1
|
Marques A, Carabineiro SAC, Aureliano M, Faleiro L. Evaluation of Gold Complexes to Address Bacterial Resistance, Quorum Sensing, Biofilm Formation, and Their Antiviral Properties against Bacteriophages. TOXICS 2023; 11:879. [PMID: 37999531 PMCID: PMC10674251 DOI: 10.3390/toxics11110879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023]
Abstract
The worldwide increase in antibiotic resistance poses a significant challenge, and researchers are diligently seeking new drugs to combat infections and prevent bacterial pathogens from developing resistance. Gold (I and III) complexes are suitable for this purpose. In this study, we tested four gold (I and III) complexes, (1) chlorotrimethylphosphine gold(I); (2) chlorotriphenylphosphine gold(I); (3) dichloro(2-pyridinecarboxylate) gold (III); and (4) 1,3-bis(2,6-diisopropylphenyl)imidazole-2-ylidene gold(I) chloride, for their antibacterial, antibiofilm, antiviral, and anti-quorum sensing activities. Results reveal that 1 significantly inhibits Escherichia coli DSM 1077 and Staphylococcus aureus ATCC 6538, while 2, 3, and 4 only inhibit S. aureus ATCC 6538. The minimum inhibitory concentration (MIC) of 1 for S. aureus ATCC 6538 is 0.59 μg/mL (1.91 μM), and for methicillin-resistant S. aureus strains MRSA 12 and MRSA 15, it is 1.16 μg/mL (3.75 μM). For E. coli DSM 1077 (Gram-negative), the MIC is 4.63 μg/mL (15 μM), and for multi-resistant E. coli I731940778-1, it is 9.25 μg/mL (30 μM). Complex 1 also disrupts biofilm formation in E. coli and S. aureus after 6 h or 24 h exposure. Moreover, 1 and 2 inhibit the replication of two enterobacteria phages. Anti-quorum sensing potential still requires further clarification. These findings highlight the potential of gold complexes as effective agents to combat bacterial and viral infections.
Collapse
Affiliation(s)
- Ana Marques
- Faculdade de Ciências e Tecnologia, Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal;
- Algarve Biomedical Center—Research Institute, 8005-139 Faro, Portugal
| | - Sónia A. C. Carabineiro
- LAQV-REQUIMTE, Department of Chemistry, NOVA School of Science and Technology, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal;
| | - Manuel Aureliano
- Faculdade de Ciências e Tecnologia, Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal;
- Centro de Ciências do Mar (CCMar), Universidade do Algarve, 8005-139 Faro, Portugal
| | - Leonor Faleiro
- Faculdade de Ciências e Tecnologia, Universidade do Algarve, Campus de Gambelas, 8005-139 Faro, Portugal;
- Algarve Biomedical Center—Research Institute, 8005-139 Faro, Portugal
- Champalimaud Research Program, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal
| |
Collapse
|
2
|
McCallin S, Drulis-Kawa Z, Ferry T, Pirnay JP, Nir-Paz R. Phages and phage-borne enzymes as new antibacterial agents. Clin Microbiol Infect 2023:S1198-743X(23)00528-1. [PMID: 37866680 DOI: 10.1016/j.cmi.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Persistent and resistant infections caused by bacteria are increasing in numbers and pose a treatment challenge to the medical community and public health. However, solutions with new agents that will enable effective treatment are lacking or delayed by complex development and authorizations. Bacteriophages are known as a possible solution for invasive infections for decades but were seldom used in the Western world. OBJECTIVES To provide an overview of the current status and emerging use of bacteriophage therapy and phage-based products, as well as touch on the socioeconomic and regulatory issues surrounding their development. SOURCES Peer-reviewed articles and authors' first-hand experience. CONTENT Although phage therapy is making a comeback since its early discovery, there are many hurdles to its current use. The lack of appropriate standardized bacterial susceptibility testing; lack of a simple business model and authorization for the need of many phages to treat a single species infection; and the lack of knowledge on predictable outcome measures are just a few examples. In this review, we explore the possible routes for phage use, either based on local specialty centres or by industry; the current status of phage therapy, which is mainly based on single-centre or single-bacterial cohorts, and emerging clinical trials; local country-level frameworks for phage utilization even without full authorization; and the use of phage-derived products as alternatives to antibiotics. We also explore what may be the current indications based on the possible availability of phages. IMPLICATIONS Although phages are emerging as a potential treatment for non-resolving and life-threatening infections, the models for their use and production still need to be defined by the medical community, regulatory bodies, and industry. Bacteriophages may have a great potential for infection treatment but many aspects still need to be defined before their routine use in the clinic.
Collapse
Affiliation(s)
- Shawna McCallin
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; ESGNTA - ESCMID study group for non-traditional antibacterials, Basel, Switzerland
| | - Zuzanna Drulis-Kawa
- ESGNTA - ESCMID study group for non-traditional antibacterials, Basel, Switzerland; Department of Pathogen Biology and Immunology, University of Wroclaw, Wroclaw, Poland
| | - Tristan Ferry
- ESGNTA - ESCMID study group for non-traditional antibacterials, Basel, Switzerland; Centre interrégional de référence pour la prise en charge des infections ostéoarticulaires complexes, CRIOAc Lyon, Hospices Civils de Lyon, Lyon, France; Infectious Diseases, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France; CIRI-Centre International de Recherche en Infectiologie, Inserm, Universite Claude Bernard Lyon, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Jean-Paul Pirnay
- ESGNTA - ESCMID study group for non-traditional antibacterials, Basel, Switzerland; Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | - Ran Nir-Paz
- ESGNTA - ESCMID study group for non-traditional antibacterials, Basel, Switzerland; Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Israeli Phage Therapy Center of Hadassah Medical Center and the Hebrew University, Jerusalem, Israel.
| |
Collapse
|
3
|
Thiel CL, Sreedhar P, Silva GS, Greene HC, Seetharaman M, Durr M, Roberts T, Vedanthan R, Lee PH, Andrade G, El-Shahawy O, Hochman SE. Conservation Practices for Personal Protective Equipment: A Systematic Review with Focus on Lower-Income Countries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2575. [PMID: 36767940 PMCID: PMC9915410 DOI: 10.3390/ijerph20032575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 06/18/2023]
Abstract
During the start of the COVID-19 pandemic, shortages of personal protective equipment (PPE) necessitated unprecedented and non-validated approaches to conserve PPE at healthcare facilities, especially in high income countries where single-use disposable PPE was ubiquitous. Our team conducted a systematic literature review to evaluate historic approaches for conserving single-use PPE, expecting that lower-income countries or developing contexts may already be uniquely conserving PPE. However, of the 50 included studies, only 3 originated from middle-income countries and none originated from low-income countries. Data from the included studies suggest PPE remained effective with extended use and with multiple or repeated use in clinical settings, as long as donning and doffing were performed in a standard manner. Multiple decontamination techniques were effective in disinfecting single use PPE for repeated use. These findings can inform healthcare facilities and providers in establishing protocols for safe conservation of PPE supplies and updating existing protocols to improve sustainability and overall resilience. Future studies should evaluate conservation practices in low-resource settings during non-pandemic times to develop strategies for more sustainable and resilient healthcare worldwide.
Collapse
Affiliation(s)
- Cassandra L. Thiel
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | | | - Genevieve S. Silva
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hannah C. Greene
- Social Science Division, New York University Abu Dhabi, Abu Dhabi P.O. Box 129188, United Arab Emirates
| | - Meenakshi Seetharaman
- College of Literature, Science, and Arts, University of Michigan, Ann Arbor, MI 48109, USA
| | - Meghan Durr
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Timothy Roberts
- Health Sciences Library, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Paul H. Lee
- Department of Oral and Maxillofacial Surgery, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Gizely Andrade
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Omar El-Shahawy
- Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Sarah E. Hochman
- Department of Medicine, Division of Infectious Diseases and Immunology, NYU Grossman School of Medicine, New York, NY 10016, USA
| |
Collapse
|
4
|
Obrová K, Vaňková E, Sláma M, Hodek J, Khun J, Ulrychová L, Nogueira F, Laos T, Sponseiler I, Kašparová P, Machková A, Weber J, Scholtz V, Lion T. Decontamination of High-Efficiency Mask Filters From Respiratory Pathogens Including SARS-CoV-2 by Non-thermal Plasma. Front Bioeng Biotechnol 2022; 10:815393. [PMID: 35237577 PMCID: PMC8883054 DOI: 10.3389/fbioe.2022.815393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/25/2022] [Indexed: 11/23/2022] Open
Abstract
The current pandemic resulted in a rapidly increasing demand for personal protective equipment (PPE) initially leading to severe shortages of these items. Hence, during an unexpected and fast virus spread, the possibility of reusing highly efficient protective equipment could provide a viable solution for keeping both healthcare professionals and the general public equipped and protected. This requires an efficient decontamination technique that preserves functionality of the sensitive materials used for PPE production. Non-thermal plasma (NTP) is a decontamination technique with documented efficiency against select bacterial and fungal pathogens combined with low damage to exposed materials. We have investigated NTP for decontamination of high-efficiency P3 R filters from viral respiratory pathogens in comparison to other commonly used techniques. We show that NTP treatment completely inactivates SARS-CoV-2 and three other common human respiratory viruses including Influenza A, Rhinovirus and Adenovirus, revealing an efficiency comparable to 90°C dry heat or UVC light. Unlike some of the tested techniques (e.g., autoclaving), NTP neither influenced the filtering efficiency nor the microstructure of the filter. We demonstrate that NTP is a powerful and economic technology for efficient decontamination of protective filters and other sensitive materials from different respiratory pathogens.
Collapse
Affiliation(s)
- Klára Obrová
- St. Anna Children’s Cancer Research Institute (CCRI), Division Molecular Microbiology, Vienna, Austria
- *Correspondence: Klára Obrová, ; Thomas Lion,
| | - Eva Vaňková
- Department of Physics and Measurements, University of Chemistry and Technology, Prague, Czech Republic
| | - Michal Sláma
- Faculty of Science, University of Hradec Kralove, Hradec Králové, Czech Republic
| | - Jan Hodek
- Institute of Organic Chemistry and Biochemistry of the Czech Academy of Sciences, Prague, Czech Republic
| | - Josef Khun
- Department of Physics and Measurements, University of Chemistry and Technology, Prague, Czech Republic
| | - Lucie Ulrychová
- Institute of Organic Chemistry and Biochemistry of the Czech Academy of Sciences, Prague, Czech Republic
- Department of Genetics and Microbiology, Charles University, Faculty of Sciences, Prague, Czech Republic
| | - Filomena Nogueira
- St. Anna Children’s Cancer Research Institute (CCRI), Division Molecular Microbiology, Vienna, Austria
| | - Triin Laos
- St. Anna Children’s Cancer Research Institute (CCRI), Division Molecular Microbiology, Vienna, Austria
| | - Isabella Sponseiler
- St. Anna Children’s Cancer Research Institute (CCRI), Division Molecular Microbiology, Vienna, Austria
| | - Petra Kašparová
- Department of Physics and Measurements, University of Chemistry and Technology, Prague, Czech Republic
| | - Anna Machková
- Department of Physics and Measurements, University of Chemistry and Technology, Prague, Czech Republic
| | - Jan Weber
- Institute of Organic Chemistry and Biochemistry of the Czech Academy of Sciences, Prague, Czech Republic
| | - Vladimír Scholtz
- Department of Physics and Measurements, University of Chemistry and Technology, Prague, Czech Republic
| | - Thomas Lion
- St. Anna Children’s Cancer Research Institute (CCRI), Division Molecular Microbiology, Vienna, Austria
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
- *Correspondence: Klára Obrová, ; Thomas Lion,
| |
Collapse
|
5
|
Gir E, Menegueti MG, Sousa LRM, Pereira-Caldeira NMV, de Carvalho MJ, Reis RK. Reusing and/or reprocessing the N95 face respirator mask or equivalent: An integrative review. Rev Lat Am Enfermagem 2021; 29:e3492. [PMID: 34730768 PMCID: PMC8570250 DOI: 10.1590/1518-8345.5135.3492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 07/04/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE to analyze the scientific evidence available on the different reprocessing methods and the necessary conditions for reuse of the N95 face respirator mask or equivalent. METHOD an integrative literature review. The PICO strategy was used to elaborate the question. The search was conducted in four databases: PubMed, SciVerse Scopus, WebofScience and EMBASE, considering any period of time. RESULTS a total of 32 studies were included from the 561 studies identified, and they were presented in two categories: "Conditions for reuse" and "Reprocessing the masks". Of the evaluated research studies, seven(21.8%) addressed the reuse of the N95 face respirator mask or equivalent and 25(78.1%) evaluated different reprocessing methods, namely: ultraviolet germicidal irradiation(14); hydrogen peroxide(8); vapor methods(14); using dry heat(5) and chemical methods(sodium hypochlorite[6], ethanol[4] and sodium chloride with sodium bicarbonate and dimethyldioxirane[1]). We emphasize that different methods were used in one same article. CONCLUSION no evidence was found to support safe reprocessing of face respirator masks. In addition, reuse is contraindicated due to the risk of self-contamination and inadequate sealing.
Collapse
Affiliation(s)
- Elucir Gir
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto,
PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP,
Brazil
| | - Mayra Gonçalves Menegueti
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto,
PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP,
Brazil
| | - Laelson Rochelle Milanês Sousa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto,
PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP,
Brazil
| | - Natália Maria Vieira Pereira-Caldeira
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto,
PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP,
Brazil
| | | | - Renata Karina Reis
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto,
PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP,
Brazil
| |
Collapse
|
6
|
Dheda K, Charalambous S, Karat AS, von Delft A, Lalloo UG, van Zyl Smit R, Perumal R, Allwood BW, Esmail A, Wong ML, Duse AG, Richards G, Feldman C, Mer M, Nyamande K, Lalla U, Koegelenberg CFN, Venter F, Dawood H, Adams S, Ntusi NAB, van der Westhuizen HM, Moosa MYS, Martinson NA, Moultrie H, Nel J, Hausler H, Preiser W, Lasersohn L, Zar HJ, Churchyard GJ. A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2. Afr J Thorac Crit Care Med 2021; 27:10.7196/AJTCCM.2021.v27i4.173. [PMID: 34734176 PMCID: PMC8545268 DOI: 10.7196/ajtccm.2021.v27i4.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 12/21/2022] Open
Abstract
SUMMARY Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death. RECOMMENDATIONS Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.
Collapse
Affiliation(s)
- K Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for
the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - S Charalambous
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - A S Karat
- TB Centre, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - A von Delft
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- TB Proof, South Africa
| | - U G Lalloo
- Gateway Private Hospital Medical Centre, Umhlanga Ridge, South Africa
- Durban International Clinical Research Site, Durban, South Africa
| | - R van Zyl Smit
- Division of Pulmonology and Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - R Perumal
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute and South African MRC/UCT Centre for
the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
| | - B W Allwood
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - A Esmail
- Clinical Trials Unit, University of Cape Town Lung Institute, South Africa
| | - M L Wong
- Division of Pulmonology, Department of Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - A G Duse
- Clinical Microbiology & Infectious Diseases, School of Pathology of the NHLS & University of the Witwatersrand, Johannesburg, South Africa
| | - G Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - C Feldman
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Mer
- Department of Medicine, Divisions of Pulmonology and Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K Nyamande
- Department of Pulmonology, Nelson R Mandela School of Medicine, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
| | - U Lalla
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - C F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - F Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - H Dawood
- Greys Hospital, Pietermaritzburg, South Africa
| | - S Adams
- Division of Occupational Medicine, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | - N A B Ntusi
- Division of Cardiology, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - H-M van der Westhuizen
- TB Proof, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
| | - M-Y S Moosa
- Department of Infectious Diseases, Division of Internal Medicine, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Southern African HIV Clinicians Society
| | - N A Martinson
- Perinatal HIV Research Unit (PHRU), University of the Witwatersrand, Johannesburg, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, MD, USA
| | - H Moultrie
- National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
- Clinical Microbiology & Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - J Nel
- Division of Infectious Diseases, Department of Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - H Hausler
- TB HIV Care, Cape Town, South Africa
| | - W Preiser
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service Tygerberg, Cape Town,
South Africa
| | - L Lasersohn
- South African Society of Anaesthesiologists
- Department of Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Critical Care, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa
| | - H J Zar
- Department of Paediatrics & Child Health, Red Cross Children’s Hospital and SAMRC Unit on Child and Adolescent Health, University of Cape Town, South Africa
| | - G J Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
7
|
Company Sancho MC, González-María E, Abad-Corpa E. [Limited Reuse and Extended Use of Filtering Facepiece Respirators]. ENFERMERIA CLINICA 2021; 31:S78-S83. [PMID: 34629854 PMCID: PMC7241318 DOI: 10.1016/j.enfcli.2020.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022]
Abstract
Objetivo Los equipos de protección individual (EPI), y dentro de ellos las mascarillas, son fundamentales en una pandemia como la del COVID-19, que ha requerido, en muchas ocasiones, de reutilización de material debido a su escasez. El objetivo de esta revisión es sintetizar la evidencia disponible sobre la reutilización y uso extendido de las mascarillas de media y alta filtración. Método Revisión exploratoria. Búsqueda a través de lenguaje natural en PubMed y Centros, Agencias y Organizaciones para el Control de Enfermedades. Se limitó a artículos publicados entre 2010-2020 en inglés y en español. Resultados Se localizaron 83 artículos, seleccionándose 14, más cinco recomendaciones. Los temas abordados se clasifican en siete apartados: Caducidad, uso extendido y reutilización de mascarillas, técnica de manipulación, sellado, efectos físicos psicológicos y cumplimentación, contaminación y descontaminación de mascarillas. Conclusiones La reutilización de las mascarillas no está recomendada por los organismos oficiales ni los fabricantes, sólo se acepta en casos extraordinarios, como las pandemias. Los estudios se caracterizan por contar con muestras pequeñas, usan diferentes modelos de mascarillas ajustando su recomendación al modelo.
Collapse
Affiliation(s)
- María Consuelo Company Sancho
- Servicio de Promoción de la Salud, Dirección General de Salud Pública. Servicio Canario de la Salud (Investén-isciii). Las Palmas de Gran Canaria, Las Palmas, España
| | - Esther González-María
- Unidad de Investigación en Cuidados de Salud (Investén-isciii). Instituto de Salud Carlos III. CIBERFES, Madrid, España
| | - Eva Abad-Corpa
- Facultad de Enfermería, Universidad de Murcia; Hospital Reina Sofía, Servicio Murciano de Salud. Instituto Murciano de Investigación Biomédica (IMIB-Arrixaca). (Investén-isciii). CIBERFES, Murcia, España
| |
Collapse
|
8
|
Transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) among health careworkers (HCWs) during three waves of the coronavirus disease 2019 (COVID-19) pandemic in Germany: Results of an anonymous survey. Infect Control Hosp Epidemiol 2021; 43:1742-1744. [PMID: 34338178 PMCID: PMC8367860 DOI: 10.1017/ice.2021.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
9
|
Smullin SJ, Tarlow BD. Room Temperature Wait and Reuse for Bioburden Reduction of SARS-CoV-2 on N95 Filtering Facepiece Respirators. APPLIED BIOSAFETY 2021; 26:103-111. [PMID: 36034690 PMCID: PMC9134324 DOI: 10.1089/apb.20.0055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction: During a pandemic, when the supply of N95 filtering facepiece respirators (FFRs) is limited, health care workers may reuse N95 FFRs. Room temperature storage of N95 FFRs-waiting before reuse-could be a simple low-cost method to reduce severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) bioburden in such a situation. The U.S. Centers for Disease Control and Prevention specify this as a strategy for reducing self-contamination risk during a time of N95 FFR shortage. Objective: To review the literature on persistence of SARS-CoV-2 on surfaces to assess room temperature waiting times for bioburden reduction on N95 FFRs. Methods: The literature was searched for studies evaluating room temperature persistence of SARS-CoV-2. A 3-log decay time was extracted from published data for quantitative comparison between different studies. Studies using surgical masks and non-peer-reviewed studies that include N95 FFRs were used to draw conclusions. Key Findings: Experimental and analytical choices vary between studies and impact the estimated 3-log decay time. There is not a clear understanding of which material properties are significant. There are no peer-reviewed studies of virus persistence on an N95 FFR. Discussion and Conclusions: SARS-COV-2 inactivation occurs spontaneously at room temperature. The precise timing depends on factors including humidity, temperature, and surface material. In reviewed studies, a 7-day waiting period encompasses the 3-log reduction in infectious titer of SARS-COV-2 on specific N95 FFRs and surgical masks. Owing to variations between studies and among N95 FFR materials and room temperature conditions, it is impossible to extrapolate from these limited data to assign a precise 3-log decay time for all used N95 FFRs.
Collapse
Affiliation(s)
| | - Branden D. Tarlow
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California, USA
| |
Collapse
|
10
|
Gnatta JR, Souza RQD, Lemos CDS, Oliveira RA, Martins LR, Moriya GADA, Poveda VDB. Safety in the practice of decontaminating filtering facepiece respirators: A systematic review. Am J Infect Control 2021; 49:825-835. [PMID: 33279587 PMCID: PMC8024221 DOI: 10.1016/j.ajic.2020.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Considering the new SARS-CoV-2 pandemic and the potential scarcity of material resources, the reuse of personal protective equipment such as filtering facepiece respirators (FFRs) for N95 filtering or higher is being discussed, mainly regarding the effectiveness and safety of cleaning, disinfection and sterilization processes. AIM To analyze the available evidence in the literature on the safety in processing FFRs. METHODS A systematic review conducted by searching for studies in the following databases: PubMed, CINAHL, LILACS, CENTRAL, EMBASE, Web of Science, and Scopus. RESULTS Forty studies were included in this review. The disinfectant/sterilizing agents most frequently tested at different concentrations and exposure periods were ultraviolet irradiation, vaporized hydrogen peroxide and steam sterilization. Microbial reduction was assessed in 21 (52.5%) studies. The only disinfectants/sterilizers that did not caused degradation of the material-integrity were alcohol, electric cooker, ethylene oxide, and peracetic acid fogging. Exposure to ultraviolet irradiation or microwave generated-steam resulted in a nonsignificant reduction in filter performance. CONCLUSION There is a complex relationship between the FFR raw materials and the cycle conditions of the decontamination methods, evidencing the need for validating FFRs by models and manufacturers, as well as the process. Some methods may require additional tests to demonstrate the safety of FFRs for use due to toxicity.
Collapse
|
11
|
A simulation study to evaluate contamination during reuse of N95 respirators and effectiveness of interventions to reduce contamination. Infect Control Hosp Epidemiol 2021; 43:764-769. [PMID: 33966671 PMCID: PMC8144809 DOI: 10.1017/ice.2021.218] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To assess the potential for contamination of personnel, patients, and the environment during use of contaminated N95 respirators and to compare the effectiveness of interventions to reduce contamination. Design: Simulation study of patient care interactions using N95 respirators contaminated with a higher and lower inocula of the benign virus bacteriophage MS2. Methods: In total, 12 healthcare personnel performed 3 standardized examinations of mannequins including (1) control with suboptimal respirator handling technique, (2) improved technique with glove change after each N95 contact, and (3) control with 1-minute ultraviolet-C light (UV-C) treatment prior to donning. The order of the examinations was randomized within each subject. The frequencies of contamination were compared among groups. Observations and simulations with fluorescent lotion were used to assess routes of transfer leading to contamination. Results: With suboptimal respirator handling technique, bacteriophage MS2 was frequently transferred to the participants, mannequin, and environmental surfaces and fomites. Improved technique resulted in significantly reduced transfer of MS2 in the higher inoculum simulations (P < .01), whereas UV-C treatment reduced transfer in both the higher- and lower-inoculum simulations (P < .01). Observations and simulations with fluorescent lotion demonstrated multiple potential routes of transfer to participants, mannequin, and surfaces, including both direct contact with the contaminated respirator and indirect contact via contaminated gloves. Conclusion: Reuse of contaminated N95 respirators can result in contamination of personnel and the environment even when correct technique is used. Decontamination technologies, such as UV-C, could reduce the risk for transmission.
Collapse
|
12
|
Lindsley WG, Blachere FM, Law BF, Beezhold DH, Noti JD. Efficacy of face masks, neck gaiters and face shields for reducing the expulsion of simulated cough-generated aerosols. AEROSOL SCIENCE AND TECHNOLOGY : THE JOURNAL OF THE AMERICAN ASSOCIATION FOR AEROSOL RESEARCH 2021; 55:449-457. [PMID: 35924077 PMCID: PMC9345365 DOI: 10.1080/02786826.2020.1862409] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/04/2020] [Accepted: 12/07/2020] [Indexed: 05/18/2023]
Abstract
Face masks are recommended to reduce community transmission of SARS-CoV-2. One of the primary benefits of face masks and other coverings is as source control devices to reduce the expulsion of respiratory aerosols during coughing, breathing, and speaking. Face shields and neck gaiters have been proposed as an alternative to face masks, but information about face shields and neck gaiters as source control devices is limited. We used a cough aerosol simulator with a pliable skin headform to propel small aerosol particles (0 to 7 μm) into different face coverings. An N95 respirator blocked 99% (standard deviation (SD) 0.3%) of the cough aerosol, a medical grade procedure mask blocked 59% (SD 6.9%), a 3-ply cotton cloth face mask blocked 51% (SD 7.7%), and a polyester neck gaiter blocked 47% (SD 7.5%) as a single layer and 60% (SD 7.2%) when folded into a double layer. In contrast, the face shield blocked 2% (SD 15.3%) of the cough aerosol. Our results suggest that face masks and neck gaiters are preferable to face shields as source control devices for cough aerosols.
Collapse
Affiliation(s)
- William G. Lindsley
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Francoise M. Blachere
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Brandon F. Law
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Donald H. Beezhold
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - John D. Noti
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| |
Collapse
|
13
|
Lindsley WG, Blachere FM, Law BF, Beezhold DH, Noti JD. Efficacy of face masks, neck gaiters and face shields for reducing the expulsion of simulated cough-generated aerosols. AEROSOL SCIENCE AND TECHNOLOGY : THE JOURNAL OF THE AMERICAN ASSOCIATION FOR AEROSOL RESEARCH 2021; 55:449-457. [PMID: 35924077 DOI: 10.1101/2020.10.05.20207241] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Face masks are recommended to reduce community transmission of SARS-CoV-2. One of the primary benefits of face masks and other coverings is as source control devices to reduce the expulsion of respiratory aerosols during coughing, breathing, and speaking. Face shields and neck gaiters have been proposed as an alternative to face masks, but information about face shields and neck gaiters as source control devices is limited. We used a cough aerosol simulator with a pliable skin headform to propel small aerosol particles (0 to 7 μm) into different face coverings. An N95 respirator blocked 99% (standard deviation (SD) 0.3%) of the cough aerosol, a medical grade procedure mask blocked 59% (SD 6.9%), a 3-ply cotton cloth face mask blocked 51% (SD 7.7%), and a polyester neck gaiter blocked 47% (SD 7.5%) as a single layer and 60% (SD 7.2%) when folded into a double layer. In contrast, the face shield blocked 2% (SD 15.3%) of the cough aerosol. Our results suggest that face masks and neck gaiters are preferable to face shields as source control devices for cough aerosols.
Collapse
Affiliation(s)
- William G Lindsley
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Francoise M Blachere
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Brandon F Law
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Donald H Beezhold
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - John D Noti
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| |
Collapse
|
14
|
Rodriguez-Martinez CE, Sossa-Briceño MP, Cortés JA. Decontamination and reuse of N95 filtering facemask respirators: A systematic review of the literature. Am J Infect Control 2020; 48:1520-1532. [PMID: 32652253 PMCID: PMC7342027 DOI: 10.1016/j.ajic.2020.07.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/04/2020] [Accepted: 07/04/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION As has happened in other emerging respiratory pandemics, demand for N95 filtering facemask respirators (FFRs) has far exceeded their manufacturing production and availability in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. One of the proposed strategies for mitigating the massive demand for N95 FFRs is their reuse after a process of decontamination that allows the inactivation of any potentially infectious material on their surfaces. This article aims to summarize all of the available evidence on the different decontamination methods that might allow disposable N95 FFRs to be reused, with emphasis on decontamination from SARS-CoV-2. METHODS We performed a systematic review of the literature in order to identify studies reporting outcomes of at least 1 decontamination method for inactivating or removing any potentially infectious material from the surface of N95 FFRs, specifically addressing issues related to reduction of the microbial threat (including SARS-CoV-2 when available), maintaining the function of N95 FFRs and a lack of residual toxicity. RESULTS We identified a total of 15 studies reporting on the different decontamination methods that might allow disposable N95 FFRs to be reused, including small-scale energetic methods and disinfecting solutions/spray/wipes. Among these decontamination methods, ultraviolet germicidal irradiation and vaporized hydrogen peroxide seem to be the most promising decontamination methods for N95 FFRs, based on their biocidal efficacy, filtration performance, fitting characteristics, and residual chemical toxicity, as well as other practical aspects such as the equipment required for their implementation and the maximum number of decontamination cycles. CONCLUSIONS Although all the methods for the decontamination and reuse of N95 FFRs have advantages and disadvantages, ultraviolet germicidal irradiation and vaporized hydrogen peroxide seem to be the most promising methods.
Collapse
Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia; Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia.
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia; Scientific Direction, Clínica de Marly Jorge Cavelier Gaviria, Avenida Paseo los Zipas, Chía, Colombia
| | - Jorge A Cortés
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| |
Collapse
|
15
|
Kirubarajan A, Khan S, Got T, Yau M, Bryan JM, Friedman SM. Mask shortage during epidemics and pandemics: a scoping review of interventions to overcome limited supply. BMJ Open 2020; 10:e040547. [PMID: 33247019 PMCID: PMC7703444 DOI: 10.1136/bmjopen-2020-040547] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/13/2020] [Accepted: 11/02/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To characterise published evidence regarding preclinical and clinical interventions to overcome mask shortages during epidemics and pandemics. DESIGN Systematic scoping review. SETTINGS All healthcare settings relevant to epidemics and pandemics. SEARCH STRATEGY English peer-reviewed studies published from January 1995 to June 2020 were included. Literature was identified using four databases (Medline-OVID, EMBASE, CINAHL, Cochrane Library), forwards-and-backwards searching through Scopus and an extensive grey literature search. Assessment of study eligibility, data extraction and evidence appraisal were performed in duplicate by two independent reviewers. RESULTS Of the 11 220 database citations, a total of 47 articles were included. These studies encompassed six broad categories of conservation strategies: decontamination, reusability of disposable masks and/or extended wear, layering, reusable respirators, non-traditional replacements or modifications and stockpiled masks. Promising strategies for mask conservation in the context of pandemics and epidemics include use of stockpiled masks, extended wear of disposable masks and decontamination. CONCLUSION There are promising strategies for overcoming face mask shortages during epidemics and pandemics. Further research specific to practical considerations is required before implementation during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Abirami Kirubarajan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Khan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tiffany Got
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Yau
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer M Bryan
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
| | - Steven Marc Friedman
- Department of Emergency Medicine, University Health Network, Toronto, Ontario, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Khan MA, Ikram A, Savul S, Lalani FK, Khan MA, Sarfraz M. Decontamination and Reuse of N95 Masks: A Narrative Review. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2020; 2020:8869472. [PMID: 33299504 PMCID: PMC7710392 DOI: 10.1155/2020/8869472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/01/2020] [Accepted: 11/16/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The COVID-19 pandemic has presented an unprecedented strain on healthcare supplies. Currently there is a global shortage of personal protective equipment (PPE), especially N95 masks. In order to safeguard healthcare personnel in this critical time and to mitigate shortages of N95 respirators, reuse of N95 respirators has to be considered. METHODS Using PubMed and Science Direct, a literature search was conducted to find and synthesize relevant literature on decontamination of N95 respirators for their subsequent reuse. Peer-reviewed publications related to methods of decontamination from January 2007 to April 2020 in the English language are included in this narrative review. Bibliographies of articles for relevant literature were also scrutinized. Findings. A total of 19 studies are included in this narrative review. The appraised methods include ultraviolet germicidal irradiation (UVGI), moist heat incubation (MHI), ethylene oxide (EtO), hydrogen peroxide vapor (HPV), microwave steam bags (MSB), microwave-generated steam (MGS), dry microwave oven irradiation, hydrogen peroxide gas plasma (HPGP), dry heat, liquid hydrogen peroxide, and bleach and alcohol. CONCLUSION In light of the COVID-19 pandemic, reuse of N95 respirators, although suboptimal, can be considered. Evidence reveals that UVGI, MHI, and HPV are amongst the safest and efficacious methods for decontamination of N95 masks. More research is needed to establish the safety and effectiveness of MGS, MSB, dry heat, EtO, liquid hydrogen peroxide, and HPGP. Alcohol, microwave irradiation, and bleach are not recommended because they damage N95 respirators.
Collapse
Affiliation(s)
- M. A. Khan
- National Institute of Health, Islamabad, Pakistan
| | - A. Ikram
- National Institute of Health, Islamabad, Pakistan
| | - S. Savul
- National Institute of Health, Islamabad, Pakistan
| | - F. K. Lalani
- National Institute of Health, Islamabad, Pakistan
| | - M. A. Khan
- National Institute of Health, Islamabad, Pakistan
| | - M. Sarfraz
- National Institute of Health, Islamabad, Pakistan
| |
Collapse
|
17
|
Bergman M, Fisher EM, Heimbuch BK. A Review of Decontamination Methods for Filtering Facepiece Respirators. JOURNAL OF THE INTERNATIONAL SOCIETY FOR RESPIRATORY PROTECTION 2020; 37:71-86. [PMID: 33268915 PMCID: PMC7707143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
During the current COVID-19 infectious disease pandemic, the demand for NIOSH-approved filtering facepiece respirators (FFR) has exceeded supplies and decontamination and reuse of FFRs has been implemented by various user groups. FFR decontamination and reuse is only intended to be implemented as a crisis capacity strategy. This paper provides a review of decontamination procedures in the published literature and calls attention to their benefits and limitations. In most cases, the data are limited to a few FFR models and a limited number of decontamination cycles. Institutions planning to implement a decontamination method must understand its limitations in terms of the degree of inactivation of the intended microorganisms and the treatment's effects on the fit and filtration of the device.
Collapse
Affiliation(s)
- Mike Bergman
- National Institute for Occupational Safety and Health, National Personal Protective Technology Laboratory, 626 Cochrans Mill Road, Pittsburgh, PA 15236
| | - Edward M. Fisher
- National Institute for Occupational Safety and Health, National Personal Protective Technology Laboratory, 626 Cochrans Mill Road, Pittsburgh, PA 15236
| | - Brian K. Heimbuch
- Applied Research Associates, 430 W 5th St, Suite 700, Panama City, FL 32401
| |
Collapse
|
18
|
Patel SH, Yim W, Garg AK, Shah SH, Jokerst JV, Chao DL. Assessing the Physiological Relevance of Cough Simulators for Respiratory Droplet Dispersion. J Clin Med 2020; 9:E3002. [PMID: 32957639 PMCID: PMC7564804 DOI: 10.3390/jcm9093002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/12/2020] [Accepted: 09/14/2020] [Indexed: 01/25/2023] Open
Abstract
Various breathing and cough simulators have been used to model respiratory droplet dispersion and viral droplets, in particular for SARS-CoV-2 modeling. However, limited data are available comparing these cough simulations to physiological breathing and coughing. In this study, three different cough simulators (Teleflex Mucosal Atomization Device Nasal (MAD Nasal), a spray gun, and GloGermTM MIST) that have been used in the literature were studied to assess their physiologic relevance. Droplet size, velocity, dispersion, and force generated by the simulators were measured. Droplet size was measured with scanning electron microscopy (SEM). Slow-motion videography was used to 3D reconstruct and measure the velocity of each simulated cough. A force-sensitive resistor was used to measure the force of each simulated cough. The average size of droplets from each cough simulator was 176 to 220 µm. MAD Nasal, the spray gun, and GloGermTM MIST traveled 0.38 m, 0.89 m, and 1.62 m respectively. The average velocities for the MAD Nasal, spray gun, and GloGermTM MIST were 1.57 m/s, 2.60 m/s, and 9.27 m/s respectively, and all yielded a force of <0.5 Newtons. GloGermTM MIST and the spray gun most closely resemble physiological coughs and breathing respectively. In conclusion, none of the simulators tested accurately modeled all physiologic characteristics (droplet size, 3-D dispersion velocity, and force) of a cough, while there were various strengths and weaknesses of each method. One should take this into account when performing simulations with these devices.
Collapse
Affiliation(s)
- Shiv H. Patel
- Simulation Training Center, University of California, San Diego, La Jolla, CA 92093, USA;
- Division of Biological Sciences, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Wonjun Yim
- Department of Material Science and Engineering, University of California, San Diego, La Jolla, CA 92093, USA; (W.Y.); (J.V.J.)
| | - Anupam K. Garg
- School of Medicine, University of California, San Diego, La Jolla, CA 92093, USA; (A.K.G.); (S.H.S.)
| | - Sahil H. Shah
- School of Medicine, University of California, San Diego, La Jolla, CA 92093, USA; (A.K.G.); (S.H.S.)
| | - Jesse V. Jokerst
- Department of Material Science and Engineering, University of California, San Diego, La Jolla, CA 92093, USA; (W.Y.); (J.V.J.)
- Department of Radiology, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
- Department of Nanoengineering, University of California, San Diego, La Jolla, CA 92093, USA
| | - Daniel L. Chao
- Viterbi Family Department of Ophthalmology, Shiley Eye Institute, University of California, San Diego, La Jolla, CA 92093, USA
| |
Collapse
|
19
|
Polkinghorne A, Branley J. Evidence for decontamination of single-use filtering facepiece respirators. J Hosp Infect 2020; 105:663-669. [PMID: 32473179 PMCID: PMC7251398 DOI: 10.1016/j.jhin.2020.05.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/20/2020] [Indexed: 12/13/2022]
Abstract
Single-use filtering face respirators (FFRs) are critical pieces of personal protective equipment for healthcare workers treating patients with suspected upper respiratory tract pathogens. Experiences during pandemics in the 2000s, as well as the ongoing COVID-19 pandemic caused by the SARS-2-CoV-2, have highlighted concerns over the pressures that sustained respiratory virus pandemics may have on supplies of FFRs globally. Decontamination of FFRs has been posited as one solution to support the re-use of FFRs with a growing body of literature over the last 10+ years beginning to examine both the efficacy of disinfection of contaminated FFRs but also the impact of the decontamination process on the FFR's performance. Physical and chemical methods of decontamination have been tested for treatment of FFRs with ultraviolet germicidal irradiation, sterilization by steam, ethylene oxide and vaporous hydrogen peroxide, demonstrating the most promising results thus far. Many of these methods utilize existing equipment that may already be available in hospitals and could be re-purposed for FFR decontamination. Importantly, some methods may also be replicated on household equipment, broadening the utility of FFR decontamination across a range of healthcare settings. Utilizing techniques to experimentally contaminate FFRs with a range of microorganisms, most decontamination methods appear to reduce the risk of the mask as a source of infection to the wearer and others to negligible levels. The performance of the filter, especially the efficiency of particle penetration following treatment, varied greatly depending on the processing method as well as the model of the filter itself, however. Urgent regulatory body-supported research is required to endorse the routine decontamination of FFRs. In emergency settings, these methods should nevertheless be carefully considered as one strategy to address potential shortfalls in supplies of FFRs for healthcare workers.
Collapse
Affiliation(s)
- A Polkinghorne
- Department of Microbiology and Infectious Diseases, New South Wales Health Pathology, Nepean Blue Mountains Pathology Service, PO Box 63, Penrith, New South Wales, 2751, Australia; Nepean Clinical School, Faculty of Medicine and Health, University of Sydney, 62 Derby St, Kingswood, New South Wales, 2747, Australia
| | - J Branley
- Department of Microbiology and Infectious Diseases, New South Wales Health Pathology, Nepean Blue Mountains Pathology Service, PO Box 63, Penrith, New South Wales, 2751, Australia; Nepean Clinical School, Faculty of Medicine and Health, University of Sydney, 62 Derby St, Kingswood, New South Wales, 2747, Australia.
| |
Collapse
|
20
|
Beam EL, Herstein JJ, Kupzyk KA, Gibbs SG. A simulation approach to measure critical safety behaviors when evaluating training methods for respirator education in healthcare workers. Am J Infect Control 2020; 48:869-874. [PMID: 32407827 PMCID: PMC7214345 DOI: 10.1016/j.ajic.2020.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 12/01/2022]
Abstract
N95 respirators are a common tool in healthcare for airborne isolation and pandemic response. Simulation can be used to train healthcare workers. Reflective practice may be a training intervention to improve N95 respirator use compared to video alone.
Background The N95 respirator is the most common safety tool used in hospitals to protect health care workers (HCW) from inhaling airborne particles. Focusing on HCW behavior related to respirator use is an effective route to improve HCW safety and respiratory health. Methods Participants were asked to perform the donning and doffing of an N95 respirator to camera. Then they were randomized to a video alone or a reflective practice intervention. After the intervention they repeated the donning and doffing to camera. A critical safety behavior scoring tool (CSBST) was developed to compare the performance of the participants over time at pretest, post-test and 1 month later for follow-up. Results The reflective practice intervention group was found to have significantly higher scores on the CSBST at post-test and follow-up than the video alone group. In the reflective practice intervention group, the participants perceived they were better at performing the N95 donning and doffing than the experts scored them. Conclusions The CSBST is a tool to measure the performance of HCWs on a specific targeted safety behaviors. The addition of a reflective practice intervention may result in a measurable and sustained improvement in the safety behaviors demonstrated when using the N95 respirator.
Collapse
|
21
|
Lindsley WG, Blachere FM, Burton NC, Christensen B, Estill CF, Fisher EM, Martin SB, Mead KR, Noti JD, Seaton M. COVID-19 and the Workplace: Research Questions for the Aerosol Science Community. AEROSOL SCIENCE AND TECHNOLOGY : THE JOURNAL OF THE AMERICAN ASSOCIATION FOR AEROSOL RESEARCH 2020; 54:1117-1123. [PMID: 35924028 PMCID: PMC9345404 DOI: 10.1080/02786826.2020.1796921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 07/14/2020] [Indexed: 06/13/2023]
Affiliation(s)
- William G. Lindsley
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Francoise M. Blachere
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Nancy C. Burton
- Division of Field Studies & Engineering, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA
| | | | - Cherie F. Estill
- Division of Field Studies & Engineering, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA
| | - Edward M. Fisher
- National Personal Protective Technology Laboratory, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Pittsburgh, Pennsylvania, USA
| | - Stephen B. Martin
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Kenneth R. Mead
- Division of Field Studies & Engineering, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA
| | - John D. Noti
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Melissa Seaton
- Division of Science Integration, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Cincinnati, Ohio, USA
| |
Collapse
|
22
|
Aziz S, Arabi YM, Alhazzani W, Evans L, Citerio G, Fischkoff K, Salluh J, Meyfroidt G, Alshamsi F, Oczkowski S, Azoulay E, Price A, Burry L, Dzierba A, Benintende A, Morgan J, Grasselli G, Rhodes A, Møller MH, Chu L, Schwedhelm S, Lowe JJ, Bin D, Christian MD. Managing ICU surge during the COVID-19 crisis: rapid guidelines. Intensive Care Med 2020; 46:1303-1325. [PMID: 32514598 PMCID: PMC7276667 DOI: 10.1007/s00134-020-06092-5] [Citation(s) in RCA: 234] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
Given the rapidly changing nature of COVID-19, clinicians and policy makers require urgent review and summary of the literature, and synthesis of evidence-based guidelines to inform practice. The WHO advocates for rapid reviews in these circumstances. The purpose of this rapid guideline is to provide recommendations on the organizational management of intensive care units caring for patients with COVID-19 including: planning a crisis surge response; crisis surge response strategies; triage, supporting families, and staff.
Collapse
Affiliation(s)
- Shadman Aziz
- London's Air Ambulance, Royal London Hospital, Barts NHS Health Trust, Whitechapel Rd, Whitechapel, London, E1 1FR, England, UK
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Waleed Alhazzani
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, Master University, Ontario, Canada
| | - Laura Evans
- Department of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA
| | | | | | - Jorge Salluh
- Instituto D'Or de Pesquisa e Ensino, Rio de Janeiro, Brazil
| | | | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Abu Dhabi, UAE
| | - Simon Oczkowski
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, Master University, Ontario, Canada
| | - Elie Azoulay
- Assistance publique - Hôpitaux de Paris, Paris, France
| | - Amy Price
- Anaesthesia and Informatics Lab, Stanford University, Stanford, USA
| | - Lisa Burry
- Sinai Health System, University of Toronto, Toronto, Canada
| | - Amy Dzierba
- New York-Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA
| | | | | | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | - Andrew Rhodes
- St Georges Hospitals NHS Foundation Trust, London, UK
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Larry Chu
- Anaesthesia and Informatics Lab, Stanford University, Stanford, USA
| | | | - John J Lowe
- Department of Environmental and Occupational Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - Du Bin
- Peking Union Medical College Hospital, Beijing, China
| | - Michael D Christian
- London's Air Ambulance, Royal London Hospital, Barts NHS Health Trust, Whitechapel Rd, Whitechapel, London, E1 1FR, England, UK.
| |
Collapse
|
23
|
Phan LT, Maita D, Mortiz DC, Bleasdale SC, Jones RM. Environmental Contact and Self-contact Patterns of Healthcare Workers: Implications for Infection Prevention and Control. Clin Infect Dis 2019; 69:S178-S184. [PMID: 31517975 PMCID: PMC6761362 DOI: 10.1093/cid/ciz558] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Respiratory viruses on fomites can be transferred to sites susceptible to infection via contact by hands or other fomites. METHODS Care for hospitalized patients with viral respiratory infections was observed in the patient room for 3-hour periods at an acute care academic medical center for over a 2 year period. One trained observer recorded the healthcare activities performed, contacts with fomites, and self-contacts made by healthcare workers (HCWs), while another observer recorded fomite contacts of patients during the encounter using predefined checklists. RESULTS The surface contacted by HCWs during the majority of visits was the patient (90%). Environmental surfaces contacted by HCWs frequently during healthcare activities included the tray table (48%), bed surface (41%), bed rail (41%), computer station (37%), and intravenous pole (32%). HCWs touched their own torso and mask in 32% and 29% of the visits, respectively. HCWs' self-contacts differed significantly among HCW job roles, with providers and respiratory therapists contacting themselves significantly more times than nurses and nurse technicians (P < .05). When HCWs performed only 1 care activity, there were significant differences in the number of patient contacts and self-contacts that HCWs made during performance of multiple care activities (P < .05). CONCLUSIONS HCWs regularly contact environmental surfaces, patients, and themselves while providing care to patients with infectious diseases, varying among care activities and HCW job roles. These contacts may facilitate the transmission of infection to HCWs and susceptible patients.
Collapse
Affiliation(s)
- Linh T Phan
- School of Public Health, University of Illinois at Chicago
| | - Dayana Maita
- College of Medicine, University of Illinois at Chicago
| | | | | | | |
Collapse
|
24
|
Weber RT, Phan LT, Fritzen-Pedicini C, Jones RM. Environmental and Personal Protective Equipment Contamination during Simulated Healthcare Activities. Ann Work Expo Health 2019; 63:784-796. [DOI: 10.1093/annweh/wxz048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/23/2019] [Accepted: 05/21/2019] [Indexed: 01/26/2023] Open
Abstract
Abstract
Providing care to patients with an infectious disease can result in the exposure of healthcare workers (HCWs) to pathogen-containing bodily fluids. We performed a series of experiments to characterize the magnitude of environmental contamination—in air, on surfaces and on participants—associated with seven common healthcare activities. The seven activities studied were bathing, central venous access, intravenous access, intubation, physical examination, suctioning and vital signs assessment. HCWs with experience in one or more activities were recruited to participate and performed one to two activities in the laboratory using task trainers that contained or were contaminated with fluorescein-containing simulated bodily fluid. Fluorescein was quantitatively measured in the air and on seven environmental surfaces. Fluorescein was quantitatively and qualitatively measured on the personal protective equipment (PPE) worn by participants. A total of 39 participants performed 74 experiments, involving 10–12 experimental trials for each healthcare activity. Healthcare activities resulted in diverse patterns and levels of contamination in the environment and on PPE that are consistent with the nature of the activity. Glove and gown contamination were ubiquitous, affirming the value of wearing these pieces of PPE to protect HCW’s clothing and skin. Though intubation and suctioning are considered aerosol-generating procedures, fluorescein was detected less frequently in air and at lower levels on face shields and facemasks than other activities, which suggests that the definition of aerosol-generating procedure may need to be revised. Face shields may protect the face and facemask from splashes and sprays of bodily fluids and should be used for more healthcare activities.
Collapse
Affiliation(s)
- Rachel T Weber
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Linh T Phan
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Rachael M Jones
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| |
Collapse
|
25
|
Rule AM, Apau O, Ahrenholz SH, Brueck SE, Lindsley WG, de Perio MA, Noti JD, Shaffer RE, Rothman R, Grigorovitch A, Noorbakhsh B, Beezhold DH, Yorio PL, Perl TM, Fisher EM. Healthcare personnel exposure in an emergency department during influenza season. PLoS One 2018; 13:e0203223. [PMID: 30169507 PMCID: PMC6118374 DOI: 10.1371/journal.pone.0203223] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/16/2018] [Indexed: 12/14/2022] Open
Abstract
Introduction Healthcare personnel are at high risk for exposure to influenza by direct and indirect contact, droplets and aerosols, and by aerosol generating procedures. Information on air and surface influenza contamination is needed to assist in developing guidance for proper prevention and control strategies. To understand the vulnerabilities of healthcare personnel, we measured influenza in the breathing zone of healthcare personnel, in air and on surfaces within a healthcare setting, and on filtering facepiece respirators worn by healthcare personnel when conducting patient care. Methods Thirty participants were recruited from an adult emergency department during the 2015 influenza season. Participants wore personal bioaerosol samplers for six hours of their work shift, submitted used filtering facepiece respirators and medical masks and completed questionnaires to assess frequency and types of interactions with potentially infected patients. Room air samples were collected using bioaerosol samplers, and surface swabs were collected from high-contact surfaces within the adult emergency department. Personal and room bioaerosol samples, surface swabs, and filtering facepiece respirators were analyzed for influenza A by polymerase chain reaction. Results Influenza was identified in 42% (53/125) of personal bioaerosol samples, 43% (28/ 96) of room bioaerosol samples, 76% (23/30) of pooled surface samples, and 25% (3/12) of the filtering facepiece respirators analyzed. Influenza copy numbers were greater in personal bioaerosol samples (17 to 631 copies) compared to room bioaerosol samples (16 to 323 copies). Regression analysis suggested that the amount of influenza in personal samples was approximately 2.3 times the amount in room samples (Wald χ2 = 16.21, p<0.001). Conclusions Healthcare personnel may encounter increased concentrations of influenza virus when in close proximity to patients. Occupations that require contact with patients are at an increased risk for influenza exposure, which may occur throughout the influenza season. Filtering facepiece respirators may become contaminated with influenza when used during patient care.
Collapse
Affiliation(s)
- Ana M. Rule
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Otis Apau
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Steven H. Ahrenholz
- Division of Surveillance, Hazard Evaluations, and Field Studies (DSHEFS), National Institute for Occupational Safety and Health, Cincinnati, Ohio, United States of America
| | - Scott E. Brueck
- Division of Surveillance, Hazard Evaluations, and Field Studies (DSHEFS), National Institute for Occupational Safety and Health, Cincinnati, Ohio, United States of America
| | - William G. Lindsley
- Health Effects Laboratory Division (HELD, National Institute for Occupational Safety and Health, Morgantown, West Virginia, United States of America
| | - Marie A. de Perio
- Division of Surveillance, Hazard Evaluations, and Field Studies (DSHEFS), National Institute for Occupational Safety and Health, Cincinnati, Ohio, United States of America
| | - John D. Noti
- Health Effects Laboratory Division (HELD, National Institute for Occupational Safety and Health, Morgantown, West Virginia, United States of America
| | - Ronald E. Shaffer
- National Personal Protective Technology Lab (NPPTL), National Institute for Occupational Safety and Health, Pittsburgh, Pennsylvania, United States of America
| | - Richard Rothman
- Johns Hopkins Hospital, Adult Emergency Department, Baltimore, Maryland, United States of America
| | - Alina Grigorovitch
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Bahar Noorbakhsh
- Health Effects Laboratory Division (HELD, National Institute for Occupational Safety and Health, Morgantown, West Virginia, United States of America
| | - Donald H. Beezhold
- Health Effects Laboratory Division (HELD, National Institute for Occupational Safety and Health, Morgantown, West Virginia, United States of America
| | - Patrick L. Yorio
- National Personal Protective Technology Lab (NPPTL), National Institute for Occupational Safety and Health, Pittsburgh, Pennsylvania, United States of America
| | - Trish M. Perl
- Division of Infectious Diseases, UT Southwestern Medical Center, Dallas, Texas, United States of America
| | - Edward M. Fisher
- National Personal Protective Technology Lab (NPPTL), National Institute for Occupational Safety and Health, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
| |
Collapse
|