SPECIAL CONTRIBUTION

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Surgical Masks or N95 Respirators for 60
61
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7 OMF Surgery During COVID-19 62
63
8 64
9 Q1 Pandemic 65
10 66
11 Q7 Mingzhu Zhang, MD,* Andrew Robert Emery, DMD,y 67
12 R. John Tannyhill III, MD, DDS, FACS,z Hui Zheng, MD,x and Jingping Wang, MD, PhDk 68
13 69
Purpose: Coronavirus Disease 2019 (COVID-19) has caused suffering and death around the world. Care-
14 70
ful selection of facial protection is paramount for preventing virus spread among healthcare workers and
15 71
preserving mask and N95 respirator supplies.
16 72
17 Methods: This paper is a comprehensive review of literature written in English and available on Pubmed 73
18 comparing the risk of viral respiratory infections when wearing masks and N95 respirators. Current interna- 74
19 tional oral and maxillofacial surgery guidelines for mask and N95 respirator use, patient COVID-19 disease 75
20 status, aerosol producing procedures were also collected and incorporated into a workflow for selecting 76
21 appropriate facial protection for oral and maxillofacial surgery procedures during the current pandemic. 77
22 Results: Most studies suggest N95 respirators and masks are equally protective against respiratory vi- 78
23 ruses. Some evidence favors N95 respirators, which are preferred for high-risk procedures when aerosol 79
24 production is likely or when the COVID-19 status of a patient is positive or unknown. N95 respirators may 80
25 also be used for multiple patients or reused depending on the type of procedure and condition of the respi- 81
26 rator after each patient encounter. 82
27 83
Conclusion: N95 respirators are preferred over masks against viral respiratory pathogens, especially dur-
28 84
ing aerosol-generating procedures or when a patient’s COVID-19 status is positive or unknown.
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Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial
30 86
Surgeons
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J Oral Maxillofac Surg -:1-14, 2020
32 88
33 *Attending Physician, Department of Anesthesiology, National 3. R. John Tannyhill, III, MD, DDS, FACS: This author helped in 89
34 Cancer Center/National Clinical Research Center for Cancer/ revising the final manuscript. 90
35 Cancer Hospital, Chinese Academy of Medical Sciences and Peking 4. Hui Zheng, MD: This author helped in revising the final manu- 91
36 Union Medical College, Beijing, China. script. 92
37 yResident, Department of Oral and Maxillofacial Surgery, 5. Jingping Wang, MD, PhD: This author helped with the concep- 93
38 Massachusetts General Hospital, Boston, MA. tion and design, revising the final manuscript, and approved of the 94
39 zResidency Program Director, Department of Oral and final submitted manuscript. 95
40 Maxillofacial Surgery, Massachusetts General Hospital and Harvard Masks or N95 Respirators During COVID-19 Pandemic – Which 96
41 School of Dental Medicine, Boston, MA. One Should I Wear? 97
42 xProfessor, Department of Anesthesiology, National Cancer Conflict of Interest Disclosures: None of the authors have any 98
43 Center/National Clinical Research Center for Cancer/Cancer relevant financial relationship(s) with a commercial interest. 99
44 Hospital, Chinese Academy of Medical Sciences and Peking Union Address correspondence and reprint requests to Dr Wang, 100
45 Medical College, Beijing, China. Department of Anesthesia, Critical Care and Pain Medicine, Massa- 101
46 kAssociate Professor, Director of Oral and Maxillofacial Surgery chusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 102
47 Anesthesia, Department of Anesthesia, Critical Care and Pain 02114; e-mail: jwang23@mgh.harvard.edu 103
48 Medicine, Massachusetts General Hospital, Boston, MA. Received July 3 2020 104
49 Mingzhu Zhang and Andrew Robert Emery equally contributed Accepted August 23 2020 105
50 to this article. Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral 106
51 Statement of IRB: Not applicable. and Maxillofacial Surgeons 107
52 AAOMS Disclosure Statement. 0278-2391/20/31090-9 108
53 1. Mingzhu Zhang, MD: This author helped in writing the draft, https://doi.org/10.1016/j.joms.2020.08.024
109
54 revising the final manuscript. 110
55 2. Andrew Robert Emery, DMD: This author helped in writing the 111
56 draft, revising the final manuscript. 112

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 2 SURGICAL MASKS OR N95 RESPIRATORS?

113 Introduction government websites (CDC) and hospital websites 169

114 for policies regarding COVID-19 protection. Publica- 170
115 The primary route for the spread of COVID-19 is tions were excluded from analysis if studies were 171
116 through aerosolized droplets that are expelled during focused on laboratory exposure simulations, non- 172
117 coughing, sneezing, or breathing. Healthcare workers healthcare workers, other types of respirators and sur- 173
118 (HCWs) caring for patients with COVID-19 are at high gical masks, and written languages other than English. 174
119 risk for nosocomial transmission, especially during Laboratory-confirmed respiratory infection or 175
120 various aerosol-generating procedures. Meanwhile, influenza-like illness was screened as the outcome 176
121 the shortage of personal protective equipment (PPE) for review and analysis. A descriptive summary and ta- 177
122 has made it difficult to continue working safely and ble of the reviewed publications were made, as shown 178
123 to reduce the risk of exposure to virus particles and in the result part. 179
124 infection among HCWs. Oral and maxillofacial sur- 180
125 geons (OMSs) are particularly vulnerable as they 181
perform surgeries in and around the mouth and face Results
126 182
127 and commonly perform in-office anesthesia via IV For this review, 8 studies were included to assess the 183
128 sedation and general anesthetics. As a result, OMSs effectiveness of surgical masks versus N95 respirators 184
129 accept great risk caring for patients and require delib- in protecting against viral respiratory infection. Of the 185
erate and thoughtful PPE selection, particularly when
130 8 studies, 5 were RCTs,1-6 1 was a cohort study,7 and 2 186
choosing mouth and nose coverings.
131 were case-control studies8,9 (Table 1). Six studies were 187
The purpose of this study was to compare the pro-
132 extracted from a previously published meta-analysis,10 188
133 tective effects of masks and N95 respirators against and the results showed no significant difference be- 189
134 SARS-CoV-2 and similar viruses. The investigators hy- tween N95 respirators and surgical masks in the asso- 190
135 pothesized that aerosol-generating procedures with ciated risk of laboratory-confirmed respiratory 191
136 COVID-19 positive or unknown patients would infection (RCTs: OR 0.89, 0.64–1.24; cohort study: 192
137 require respirators and that nonaerosol-generating OR 0.43, 0.03–6.41; case–control studies: OR 0.91, 193
138 procedures and asymptomatic patients may be safely 194
0.25–3.36) and influenza-like illness (RCTs: OR 0.51,
139 treated with medical or surgical masks. The specific 195
0.19–1.41). In addition, a large randomized clinical
aims were: 1) compare the protective effects of masks
140 trial (RCT) performed in China5 was included in 196
141 and N95 respirators against SARS-CoV-2 and similar vi- Table 1, which showed that rates of all outcomes of 197
142 ruses, 2) compare recommendations for masks and infection were lower in the N95 groups, while another 198
143 N95 respirators in low- and high-risk OMS procedures, large RCT performed in the US showed there was no 199
144 3) apply N95 extended use and reuse policies to OM significant difference in the incidence of laboratory- 200
145 surgery, and 4) create a workflow for selecting facial confirmed influenza.6 201
146 PPE based on OMS procedure type, patient risk, and 202
The WHO’s recommendations about when to use a
147 reusability of N95 respirators. 203
surgical mask versus an N95 respirator based on path-
148 ogens and situational risks were used to create Table 2. 204
149 Table 3 converts the information from Table 1 and 205
Methods
150 Table 2 into recommendations for OMSs and anesthe- 206
151 The study was designed to make a comprehensive siologists based on the dichotomy of a patient’s fever 207
152 review of the efficacy of PPE for mouth and nose pro- status charted against the type of patient encounter 208
153 tection, especially in OM surgery. N95 respirators and area. International guidelines on mask and respirator 209
154 surgical masks, which are the most common forms of use during COVID-19 from oral-maxillofacial surgery 210
155 facial PPE, were selected as the predictors. To address associations, journals, and relevant government web- 211
156 the research purpose, the investigators designed and sites cited in the oral-maxillofacial surgery literature 212
157 implemented a comprehensive review modeled after are represented in Table 4.13,14,17-20,23-25,29-33 The 213
158 the Cochrane Collaboration’s recommendations for mask or respirator most frequently cited for each 214
159 systematic reviews. Publication searching was con- scenario is represented by the highest tally of 215
160 ducted using PubMed, and the study population was checkmarks associated with each scenario. Overall, 216
161 composed of all publications on the topic of ‘‘Corona- N95 respirators were the favorite in all scenarios, 217
162 virus’’, ‘‘COVID-19’’, ‘‘SARS-CoV-2’’, ‘‘Aerosol and except when performing nonaerosol-generating medi- 218
163 droplet transmission’’, ‘‘N95 respirators’’, ‘‘Surgical cal procedures (non-AGMPs) on symptomatic pa- 219
164 mask’’; ‘‘Personal Protective Equipment (PPE)’’; ‘‘Maxil- tients, which favored surgical masks, and when 220
165 lofacial procedures’’, ‘‘Oral and Maxillofacial Surgeons performing aerosol-generating medical procedures 221
166 (OMFSs)’’ between January 1, 2000 and July 7, 2020). (AGMPs) on COVID positive patients, which favored 222
167 Peer-reviewed articles or followed clinical trial results N99 respirators. Table 4 also collates global oral- 223
168 were included in the study sample. We also checked maxillofacial surgery recommendations pertaining to 224

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ZHANG ET AL
Table 1. CHARACTERISTICS OF STUDIES OF COMPARISON OF N95 RESPIRATORS AND MEDICAL MASKS IN REDUCING THE RISK OF INFECTION

Study Country/Area Research Type Participants Interventions Outcome Results

1* Loeb et al., 8 hospitals in RCT 446 *Targeted use, fit-tested Laboratory-confirmed  No difference in outcome.
200912 Ontario N95 respirator respiratory
*Targeted use, surgical infection, influenza-
mask like illness
2* MacIntyre 15 hospitals in RCT 1441 *Continual use, fit-tested Laboratory-confirmed  CRI (OR 0.38, 0.17 to 0.86) and labora-
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et al., 2011/ Beijing N95 respirator respiratory tory confirmed viral infection (OR
20142,3 *Continual use, non–fit- infection, influenza- 0.19,0.05 to 0.67) significantly lower in
tested N95 respirator like illness N95 group;
*Continual use, surgical  Bacterial colonization was significantly
mask lower among HCWs who used N95
respirators (RR 0.34, 0.21 to 0.56);
 Dual infections significantly lower in
N95 arm
3* MacIntyre 19 hospitals in RCT 1669 *Continual use, fit-tested Laboratory-confirmed  Rates of CRI (HR 0.39, 0.21 to 0.71) and
et al., 20134 Beijing N95 respirator respiratory bacterial colonization (0.40,0.21 to
*Targeted use, fit-tested infection, influenza- 0.73) significantly lower in the contin-
N95 respirator like illness uous N95 respirator use arm.
*Control: continual use,
surgical mask
4* Loeb et al., 2 hospitals in Cohort study 43 *N95 respirator Laboratory-confirmed  Consistently wearing a mask or an N95
20047 Ontario *Surgical mask respiratory while caring for a SARS patient was
infection protective, and consistent use of the
N95 mask was more protective.
 Risk was reduced by consistent use of a
surgical mask, not significantly.
 Risk was lower with consistent use of
an N95 mask than a surgical mask.
5* Seto et al., 5 hospitals in Case–control 13 infected *N95 respirator Laboratory-confirmed  69 staff used of all four measures were
20038 Hong Kong studies 241 *Surgical mask respiratory not infected.
noninfected *Paper mask infection  All infected staff had omitted at least
one measure (P = .0224).
 Staff wore masks (P = .0001), gowns
(P = .006), and washed their hands
(P = .047) get infected fewer vs those
who did not, but significant only for
masks (P = .011).
 Practice of droplets precaution and
contact precaution is adequate in
significantly reducing the risk of infec-
tion after exposures to patients with
SARS.

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Table 1. Cont’d

Study Country/Area Research Type Participants Interventions Outcome Results

6* Zhang et al., 25 hospitals in Case–control 51 infected *N95 respirator Laboratory-confirmed  19.6% (10/51) of cases and 26.0% (53/
20139 Beijing studies 204 *Surgical mask respiratory 204) of controls recalled a high-risk
noninfected *Cloth mask infection procedure on a patient with pandemic
(H1N1) 2009.
 72.5% (37/51) of cases and 71.6% (146/
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204) of controls wore medical masks in

$80% of working time.
 5.9% (3/51) of cases and 36.3% (74/
204) of controls received pandemic
vaccination.
7 MacIntyre 9 hospitals in RCT 3591 *Continuous N95 Laboratory confirmed  Rates of all outcomes were lower in the
et al., 20175 Beijing respirator use viral respiratory continuous N95 and/or targeted N95
*Targeted N95 respirator infection arms.
use  laboratory-confirmed bacterial coloni-
*Medical mask use zation (RR 0.33, 0.21-0.51), laboratory-
*Control arm. confirmed viral infections (RR 0.46,
0.23-0.91) droplet-transmitted
infections (RR 0.26, 0.16-0.42),
laboratory-confirmed influenza was
lowest in the continuous N95 arm (RR
0.34, 0.10-1.11), not statistically
significant.
 Rates of laboratory-confirmed bacterial
colonization (RR 0.54, 0.33-0.87) and
droplet-transmitted infections (RR 0.43,
0.25-0.72) were lower in the targeted
N95 arm.

SURGICAL MASKS OR N95 RESPIRATORS?

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ZHANG ET AL
8 Radonovich 7 hospitals in RCT 4051 *N95 respirators Laboratory-confirmed  207 laboratory-confirmed influenza
et al., 20196 US *Medical masks influenza; infection events (8.2% of HCP-seasons)
in N95 group and 193 (7.2% of HCP-
seasons) in mask group (difference,
1.0%, [0.5% to 2.5%]; P = .18) (OR
1.18, 0.95-1.45).
 1,556 acute respiratory illness events in
N95 group vs 1,711 in mask group
(difference, 21.9 per 1,000 HCP-
seasons, 48.2 to 4.4; P = .10).
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 679 laboratory-detected respiratory

infections in N95 group vs 745 in
mask group (difference, 8.9 per 1,000
HCP-seasons, 33.3 to 15.4; P = .47).
 371 laboratory-confirmed respiratory
illness events in N95 group vs 417 in
mask group (difference, 8.6 per 1,000
HCP-seasons, 28.2 to 10.9; P = .39).
 128 influenza like illness events in N95
group vs 166 in mask group (difference,
11.3 per 1,000 HCP-seasons, 23.8 to
1.3; P = .08).
 89.4% of participants reported ‘‘always’’
or ‘‘sometimes’’ wearing their assigned
devices in the respirator group vs 90.2%
in the mask group.
Abbreviations: CRI (credible interval)), HCP (healthcare personnel), HR (hazard rate), OR (odds ratio), RCT (Randomized controlled trial), RR (relative risk), SARS (severe acute
respiratory syndrome.
* 1-6 were included in the meta-analysis: Effectiveness of N95 respirators versus surgical masks in protecting healthcare workers from acute respiratory infection: a systematic
review and meta-analysis.10
Zhang et al. Surgical Masks or N95 respirators? J Oral Maxillofac Surg 2020.

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 6 SURGICAL MASKS OR N95 RESPIRATORS?

561 facial PPE during COVID-19, with a comparison of The risk of aerosol exposure lies in the potential 617
562 mask/respirator rating systems used in the United they have to carry infectious organisms, mainly vi- 618
563 States and Europe, as seen in the right two ruses. The family of Coronaviridae contains viruses 619
564 columns.15,16,21,22,26,27 Tables 2 through 4, and supple- that are known to be transmitted between humans 620
565 mentary literature on facial PPE,23,34-36 helped form routinely through an aerosol route, such as Middle 621
566 the workflow seen in Figure 1 for mask or respirator East Respiratory Syndrome Coronavirus (MERS-CoV) 622
567 selection prior to an AGMP or non-AGMP. It also pro- and Severe Acute Respiratory Syndrome Coronavirus 623
568 vided a workflow following AGMPs when deciding 2 (SARS-CoV-2). During the SARS outbreak in 2003, 624
569 eligibility for respirator re-use, extended use, or many HCWs suffered severe illness and death, suggest- 625
570 replacement. The workflow for mask or respirator se- ing nosocomial transmission of Coronavirus is signifi- 626
571 lection starts with patient COVID status, then assesses cantly associated with AGMPs.39,40 Therefore, 627
572 procedure type (AGMP or non-AGMP), followed by reducing exposure to aerosol production is vitally 628
573 procedure length, and secondary layers of facial pro- important to the safety of healthcare workers. 629
574 tection. Following an AGMP, there is then the question 630
575 of visible mask contamination, which then leads to 631
576 disposal if present, potential extended use if the pa- MASKS AND RESPIRATORS 632
577 tients have respiratory symptoms, or re-use if the pa- More than 1,700 HCWs had confirmed COVID-19 in 633
578 tients are symptom-free. China due to lack of self-protection as of February 11, 634
579 2020.41 Meanwhile, one case report described 41 635
580 HCWs (85% wearing surgical masks, and the rest wear- 636
581 Discussion ing N95 respirators) who were exposed for at least 637
582 10 minutes during AGMPs, including intubation, extu- 638
583 AEROSOL TRANSMISSION bation, and noninvasive ventilation. After 2 weeks of 639
584 For viruses causing acute respiratory diseases quarantine, it was reported that no one developed 640
585 (ARD), the main mode of transmission is by contact, symptoms, and all COVID-19 Polymerase chain reac- 641
586 droplets, and aerosols or airborne particles. Droplet tion (PCR) tests were negative.42 This raises the ques- 642
587 transmission refers to large particles (>5 mm) that tion as to what the safety efficiency is for the use of 643
588 have a very low risk of transmission beyond 1 to 2 m surgical masks combined with other standard proced- 644
589 and sink rapidly in the air. In contrast, the airborne ures compared with using respirators during COVID- 645
590 transmission allows for relatively long-distance travel 19 pandemics. Masks and respirators are recommen- 646
591 over 2m by aerosols of multiple different sizes. Aero- ded for diseases spread by droplet transmission and 647
592 sols can vary in size and include small droplets and aerosol transmission, but recommendations and termi- 648
593 droplet nuclei. Aerosols <5 to 10 mm in diameter nology differ among the various different guidelines.43 649
594 follow airflow streamlines, and transmission may be A surgical mask prevents aerosol produced by the 650
595 over a short- or long-range. Small aerosols (<5 mm) wearer from spreading to the patient or into the envi- 651
596 can reach the alveolar spaces. Large aerosols ronment, which is the original design purpose. At the 652
597 (<10 mm) can penetrate below the glottis,28,37 while same time, it can be used as a liquid barrier to prevent 653
598 those >20 mm fall mostly under the influence of gravity the wearer from being contaminated by blood and 654
599 without the following airflow streamline.37 large droplets.44 The N95 respirator is a National Insti- 655
600 Aerosols are produced during everyday activities tute for Occupational Safety and Health (NIOSH) certi- 656
601 such as breathing, coughing, sneezing, or talking. fied respiratory protection device designed to reduce 657
602 Healthcare workers are often exposed to higher aero- aerosol exposure. The term ‘‘N95’’ indicates that the 658
603 sol levels during AGMP,38 which are various, but respirator blocks at least 95 percent of test particles 659
604 include the following: (1) bronchoscopy, cardiopul- of 300 nm. Laboratory studies have shown that the 660
605 monary resuscitation, manual ventilation, tracheal most penetrating particle size (MPPS) of N95 respira- 661
606 intubation, sputum induction suctioning, and nebu- tors is 0.03-0.1 mm, and of surgical masks, it is approx- 662
607 lizer treatment; (2) noninvasive ventilation such as bi- imately up to 0.3 mm.45 Surgical masks may not 663
608 level positive airway pressure (BiPAP) therapy, provide substantial protection from aerosol of at least 664
609 continuous positive airway pressure (CPAP) therapy, up to 0.5 mm.45 Furthermore, it has been shown that 665
610 and high-frequency oscillatory ventilation (HFOV); for nano-sized airborne viral agents, the blocking abil- 666
611 (3) oral-maxillofacial surgeries that utilize lasers, or ity of some N95 respirators may be less than 95%, 667
612 pneumatic or electric tools, such as rotary drills and which was even lower for surgical masks.44 Both 668
613 saws. These procedures can either mechanically SARS-CoV-2 and SARS-CoV are about 85 nm in size,46 669
614 create and disperse aerosols or provoke patients to and it can be inferred that the new Coronavirus that 670
615 produce aerosols and are recognized as essential sour- causes COVID-19 is of similar size. Table 2 shows the 671
616 ces of respiratory virus transmission in hospitals.39 risk situations described in influenza guidelines12 672

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 ZHANG ET AL 7

673 Table 2. WHO RECOMMENDATION FOR PPE BASED ON RISK OF SITUATION

729
674 730
675 PPE choice11 Surgical Masks11 N95 Respirators11 731
676 732
677 Rationale11 Large droplets (>5 mm) in short distance (<2m) Infectious aerosols (<5 mm) over a long distance 733
678 (>2m) 734
679 Pathogens11 Febrile acute respiratory disease, RSV, Pulmonary tuberculosis, measles, SARS, novel or 735
680 adenovirus, and influenza unknown organism causing acute respiratory 736
681 diseases 737
Risk situations12  Close contact within one meter of the pa-  Aerosol-generating procedures (AGPs);
682 738
tient;  Procedures involving the respiratory tract;
683  Close contact within 2 meters of the pa-  Laboratory specimen collection from the respira-
739
684 tient; tory tract; 740
685  Entering infectious patient’s room;  If patients cough forcefully; 741
686  Clinical care;  If patients do not comply with respiratory hy- 742
687  All patients contact; giene; 743
688  When infected patient used masks;  When patients may not be able to wear a mask; 744
689  Routine care;  Mortuary and critical care areas. 745
690  In screening area; 746
 During patients’ transport;
691 747
 Before and after patients contact and risk
692 of splashes into the face. 748
693 749
694 Data from World Health Organization (WHO): Infection prevention and control of epidemic- and pandemic-prone acute respi- 750
695 ratory infections in healthcare, 2014.11 751
696 Abbreviations: AGP, aerosol-generating procedures; PPE, personal protective equipment; RSV, respiratory syncytial viral; 752
SARS, severe acute respiratory syndrome.
697 753
Zhang et al. Surgical Masks or N95 respirators? J Oral Maxillofac Surg 2020.
698 754
699 755
700 756
701 and recommendations according to the World Health There are few studies analyzing the cost- 757
702 Organization (WHO).11 It is recommended for HCWs effectiveness of masks. A study conducted during the 758
703 in direct contact with infected patients to wear N95 influenza season in China showed that the cost of 759
704 respirators, not surgical masks, during the current wearing an N95 in order to prevent a single case of a 760
705 COVID-19 epidemic. clinical respiratory illness (CRI) was US $490 to 761
706 There have been several clinical studies comparing $1,230 more than if only medical masks were worn. 762
707 the effectiveness of N95 respirators and medical masks In a high incidence period, the incremental cost can 763
708 on the protection of the virus’s infection. As shown in even be much lower, which suggests continuously us- 764
709 Table 1, six studies included in meta-analysis10 showed ing respirators may be a cost-effective choice when 765
710 no significant difference between N95 respirators and there is a pandemic like COVID-19.47 This information 766
711 surgical masks in terms of protective effect. At the provides new evidence for effective allocation of med- 767
712 same time, this review collected 23 surrogate expo- ical resources and medical decision making at the pre- 768
713 sure studies, which showed that N95 respirators sent time. 769
714 were associated with less filter penetration, less face- 770
715 seal leakage, and less total inward leakage under exper- 771
716 imental laboratory conditions. Similarly, the remaining MASK AND RESPIRATOR EXTENDED USE/REUSE 772
717 two studies from Table 1 indicated that the N95 was GUIDELINES 773
718 superior in one situation5 and equal to the surgical Mass General Brigham (MGB) is the largest health- 774
719 mask in the other one.6 The mixed results of these care system in Massachusetts, with 12 hospitals and 775
720 studies fail to identify the superior choice for facial more than 75,000 employees. In March 2020, 776
721 PPE among N95 respirators and surgical masks, and extended use and reuse policies for masks and respira- 777
722 thus, indicate that more RCTs are needed to make a tors have been adopted from the CDC published 778
723 clinical conclusion. However, some sources advocate guidelines.34,48 Universal masking of all HCWs and pa- 779
724 for the use of respirators in some risk situations, as tients with surgical masks at MGB was associated with 780
725 shown in Table 2.12 In addition to using masks and res- a significantly lower rate of SARS-CoV-2 positivity 781
726 pirators, successful prevention of disease spread also among HCWs. This association may be related to a 782
727 relies on education programs, user compliance, and decrease in transmission between patients and 783
728 other preventative hygiene protocols. HCWs and among HCWs.49 Extended use of N95 784

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 8 SURGICAL MASKS OR N95 RESPIRATORS?

785 Table 3. SURGICAL MASK OR N95 RESPIRATOR FOR OMSS AND ANESTHESIOLOGISTS
841
786 842
787 Status of Patients 843
788 Classification of area Without Fever With Fever 844
789 845
790 OR Surgical Mask N95 respirator or PAPR/CAPR 846
791 Regular Ward Surgical Mask N95 respirator 847
792 Clinic Surgical Mask N95 respirator 848
793 Fever Clinic/ER N95 respirator N95 respirator 849
794 Abbreviations: CAPR (controlled air-purifying respirator); ER (emergency room); OMSs (Oral and Maxillofacial Surgeons); 850
795 OR(operation room); PAPR (powered air-purifying respirator); ‘‘Ward’’ represents a standard hospital floor occupied 851
796 by patients admitted for medical or surgical reasons. 852
797 Zhang et al. Surgical Masks or N95 respirators? J Oral Maxillofac Surg 2020. 853
798 854
799 respirators is allowed after AGMP in patients with pre- and as such, they advocate for cloth masks over face 855
800 sumed viral respiratory symptoms such that they can shields as the primary source of mouth and nose pro- 856
801 continue to be worn to see other patients, but once tection for the general public.51 However, face shields 857
802 removed, must be discarded and not redonned or worn by OMSs may serve as a second line of defense 858
803 reused (see Fig 1). If AGMP is done in patients with against aerosols and splatter when worn over masks 859
804 no symptomatology of a viral respiratory illness, then or respirators. One notable consideration with adding 860
805 the N95 respirator may be redonned and reused after a face shield over a mask or respirator is that many 861
806 it has been doffed. Given that extended use is OMSs wear loupes to perform procedures, which 862
807 preferred over reuse, it is highly recommended to often stick out and prevent face shields from folding 863
808 avoid the removal of N95 respirators as much as down completely. Some oral-maxillofacial researchers 864
809 possible between patient encounters. At our institu- have looked into more appropriate designs that pro- 865
810 tion, designated receptacles (eg labeled storage con- vide protection in a more customized way with the 866
811 tainers such as a paper tray, paper bag, emesis basin) help of 3D printed face shields.52 Properly designed 867
812 are used to store all N95 still eligible for reuse (based face shields can ultimately help extend the usefulness 868
813 on the above criteria). The American Dental Associa- of respirators, especially when in short supply. The 869
814 tion (ADA) and NIOSH recommend limiting the N95 protective effect of the face shield is especially impor- 870
815 reuse to 5 times,35 and N95 are believed to provide tant for AGMPs in patients without respiratory symp- 871
816 protection as designed for 8 hours of continuous or toms, where contaminating the mask would 872
817 intermittent use.34 With some oral-maxillofacial sur- otherwise relegate it to be discarded the next time it 873
818 geries extending beyond 8 hours, particularly exten- is doffed, as opposed to being reusable if not visibly 874
819 sive orthognathic or craniofacial surgeries, soiled. One study of influenza-laden cough aerosols 875
820 resections, and reconstructions, and for surgeons found that face shields worn by providers reduce the 876
821 with longer average operating times, it may be more surface contamination of a respirator by 97% when 877
822 appropriate to wear a powered air-purifying respirator the provider is about 18 inches from the patient.36 878
823 (PAPR) or controlled air-purifying respirator (CAPR). This benefit could lead to greater respirator reuse 879
824 Additionally, it has also been found that SARS-CoV-2 over time, and overall greater PPE efficiency, especially 880
825 can last up to 72 hours on plastic, cardboard, and stain- since face shields can be cleaned and continually 881
826 less steel, suggesting that donning and doffing of used, reused. Another benefit is that face shields create a bar- 882
827 but nonsoiled, respirators requires great caution so as rier preventing inadvertent or subconscious urge to 883
828 not to contaminate the inside of the mask or oneself.50 scratch or touch one’s own face. In a similar fashion, 884
829 Both N95 and surgical masks that are not soiled or wearing a surgical mask over an N95 respirator for 885
830 damaged after use in clinical settings should be limited AGMP can help prevent direct contamination of the 886
831 to only one work shift. In situations when N95 respira- respirator to extend its use, especially since they are 887
832 tors are used in patients with viral respiratory symp- reusable and more difficult to manufacture than 888
833 toms, extended use guidelines should be applied, more simple surgical masks. 889
834 which dictate that the N95 respirator be discarded 890
835 the next time it is removed.34 891
836 EFFECTS OF PROLONGED RESPIRATOR USE ON 892
837 HEALTHCARE PROVIDERS 893
838 FACE SHIELDS AND OVERLYING MASKS Wearing masks for extended periods of time can be 894
839 The CDC reports that the benefit of face shields in uncomfortable. Wearing an N95 respirator for 895
840 preventing viral spread is not completely known, extended periods of time can lead to nausea, 896

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 ZHANG ET AL 9

897 953
898 954
899 955
900 956
901 957
902 958
903 959
904 960
905 961
906 962
907 963
908 964
909 965
910 966
911 967
912 968
913 969
914 970
915 971
916 972
917 973
918 974
919 975
920 976
921 977
922 978
923 979
924 980
925 981
926 982
927 983
print & web 4C=FPO

928 984
929 985
930 986
931 987
932 988
933 FIGURE 1. Preprocedure workflow (above) and OMSs AGMP procedure workflow (below) for Mask/Respirator Selection. Solid lines are 989
primary pathway and dotted line represents alternative options.
934 990
935 Zhang et al. Surgical Masks or N95 respirators? J Oral Maxillofac Surg 2020. 991
936 992
937 shortness of breath, complaints of visual challenges, respirator removal between AGMP and blocking 993
938 headache, lightheadedness, and difficulty with scheduled AGMP patients in order to conserve sup- 994
939 communication.53 plies. Also, for longer procedures, such as in the OR, 995
940 It is also important to consider provider fatigue and PAPR, and CAPR may be more appropriate choices 996
941 barriers to compliance. One study found that wearing over N95 respirators. 997
942 an N95 with an overlying surgical mask resulted in Another issue is the discomfort experienced by the 998
943 greater blood CO2 levels as compared to wearing an prolonged use of masks with ear loops. This has moti- 999
944 N95 alone. Although these levels of CO2 never met vated some to use ear guards or ear relief caps for face 1000
945 the definition of clinical hypercapnia (ie 45 mmHg or masks with ear loops55 or alternative mask designs 1001
946 greater arterial CO2 levels), 25% of the time, respira- such as those that have two sets of strings that tie 1002
947 tors needed to be removed due to discomfort over a around the back of one’s head. Greater mask/respi- 1003
948 12-hour shift.53 The CDC recommends taking sched- rator comfort theoretically reduces the need to adjust 1004
949 uled breaks where providers can remove their respira- the mask leading to fewer opportunities for contami- 1005
950 tors in a safe area.54 Given the preference for extended nation of oneself or others and for greater overall 1006
951 use of respirators over reuse, we recommend avoiding compliance. 1007
952 1008

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 1064
1063
1062
1061
1060
1059
1058
1057
1056
1055
1054
1053
1052
1051
1050
1049
1048
1047
1046
1045
1044
1043
1042
1041
1040
1039
1038
1037
1036
1035
1034
1033
1032
1031
1030
1029
1028
1027
1026
1025
1024
1023
1022
1021
1020
1019
1018
1017
1016
1015
1014
1013
1012
1011
1010
1009

10
Table 4. CURRENT OMFS LITERATURE AND GUIDELINES ON THE SURGICAL MASK OR RESPIRATOR USE DURING THE COVID-19 PANDEMIC

NonAerosol-Generating Medical Procedures Aerosol-Generating Medical Procedures USA European

(non-AGMP) (AGMP) Mask/Respirator Levels Mask/Respirator Levels

COVID-19 Standard PPE UU PAPR/CAPR15 PAPR/CAPR16

13,14
Negative Use HEPA or ULPA filters Use HEPA or ULPA filters
Filtration efficiency: Filtration efficiency:
$ 99.97% @ 0.3 micron $ 99.95% @ 0.3 micron
U
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17

Unknown No symptoms UU UU N10021 RESPIRATORS

18,19 14,20
COVID-19 - or - Infection (no valve, with Filtration efficiency:
status unlikely overlying surgical mask or $ 99.97% @ 0.3 micron
visor)

UUUUUUU UUU N9921 FFP322

18 19
, * 17 [6/12 (50%) sources (withouta valve and with Filtration efficiency: Filtration efficiency:
recommend FFP2 mask or overlying surgical mask or $ 99% @ 0.3 micron $ 99% @ 0.3 micron
equivalent] visor),18,20
U UUUUUUUUUUUU N9521 FFP222
23 24,25
(outpatient exam) (if ‘ risk of exposure is Filtration efficiency: Filtration efficiency:
high’’), 18, * 17 [8/12 $ 95% @ 0.3 micron $ 94% @ 0.3 micron
(67%) sources
recommend FFP2 mask or
equivalent (change after
each patient)], 20 (if PAPR
or FFP3 not available)
UUUUU U FFP122
17,19,24,25
(exam only),23 25
Filtration efficiency:
(outpatient exam) $ 80% @ 0.3 microns

SURGICAL MASKS OR N95 RESPIRATORS?

Symptoms U UUU ASTM Level 326 Type IIR27 MASKS
18 14,17,20
- or -Infection Filtration efficiency: Filtration efficiency:
likely BFE $ 98% @ 3 microns BFE $ 98% @ 3 microns
PFE $ 98% @ 0.1 micron
High fluid resistance:
160 mmHg
UU UU ASTM Level 226 Type II27
23 18,20
(outpatient clinical Filtration efficiency: Filtration efficiency:
exam),18 BFE $ 98% @ 3 microns BFE $ 98% @ 3 microns
PFE $ 98% @ 0.1 micron
Mod. fluid resistance:
160 mmHg
1120
1119
1118
1117
1116
1115
1114
1113
1112
1111
1110
1109
1108
1107
1106
1105
1104
1103
1102
1101
1100
1099
1098
1097
1096
1095
1094
1093
1092
1091
1090
1089
1088
1087
1086
1085
1084
1083
1082
1081
1080
1079
1078
1077
1076
1075
1074
1073
1072
1071
1070
1069
1068
1067
1066
1065
 1176
1175
1174
1173
1172
1171
1170
1169
1168
1167
1166
1165
1164
1163
1162
1161
1160
1159
1158
1157
1156
1155
1154
1153
1152
1151
1150
1149
1148
1147
1146
1145
1144
1143
1142
1141
1140
1139
1138
1137
1136
1135
1134
1133
1132
1131
1130
1129
1128
1127
1126
1125
1124
1123
1122
1121

ZHANG ET AL
UUU UUUUUUU
17,24,25 18,20,24
(if does not have
PAPR or FFP3),28 (if PAPR
not available),17 (N95
with surgical mask over it
if PAPR unavailable),25
(consider Hazmat suit if
the risk of exposure is
high),29
COVID-19 U UU ASTM Level 126 Type I27
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18
Positive
UUUUUUUUUUUU
23,24
(inpatient exam room
with patient contact, or
outpatient exam), 18, * 17
[9/12 (75%) sources
recommend use of FFP2
mask or equivalent]
U UUUUUUUUUUUU
23
(inpatient exam room
without patient contact)
UU
17,23
(inpatient exam room
without patient contact)
14,17
Filtration efficiency: Filtration efficiency:
BFE $ 95% @ 3 microns BFE $ 95% @ 3 microns
PFE $ 95% @ 0.1 micron
Low fluid resistance:
80 mmHg
UUUU
23
(In the patient room/exam
room/negative pressure
operating room), *17 [3/
12 (25%) sources suggest
the use of FFP3 masks or
equivalent if available.]
Low performance26
17
(with a surgical mask over Physical barrier only
it), * 17 [10/12 (83%)
sources recommend the
use of an FFP2 mask or
equivalent (changed after
each patient)], 18
UUU
18,24,29

Note: medical masks and surgical masks are the same in this table; AGMPs were described slightly differently in each paper, but generally involve operating room procedures or the
use of drills or ultrasonic instruments.
Abbreviations: AGMP, aerosol-generating medical procedure; ASTM, American Society for Testing and Materials; BFE, bacterial filtration efficiency; CAPR, controlled air-
purifying respirator; PAPR, powered air-purifying respirator; PFE, particle filtration efficiency.
U = tally of references recommending each type of PPE.

(PAPR/CAPR31) (N10032) (N99/FFP332) (N95/FFP232) (FFP132) (FFP133).

* Cochrane review of the national recommendations for the re-structuring and reopening of dental services from 11 countries with 12 guidance documents (produced between
March 18 and May 5, 2020).30
Zhang et al. Surgical Masks or N95 respirators? J Oral Maxillofac Surg 2020.

11
1232
1231
1230
1229
1228
1227
1226
1225
1224
1223
1222
1221
1220
1219
1218
1217
1216
1215
1214
1213
1212
1211
1210
1209
1208
1207
1206
1205
1204
1203
1202
1201
1200
1199
1198
1197
1196
1195
1194
1193
1192
1191
1190
1189
1188
1187
1186
1185
1184
1183
1182
1181
1180
1179
1178
1177
 12 SURGICAL MASKS OR N95 RESPIRATORS?

1233 ROLE OF CLOTH MASKS without fever, or with suspected or diagnosed COVID- 1289
1234 As OMSs and other healthcare providers struggled 19; and second, whether the procedure is in a low- or 1290
1235 to acquire mask supplies during some of the busiest high-risk situation (Table 2). For OMSs and anesthesiol- 1291
1236 periods of the pandemic, community members were ogists, AGMPs are experienced each day in the oper- 1292
1237 also asked to take precautions by wearing masks. How- ating room (OR) and clinic, during bronchoscopy, 1293
1238 ever, with masks and respirators in short supply, many cardiopulmonary resuscitation, manual ventilation, 1294
1239 have sought out homemade or cloth masks. Although tracheal intubation, and extubation, suctioning, and 1295
1240 cloth masks are not recommended for healthcare pro- surgeries (especially using drills and ultrasonic instru- 1296
1241 viders during direct patient care, the general public is ments). In most cases, the patient who is undergoing 1297
1242 encouraged to wear some type of mask, regardless of surgery has been graded for risk before being admitted 1298
1243 the type.56 Cloth masks, in particular, should be to the operating room. In the operating room, some of 1299
1244 washed daily with soap and water.57 Oral- the most high-risk or aerosol producing moments 1300
1245 maxillofacial surgery patients presenting to the clinic involve anesthesia induction and intubation, patient 1301
1246 or hospital should, at a minimum, wear a mask, either awakening and extubation, and during aerosol genera- 1302
1247 a disposable facemask or cloth mask. Doing so pro- tion from surgical instrumentation.60 Since OMSs are 1303
1248 vides a barrier to protect patients from one another often aiding the anesthesiologist with routine or diffi- 1304
1249 when in the same waiting room and clinical areas. cult intubations by holding jaw thrust or holding the 1305
1250 tongue forward, they are also susceptible to aerosol 1306
1251 generated from patient coughing. Aerosol production 1307
1252 MOUTH RINSE from coughing is especially likely during awake fiberop- 1308
1253 A recent study by Bidra et al58 showed that tic intubations for difficult airways such as for severe 1309
1254 povidone-iodine (PVP-I) oral antiseptic rinse of various odontogenic infections. As a result, anesthesia clini- 1310
1255 concentrations can inactivate SARS-CoV-2 within cians have developed intubation hoods that are draped 1311
1256 15 seconds, suggesting potential utility as an adjuvant over the patient during traditional endotracheal intuba- 1312
1257 to existing treatment algorithms for treating dental and tion and extubation, and most recently, for fiberoptic 1313
1258 oral-maxillofacial surgery patients with known or un- intubation.61 For oral-maxillofacial surgical trainees 1314
1259 known COVID-19 status. By reducing the infectivity and attendings, having a barrier during intubation and 1315
1260 of oral secretions, the clinician will be afforded greater extubation may help augment the protection provided 1316
1261 protection during AGMP in the oral-maxillofacial sur- by wearing a respirator. Regarding AGMP from surgical 1317
1262 gery clinic or operating room and will ultimately instrumentation in the operating room, it is advanta- 1318
1263 reduce the burden on masks and N95 respirators as geous to supplement N95 respirator use with a face 1319
1264 the sole mechanism of preventing SARS-CoV-2 trans- shield if possible, or at least an overlying surgical 1320
1265 mission. In addition, it could also reduce the infectivity mask to protect respirators from direct contamination 1321
1266 of the smaller aerosols that unknowingly contaminate that may compromise their filtering capacity (Fig 1). Pa- 1322
1267 the provider’s mask. tients that have tested negative for COVID-19, or are 1323
1268 Choices for oral and maxillofacial surgeons and an- afebrile and asymptomatic, can be treated with stan- 1324
1269 esthesiologists in routine, daily activities during dard PPE inside the operating room as was done 1325
1270 COVID-19 pandemic. pre-COVID. 1326
1271 In the midst of COVID-19, the daily work of the OMS At the same time, OMSs and anesthesiologists are 1327
1272 must continue to be carried out in a routine and orderly also involved in medical procedures outside the OR, 1328
1273 fashion. The question remains of how to choose among such as outpatient clinics, patient transport, and care 1329
1274 different forms of mouth and nose protection and how at the bedside, which do not involve a significant 1330
1275 to then use them properly to adequately protect HCWs. risk of AGMPs. However, in areas outside the OR, there 1331
1276 Other options for mouth and nose protection are also exists a large number of patients and people with un- 1332
1277 available, such as PAPR, CAPR, and elastomer half-face known nosocomial transmission risk. As such, it is 1333
1278 respirators (EHFRs) for OMSs and anesthesiologists, necessary to assess the risk of each location and 1334
1279 and barrier enclosures with/without negative pressure respond with appropriate PPE.62 For example, the 1335
1280 for patients.59 These high-level PPE are often available emergency room and fever clinics are more likely to 1336
1281 in limited quantities and require complicated don/ have COVID-19 patients than routine outpatient 1337
1282 doff procedures, and are, therefore, only used in select clinics and wards. Table 3 summarizes the recommen- 1338
1283 situations. For OMSs and anesthesiologists in most dations for the choice of a surgical mask and N95 respi- 1339
1284 countries and patient care settings, surgical masks and rator in the daily work of OMSs and anesthesiologists, 1340
1285 N95 respirators are the most commonly used daily and Table 4 organizes the current literature guiding 1341
1286 mouth and nose protection equipment. There are two OMSs on the mask or respirator use using the two 1342
1287 major considerations when making a choice: first, the aforementioned PPE selection criteria (ie patient 1343
1288 classification of the patient, whether he/she is with or COVID-19 risk and AGMP risk). 1344

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1345 Summary 11. World Health Organization (WHO). Infection Prevention and 1401
Control of Epidemic- and Pandemic-Prone Acute Respiratory In-
1346 1402
Q2 Aerosol production during many AGMPs poses a sig- fections in Health Care; 2014
1347 12. Chughtai AA, Seale H, Macintyre CR: Availability, consistency 1403
1348 nificant risk of COVID-19 transmission. AGMPs are and evidence-base of policies and guidelines on the use of 1404
1349 routinely experienced in the daily work of OMSs and mask and respirator to protect hospital health care workers: A
1405
anesthesiologists. We have briefly reviewed the global analysis. BMC Res Notes 6:1, 2013
1350 13. Barca I, Cordaro R, Kallaverja E, et al: Management in oral and 1406
1351 comparative protective efficiency between masks maxillofacial surgery during the COVID-19 pandemic: Our expe- 1407
1352 and respirators and have synthesized that information rience. Br J Oral Maxillofac Surg, 2020 Q4 1408
into our Tables and workflows. Comprehensive assess- 14. Hsieh T-Y, Dedhia RD, Chiao W, et al: A guide to facial trauma
1353 triage and precautions in the COVID-19 pandemic. Facial Plast 1409
1354 ment of the risks and protective efficiency of surgical Surg Aesthet Med 22:164, 2020 1410
1355 masks and N95 respirators is vital as PPE is in short sup- 15. Department of Energy (DOE). Technical standard: Quality assur-
1411
ply. A large number of procedures performed by OMSs ance inspection and testing of HEPA filters. Available at: https://
1356 www.standards.doe.gov/standards-documents/3000/3025-astd- 1412
1357 and anesthesiologists are AGMPs, with other proced- 2007/@@images/file 1413
1358 ures having an unknown nosocomial transmission 16. EMW. ISO 29463 - new standard for HEPA filters. Available at:
1414
risk, thereby making the decision on how to properly https://www.emw.de/en/filter-campus/iso29463.html. Ac-
1359 cessed June 12, 2020 1415
1360 and efficiently choose PPE for mouth and nose protec- 17. Panesar K, Dodson T, Lynch J, et al: Evolution of COVID-19 1416
1361 tion critically important. At this point, COVID-19 has guidelines for University of Washington oral and maxillofacial
1417
spread to more than 200 countries, and given the differ- surgery patient care. J Oral Maxillofac Surg 1, 2020
1362 18. Dominiak M, R ozy1o-Kalinowska I, Gedrange T, et al: COVID-19 1418
1363 ence in medical resources and personnel found at and professional dental practice. The Polish Dental Association 1419
1364 various hospitals, adjustments will have to be made working group recommendations for procedures in dental of-
1420
to these recommendations based on what is available fice during an increased epidemiological risk. J Stomatol 73:1,
1365 2020 1421
1366 and feasible. Timely communication and prompt re- 19. Magennis P, Coulthard P: FFP3 Masks with Valves Should Be 1422
1367 view of protocols around PPE will continue to be Avoided to Reduce Risk to Patients during Close Interactions
1423
extremely important in optimally protecting HCWs. when a Clinician Is Unknowingly COVID Positive; 2020 Q5
1368 20. Grant M, Schramm A, Strong B, et al: AO CMF International Task 1424
1369 Force Recommendations on Best Practices for Maxillofacial Pro- 1425
cedures during COVID-19 Pandemic; 2020
1370 21. The National Personal Protective Technology Laboratory
1426
1371 Q3 References (NPPTL). 42 CFR Part 84 respiratory protective devices. Avail- 1427
1372 able at: https://www.cdc.gov/niosh/npptl/topics/respirators/ 1428
1. Loeb M, Dafoe N, Mahony J, et al: Surgical mask vs N95 respirator pt84abs2.html. Accessed June 12, 2020
1373 22. Lee S-A, Hwang D-C, Li H-Y, et al: Particle size-selective assess-
1429
for preventing influenza among health care workers: A random-
1374 ized trial. JAMA 302:1865, 2009 ment of protection of European standard FFP respirators and 1430
1375 2. MacIntyre CR, Wang Q, Cauchemez S, et al: A cluster random- surgical masks against particles-tested with human subjects, in 1431
ized clinical trial comparing fit-tested and non-fit-tested N95 res- Affatato S (ed): J Healthc Eng; 2016, p 1 Q6
1376 23. Zimmermann M, Nkenke E: Approaches to the management of
1432
pirators to medical masks to prevent respiratory virus infection
1377 in health care workers. Influenza Other Respi Viruses 5:170, patients in oral and maxillofacial surgery during COVID-19 1433
1378 2011 pandemic. J Cranio-maxillo-facial Surg 48:521, 2020 1434
3. MacIntyre CR, Wang Q, Rahman B, et al: Efficacy of face masks 24. Societe Française de Stomatologie, Chirurgie Maxillo-Faciale et
1379 Chirurgie Orale (SFSCMFCO). Practitioners specialized in oral
1435
and respirators in preventing upper respiratory tract bacterial
1380 colonization and co-infection in hospital healthcare workers. health and coronavirus disease 2019: Professional guidelines 1436
1381 Prev Med (Baltim) 62:1, 2014 from the French society of stomatology, maxillofacial surgery 1437
4. MacIntyre CR, Wang Q, Seale H, et al: A randomized clinical trial and or. J Stomatol Oral Maxillofac Surg 121:155, 2020
1382 25. Yang Y, Soh HY, Cai ZG, et al: Experience of diagnosing and man-
1438
of three options for N95 respirators and medical masks in health
1383 workers. Am J Respir Crit Care Med 187:960, 2013 aging patients in oral maxillofacial surgery during the preven- 1439
1384 5. MacIntyre CR, Chughtai AA, Rahman B, et al: The efficacy of tion and control period of the new coronavirus pneumonia. 1440
medical masks and respirators against respiratory infection in Chin J Dent Res 23:57, 2020
1385 1441
healthcare workers. Influenza Other Respi Viruses 11:511, 2017 26. ASTM International. Astm F2100 - 19e1 standard specification
1386 6. Radonovich LJ, Simberkoff MS, Bessesen MT, et al: N95 respira- for performance of materials used in medical face masks. Avail- 1442
1387 tors vs medical masks for preventing influenza among health able at: https://www.astm.org/Standards/F2100.htm. Accessed 1443
care personnel: A randomized clinical trial. JAMA 322:824, 2019 June 12, 2020
1388 27. Crosstex: The right mask for the right task!. Available at: https://
1444
7. Loeb M, McGeer A, Henry B, et al: SARS among critical care
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