Beyond the PPE shortage: Improperly fitting personal protective equipment and COVID-19 transmission among health care professionals

ABSTRACT

Background: Personal protective equipment (PPE) use is required when caring for COVID-19 patients. Proper mask fitting is essential in prevention of infectious agent transmission at hospital setting.Methods and Results: We describe three cases of health care professionals (HCP) in a COVID-19 designated ward with positive SARS-CoV-2 RT-PCR results, and were found to have improperly fitted masks.Conclusion: These cases of improperly fitting masks in HCP may have contributed to their eventual COVID-19 infection. These cases raise the important issue of PPE fitting.

Abbreviations: Personal Protective Equipment (PPE), Health Care Professional (HCP), Real-time PCR (RT-PCR)

KEYWORDS:

• Covid-19
• personal protection equipment (PPE)
• facemask
• transmission
• N95
• transmission
• equipment
• testing

Introduction

We report three cases of COVID-19 possible infection due to improperly fitting masks in health care professionals (HCP) in a New Jersey hospital. All three HCP worked on a COVID-19 designated inpatient floor, 12-hour shifts for several weeks. The index HCP had a low-grade fever but was initially asymptomatic. A colleague noticed his N95 mask was ill-fitting and sent him for qualitative fit testing. He could not smell the test substance, which prompted SARS-CoV-2 RT-PCR testing that was positive. His symptoms of fatigue, myalgia, chest heaviness, and ageusia ensued the following days, while he was no longer febrile. He reported adherence to CDC guidelines while caring for COVID-19 patients.

Upon the news of his possible COVID-19 infection, several HCP working on the same floor went for fit testing. Among them, two additional HCP tested positive for COVID-19. Regrettably, all 3 HCP failed the mask fitting. The second HCP had been asymptomatic; and the third, had rhinorrhea and ‘allergy-like’ symptoms.

All three subjects denied any known COVID-19 contact except in the hospital. They were self-quarantined at home. None of the three HCPs undergo a fit test for N95 mask prior to caring for COVID patients. The individuals may have unknowingly been exposed to COVID-19 outside the hospital, e.g., shopping. The improper fitting of PPE or N95 masks makes possible infection more likely regardless of where the transmission occurred.

These cases raise the important issue of COVID-19 transmission due to improperly fitting personal protective equipment (PPE). While much attention has been given to PPE shortages, less has been given to the importance of appropriate fit in intra-hospital transmission prevention. A preliminary search on pubmed.gov resulted in minimal mention of assessment of PPE fit. Literature emphasized appropriate PPE for specific work tasks (i.e. for aerosol generating procedures, use of a gown, gloves, eye protection, and an N95 or powered air-purifying respirator) [1]. The need for retraining staff on the safe use of PPE was also cited, however ensuring satisfactory fit was not discussed [2]. For adequate respiratory protection, annual fit-testing alone is insufficient. HCP must assess for appropriate facemask fit prior to each use using ‘fit checks’ outlined in the manufacturer’s instructions [3].

Due to inadequate supply, HCP across the country have reported reusing PPE, raising the additional issue of breakdown and loss of fit of over time. While the CDC has recommended decontamination and reuse of filtering facepiece respirators as a ‘crisis capacity strategy,’ they cannot determine a generic maximum possible number of safe reuses [4]. A 2019 study on the effect of multiple consecutive uses of N95 respirators on fit in 25 subjects found that 48% failed at least one fit test after 1 of 7 episodes of re-donning [5].

This report does not try to determine the source of the SARS-CoV-2 transmission. The three coworkers who were affected by SARS-CoV-2 within a few days of the initial observation had improperly fitting N95 masks, so this may be a potential cause of their positive SARS-CoV-2 test results. Thus, the aim of this report is a call for awareness of the proper use of N95 and PPE. We recommend that ill-fitting caused by facial hair, weight, or other factors, be considered when training individuals on proper fitting and ordering of PPE. Formal mask fitting periodically following OHSO guidelines (OSHA n.d) [6] should be mandatory for every HCP, especially when facial features are changed, or a new type of face masks will be used. When donning a new type of masks, performing a self-check using a standard test agent to test the integrity of the seal of N95 or a respirator is recommended.

Healthcare providers are working tirelessly in the fight against COVID-19, extended hours, and extra shifts. Repeated donning and doffing of PPE undoubtedly adds to their physical fatigue and mental stress. It is imperative that HCP are educated in inadequate PPE fit and work together to take care of each other’s safety and well-being, as seen in the above case.

Declaration of interest

The contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.