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MAY 01, 2020 -- As the COVID-19 pandemic rages, guidelines have scrambled to adapt. Only a few weeks ago, the Centers for Disease Control and Prevention (CDC) and other public health luminaries pleaded with the public not to don face masks. Now many supermarkets across the nation won't let you enter unless your face is covered.
As a staff cardiologist in a hospital in upstate New York, I followed guidelines to conserve and reuse single-use masks amid the shortage of personal protective equipment (PPE). We were hoping that the shortage of face masks would be resolved by federal, state, and private initiatives by now. Reality, however, is grim: Global demand has strained the supply chain, leaving many of us unprotected.
But there is a solution, and it's one that is not often considered: reusables such as elastomeric respirators.
The Overlooked Elastomeric
You have probably seen industrial workers wearing the reusable elastomeric mask. These respirators have tight-fitting facepieces held by straps. According to the CDC, they provide equal or superior protection to disposable N95 respirators, last for years, and can endure repeated cleaning. The filter in these masks is an exchangeable cartridge that can be used for an extended amount of time.
The CDC refers to them as "the overlooked elastomeric" because many healthcare workers have never heard of them and they are rarely used in healthcare. The supply of disposable respirators, while convenient for routine use, cannot be sustained during an outbreak.
According to the Department of Health and Human Services (HHS), the need for masks during a pandemic may reach a staggering 3.5 billion N95 masks per year. In early March, the United States had barely more than 1% of that required amount in the Strategic National Stockpile. To make matters worse, the supply chain of disposable masks, which are largely manufactured in Asia, was severely interrupted during the pandemic. Dire need has created a worldwide frenzy replete with bidding wars and price-gouging.
Concerned by supply shortage during the H1N1 pandemic, the National Institute for Occupational Safety and Health (NIOSH) reviewed the use of reusable respirators in healthcare both for routine and emergency use. Back in 2017, Dr Lewis Radonovich, head of research for NIOSH, concluded that these respirators are a practical option for respiratory protection within healthcare institutions. In 2018, the National Academies of Sciences, Engineering, and Medicine further evaluated reusable elastomeric respirators and published a book, outlining evidence-based considerations for their use in the healthcare setting.
That publication noted that the "durability and reusability of elastomeric respirators make them desirable for stockpiling for emergencies." However, the HHS, citing budget constraints and priorities, didn't include them in the national stockpile, a decision that has been criticized by former CDC director Tom Frieden, MD.
Amid the current demand for guidance, the CDC published "Strategies to Optimize the Supply of PPE and Equipment," which focuses mostly on how to conserve and reuse disposable masks and respirators. A section on elastomeric respirators was added on April 20.
The medical community has been slow to take note of reusables. A recent review of protective gear, published in the New England Journal of Medicine, did not mention reusables.
Reusable respirators are not without shortcomings. They are cumbersome, interfere with speech and vision, and require disinfection and storage between shifts. On the upside, they protect against respiratory virus transmission and are cost-effective.
The few institutions to have adopted reusables provide an encouraging example. University of Maryland Medical Center (UMMC) has weathered the national shortage through a reusable stockpile begun in response to the H1N1 pandemic of 2009. When the coronavirus outbreak started in China, UMMC ordered more and was able to protect its workers.
So why didn't more institutions follow suit? Despite the knowledge that reusables are a viable option, "cognitive myopia," or status quo bias, can cloud our decision-making process. As in the broader society, "disposable" became the convenient norm in healthcare.
The dangerously short supply of disposable respirators and masks during COVID-19 demands that we overcome these biases and start implementing the use of reusable respirators according to recent CDC guidelines. Even if it's too late for the current wave of infection, it may help in the subsequent waves or the next outbreak, believed to be only a matter of time.
Eldad Einav, MD, is a cardiologist in New York city. He also enjoys cooking Mediterranean food and hanging out with his son. You can follow him on Twitter: @eeinav