask A cluster randomised trial of cloth masks compared with medical masks in healthcare workers Cloth masks and mask sterilisation as options in case of shortage of surgical masks and respirator World Health Organization (WHO). 2020. Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations We thank the members of the scientific committee of the French Society for Hospital Hygiene and the members of the Coronavirus permanent committee of the French Hight Council for Public Health.