The outbreak of the COVID-19 pandemic has emphasised the importance in preparing for the future by optimising the availability and quality of our personal protective equipment. The widespread shortage of PPE during the peak of the pandemic highlighted a vulnerability in our health system leading many to consider methods by which we could become more self-reliant. One of many proposals is the re-sterilisation of facemasks, however within our institution, this approach was met with a variety of opinions. For this reason, we performed a qualitative study regarding the knowledge of HCWs with regard to surgical facemasks and respiratory masks as well as the attitude towards reuse of respiratory masks following re-sterilisation processes.
Understanding of face masks
Ensuring our HCWs have an adequate understanding of face masks, and more generally PPE, is crucial. Schwatz et al (2014) demonstrated that a high level of knowledge, both tested and self-perceived, regarding PPE use for A/H1N1 was associated with increased confidence in PPE among HCWs, potentially promoting a sense of efficacy in coping with the pandemic. (14) They observe that the strong association between knowledge and confidence in PPE and its possible implications on preparedness and response to future events is promising, given that knowledge regarding the efficacy and appropriate use of PPE can easily be augmented. Similarly, Qureshi et al when looking at HCWs willingness to respond to duty during a catastrophe, describe HCW education as one of the most effective methods to allay fears and concerns for personal safety. (15)
Some of our initial questions aimed to evaluate HCWs general understanding of surgical facemasks and respirators. The majority of respondents knew the level of protection offered by both surgical facemasks and respirator masks. However, the questions revealed that 25% of HCWs underestimated the need for respirator masks and 16.8% of respondents incorrectly identified a respirator mask from Figure 2. This finding indicates that there may be a need for continual education on a hospital wide basis, particularly for those who do not regularly use a respirator mask, which included over 40% of our respondents. Another interesting finding regarding knowledge of HCWs was that when shown a respirator mask with an outlet valve, the majority of respondents identified this as something that was necessary to obtain the best filtration. They did not realise that it was inappropriate in the healthcare setting as outlet valves allow unfiltered exhaled air leave the user leaving those surrounding them susceptible to infection. Our interpretation of this finding is that it is possibly pre-conceived. If one searches the internet for respirators, which many did during the outbreak of the pandemic, the marketing of specific masks may lead people to believe that this is the more superior type of respirator.
Concerns regarding face masks
Our study identified availability, quality and lack of face-fitting as the three major areas of concern. One third of HCWs had concerns about the availability of face masks in their hospital setting. One third also had concerns about the quality of masks provided. For these respondents, they were given the option to describe their concerns and the majority related to the poor fit and quality of the ties or ear loops to secure the mask in place. There was also the feeling of general deterioration of quality as the pandemic went on, presumably indicative of the supply concerns around face masks. Disappointingly, the majority of HCWs at time of survey had not had a face-fit for a respirator mask. This was unsurprising to the authors as when researching the potential of re-sterilisation, the issue of face-fit was a concern and when speaking anecdotally to various HCWs in our institution and others, there did not seem to be a hospital wide face-fitting process. This may be unique to our jurisdiction, however, given the nature of the pandemic suddenly changing the working environment of our HCWs, many who ordinarily would not encounter respiratory droplet spread precautions, it can be seen how this key step was not implemented correctly. We identified that over three quarters of the respondents use multiple surgical face masks per day since the start of the pandemic. These concerns relating to quality and availability are hard to ignore and may herald the use of re-sterilised quality respirators in the healthcare setting as an alternative to disposable surgical facemasks.
Attitudes towards re-sterilisation
The majority of our respondents agreed that in the setting of a shortage of respirator masks, they would be happy to use a re-sterilised mask. The majority of this group also reported that they would prefer the ability to identify their own facemask after sterilisation. The majority of the respondents indicated they would not require formal education regarding the re-sterilisation process providing the process had been validated by an appropriate authority. Given previous concerns over the quality of current face masks, we predict that these attitudes may change. If re-sterilisation is to be implemented, it is important to make the process and methods of certification publicly available. One of the biggest concerns among HCWs with regards to re-sterilised masks is the filtering efficacy of a respirator mask following re-sterilisation. This is a concern that can be at least reassured against with scientific evidence, for which there is growing literature (8, 9). 5% of our respondents said that they would not be satisfied to use a re-sterilised mask under any circumstances. This is significant as if re-sterilised masks were the only available option in a future pandemic, we could potentially lose this 5% of our HCW population. It is possible that if we were to further explore the concerns of this subgroup, we may be able to take steps to address these concerns and lower this number.