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Advice on face masks and gowns during COVID-19

17 September 2020

Information for health professionals

The demand for face masks (including surgical masks and respirators), surgical and isolation gowns, and surgical suits may overtake the supply available to healthcare organisations during the COVID-19 pandemic. In response to this increased demand, the Department of Health including the Therapeutic Goods Administration (TGA) and the Office of Health Protection (OHP) has prepared the following information to assist healthcare organisations as they update their operating procedures during the outbreak.

Recommendations

For face masks, gloves and gowns, the OHP and TGA suggest that health professionals follow the recommendations below, based on the supply needs of their healthcare organisations.

  • Be aware that shortages may occur and plan accordingly in a composed manner.
  • Face masks, gloves and gowns intended by the manufacturer for use in an Australian hospital setting should be included on the Australian Register of Therapeutic Goods (ARTG). It is advised that you source your supplies bearing this in mind.
  • Face masks, gloves and gowns not intended by the manufacturer for use in a hospital or clinical setting are not required to be included in the ARTG, even if they are used in a hospital or clinical setting.
  • Use face masks, gloves and gowns according to labelling/Instructions for Use (IFU).
  • Follow your healthcare facilities' infection control policies around the use of face masks, gloves and gowns.

Supply needs in health care organisations

Supply levels are categorised at three levels:

  1. Standard conventional supply levels: supply levels are adequate to provide patient care without any change in routine practice.
  2. Contingency supply levels: limited supply levels may change patient care, but may not have a significant impact on patient care and healthcare provider safety.
  3. Crisis supply levels: may need to be considered if face mask or gown demand exceeds the supply.

While standard conventional supply levels or contingency supply levels are available, all IFU instructions should be adhered to, such as single use and clinical guidelines and protocols.

Recommendations for crisis supply levels

Although the following recommendations for gowns, gloves and face masks do not comply with the IFU for these items, they can be considered where there is no other alternative.

It should be noted that the efficacy of gowns, gloves and masks cannot be assured when used after their expiry date, but should be used where there is no alternative.

Face masks, including respirators

While not recommended, where there is low supply and/or high demand, surgical masks and respirators can be used past their shelf life if:

  • the straps are intact;
  • there are no signs of visible damage; and
  • proper fit can be achieved for respirators.

Where there is high demand and/or limited access to surgical masks, healthcare facilities could consider allowing healthcare professionals to continue wearing the same mask between treating patients with the same diagnosis or infectious disease.

The use of masks should be prioritised for aerosol-generating procedures. These include but are not limited to suctioning and nebuliser treatments (currently nebulising medication is not recommended due to aerosolisation risk).

Note

The TGA is aware of recently identified issues with some filtering face piece respirators (FFRs) which claim compliance as KN95 respirators against the Chinese national standard for Respiratory Protection, GB 2626.

There are concerns they may not provide consistent and adequate respiratory protection based on testing conducted by National Institute for Occupational Safety and Health (NIOSH) - National Personal Protective Technology Laboratory (NPPTL) of the Centers for Disease Control and Prevention (CDC). These concerns do not relate to the GB 2626 standard, but to the manufacture of some masks. For further information see comparison guide of some respirators standards (pdf,191kb).

The TGA is currently undertaking a post-market review of all filtering face piece respirators (FFRs) and face masks that are included in the ARTG. Further information is available on post market review of face masks.

Gowns

While not recommended, where there is low supply and/or high demand, gowns could be used as follows in crisis response measures:

  • Expired sterile surgical gowns may be used as single use isolation gowns as they provide a physical barrier for isolation care.
  • Healthcare providers may continue to wear the same gown between treating patients with the same diagnosis or infectious disease, such as COVID-19, providing they are being cared for in a confined area. If there are other concomitant infections present, such as C. difficile or MRSA, wearing the same gown between treating patients is not an appropriate action.
  • Cloth gowns may be used where they are able to be re-processed as isolation protective equipment.
  • Aprons should be worn underneath gowns which are not fluid resistant.

Gloves

Gloves should continue to be worn for patient care activities along with strict adherence to the organisation's hand hygiene and infection control policies.

Background

Non-sterile PPE including masks, gowns and gloves that do not make any therapeutic claims are regulated as general consumer items and do not need to be included in the ARTG before they can be supplied.

PPE including face masks, gowns and gloves that are presented or claim to be for therapeutic use, such as surgical or examination masks, or respirators intended to reduce or prevent the transmission of disease or micro-organisms (such as bacteria or viruses) between people, meet the definition of a medical device. These products are regulated by the TGA under the Therapeutic Goods Act 1989 and will need to be included in the ARTG before they can be supplied.

Masks and respirators

Face masks that are specifically intended to be used to reduce the risk of transmission of pathogens between people, or are intended for use in a health setting are required to be included on the ARTG prior to their importation and supply. All single use facemasks and respirators that are currently included on the ARTG are not intended for reprocessing to make suitable for re-use. Facemasks cannot be guaranteed to have the same risk profile for children or people with facial hair.

  • Respirators which are included on the ARTG are intended to be used in a health care setting. They are designed to form a very close seal around the nose and mouth, to protect the wearer from exposure to airborne particles, including pathogenic biological airborne particulates such as viruses and bacteria. Respirators can be designed to different international standards and are expected to have comparable performance in terms of protection against airborne contaminants; common designations include P2, N95, KN95 and FFP2. These respirators need to be tested for particulate filtration to ensure they filter out a minimum of 94% or 95% solid and liquid aerosols that do not contain oil. They also need to be fit tested to ensure proper facial seal to the wearer. They are a single use item.
  • Surgical respirators are of a similar structure and design to standard respirators and therefore meet the same testing requirements to achieve the protection against airborne particulates, but have also been tested for fluid resistance against penetration by synthetic blood under different pressures, such as may occur during certain high risk medical procedures. Surgical respirators should not feature exhalation valves as they allow unfiltered air to be expelled.
  • Surgical masks are single use, fluid-resistant, disposable, and loose-fitting protection devices that create a physical barrier between the mouth and nose of the wearer and the immediate environment but do not achieve a close seal to the wearer’s face. When used, surgical masks should cover both the mouth and the nose, and be secured using the ear loops or ties at the back of the head. Surgical masks have different grades of filtration and are useful for blocking splashes and large particle droplets or sprays which may occur. They do not provide complete protection from germs and other small particle contaminants.
Importance of proper fit

For a respirator to provide its designed protection, it is essential that an adequate face seal is achieved between the facepiece of the respirator and the face of the wearer. End users should also check facial fit to ensure the right respirator products have been issued and that they are wearing the respirators properly. This is achieved through Fit Testing and Fit Checking.

Fit tests

The purpose of fit testing is to identify which size and style of respirator is suitable for an individual, and to ensure that it is worn correctly. It also provides an opportunity to ensure workers are properly trained in the correct use of the mask.

Fit tests should be performed routinely (the Standard advises at least yearly), whenever a new model of tight fitting respirator is selected, or whenever there is a change in the wearer’s facial characteristics or other features that may affect the facial seal of the respirator.

There are two types of fit test methods – qualitative and quantitative. Qualitative fit tests are fast and easily performed. The subject wearing the respirator is placed in an aerosol environment of a specific test agent. The pass/fail result is based on whether the subject can smell or taste the agent. The qualitative test relies on the subjective response of the wearer and thus is not entirely reliable. The quantitative test is more objective and accurate but requires specialised equipment. It measures how much the air leaks into the wearer’s breathing zone.

Fit checks

This is a check that should be carried out by the employee/wearer checks every time they put on a respirator to ensure it is properly applied, even if this occurs several times per day. Fit checks ensure the respirator is sealed over the bridge of the nose and mouth and that there are no gaps between the respirator and face. The manufacturer’s instructions for fit checking of individual brands and types of respirator should be referred to at all times. Typically, the wearer inhales/exhales sharply and readjusts the respirator if airstream is felt channelling through leaks.

More details about respirator fit tests and checks can be found in:

Note

During high-risk activities, the use of a face-shield in addition to respiratory protection will provide additional protection against fluid and droplets, which is part of current clinical guidance.

Gowns

Surgical gowns are single use items intended for use in the operating room to protect operating room personnel from the transfer of body, fluids, micro-organisms and particulate material.

Single use isolation gowns are intended to protect either the patient, or healthcare providers and visitors from the transfer of infectious agents when they are in contact with each other. They must have long sleeves and cuffs that cover the wearer to the wrist.

To ensure these gowns fit correctly, they should cover the wearer from the neck to the knees and sleeves should finish at the wrists with cuffs. They should have enough overlap at the back that they do not separate when the person wearing them is sitting and come to below the knee.

Gloves

Medical gloves are disposable and include examination gloves, sterile gloves and medical gloves for handling chemotherapy. Gloves are used during medical examinations and procedures to help prevent cross-contamination between healthcare providers and patients and vice versa, as well as from one patient to another.

The World Health Organisation (WHO) recommends, as a general policy, that examination gloves be powder free to avoid reactions with alcohol-based hand rubs used in healthcare facilities. If there are no other gloves available, powdered gloves should be used to maintain infection control standards.

Gloves should be used during all patient-care activities that may involve exposure to blood and all other body fluids (including contact with the mucous membrane and non-intact skin); during contact precautions; and outbreak situations. It is important to monitor the integrity of gloves and change them as soon as possible following appropriate hand hygiene measures.

All medical gloves are single-use items and, according to the WHO, there are no standardised, validated and affordable procedures for safe glove re-processing available.

Local hand hygiene policy should be followed before applying gloves and when removing or changing gloves. The wearing of gloves is not a substitute for hand hygiene. Gloves should be applied and removed following local policy and discarded appropriately.

Goggles

A personal protective device in the form of eyewear/glasses with clear lenses intended to be used to shield the eyes of healthcare staff from blood and other body fluid splashes while performing a clinical or laboratory procedure. It is designed as uncorrected (non-prescription) or corrected (prescription) goggles or spectacles with lenses and side shields. The lenses and side shields offer additional physical barrier protection.

Visors

A transparent personal protective device intended to shield the face and eyes of a healthcare worker from unnecessary exposure from blood and other body fluid splashes while performing a clinical or laboratory procedure. Visors are suitable for use with prescription lenses and protective masks.

Note

The use of petroleum-based hand creams or lotions following hand hygiene may affect the integrity of latex gloves.

For further information:

Contact information

If you have questions around supply of masks or gowns please contact the Office of Health Protection at health.ops@health.gov.au.

If you wish to report any adverse events or suspected adverse events experienced with gowns or surgical masks contact: IRIS@health.gov.au