Efficacy and safety of disinfectants for decontamination of N95 and SN95 filtering facepiece respirators: a systematic review

BACKGROUND

Decontaminating and reusing filtering facepiece respirators (FFRs) for healthcare workers is a potential solution to address inadequate FFR supply during a global pandemic.

AIM

The objective of this review was to synthesize existing data on the effectiveness and safety of using chemical disinfectants to decontaminate N95 FFRs.

METHODS

A systematic review was conducted on disinfectants to decontaminate N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined study eligibility and extracted predefined data fields. Original research reporting on N95 FFR function, decontamination, safety, or FFR fit following decontamination with a disinfectant was included.

FINDINGS AND CONCLUSION

A single cycle of vaporized hydrogen peroxide (H₂O₂) successfully removes viral pathogens without affecting airflow resistance or fit, and maintains an initial filter penetration of <5%, with little change in FFR appearance. Residual hydrogen peroxide levels following decontamination were within safe limits. More than one decontamination cycle of vaporized H₂O₂ may be possible but further information is required on how multiple cycles would affect FFR fit in a real-world setting before the upper limit can be established. Although immersion in liquid H₂O₂ does not appear to adversely affect FFR function, there is no available data on its ability to remove infectious pathogens from FFRs or its impact on FFR fit. Sodium hypochlorite, ethanol, isopropyl alcohol, and ethylene oxide are not recommended due to safety concerns or negative effects on FFR function.

Decontamination interventions for the reuse of surgical mask personal protective equipment: a systematic review

BACKGROUND

The high demand for personal protective equipment during the novel coronavirus outbreak has prompted the need to develop strategies to conserve supply. Little is known regarding decontamination interventions to allow for surgical mask reuse.

AIM

To identify and synthesize data from original research evaluating interventions to decontaminate surgical masks for the purpose of reuse.

METHODS

MEDLINE, Embase, CENTRAL, Global Health, the WHO COVID-19 database, Google Scholar, DisasterLit, preprint servers, and prominent journals from inception to April 8^th, 2020, were searched for prospective original research on decontamination interventions for surgical masks. Citation screening was conducted independently in duplicate. Study characteristics, interventions, and outcomes were extracted from included studies by two independent reviewers. Outcomes of interest included impact of decontamination interventions on surgical mask performance and germicidal effects.

FINDINGS

Seven studies met eligibility criteria: one evaluated the effects of heat and chemical interventions applied after mask use on mask performance, and six evaluated interventions applied prior to mask use to enhance antimicrobial properties and/or mask performance. Mask performance and germicidal effects were evaluated with heterogeneous test conditions. Safety outcomes were infrequently evaluated. Mask performance was best preserved with dry heat decontamination. Good germicidal effects were observed in salt-, N-halamine-, and nanoparticle-coated masks.

CONCLUSION

There is limited evidence on the safety or efficacy of surgical mask decontamination. Given the heterogeneous methods used in studies to date, we are unable to draw conclusions on the most efficacious and safe intervention for decontaminating surgical masks.

Decontamination interventions for the reuse of surgical mask personal protective equipment: a systematic review

BACKGROUND

The high demand for personal protective equipment during the novel coronavirus outbreak has prompted the need to develop strategies to conserve supply. Little is known regarding decontamination interventions to allow for surgical mask reuse.

AIM

To identify and synthesize data from original research evaluating interventions to decontaminate surgical masks for the purpose of reuse.

METHODS

MEDLINE, Embase, CENTRAL, Global Health, the WHO COVID-19 database, Google Scholar, DisasterLit, preprint servers, and prominent journals from inception to April 8^th, 2020, were searched for prospective original research on decontamination interventions for surgical masks. Citation screening was conducted independently in duplicate. Study characteristics, interventions, and outcomes were extracted from included studies by two independent reviewers. Outcomes of interest included impact of decontamination interventions on surgical mask performance and germicidal effects.

FINDINGS

Seven studies met eligibility criteria: one evaluated the effects of heat and chemical interventions applied after mask use on mask performance, and six evaluated interventions applied prior to mask use to enhance antimicrobial properties and/or mask performance. Mask performance and germicidal effects were evaluated with heterogeneous test conditions. Safety outcomes were infrequently evaluated. Mask performance was best preserved with dry heat decontamination. Good germicidal effects were observed in salt-, N-halamine-, and nanoparticle-coated masks.

CONCLUSION

There is limited evidence on the safety or efficacy of surgical mask decontamination. Given the heterogeneous methods used in studies to date, we are unable to draw conclusions on the most efficacious and safe intervention for decontaminating surgical masks.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H₂O (7.97-11.70 mm H₂O) vs 9.85 mm H₂O (8.33-11.44 mm H₂O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m² resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m². Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m²) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m² or greater, and confirm appropriate mask fit following decontamination.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H₂O (7.97-11.70 mm H₂O) vs 9.85 mm H₂O (8.33-11.44 mm H₂O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m² resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m². Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m²) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m² or greater, and confirm appropriate mask fit following decontamination.

Influence of race/ethnicity on prevalence and presentation of endometriosis: a systematic review and meta-analysis

BACKGROUND

Understanding the impact of race/ethnicity on the prevalence and presentation of endometriosis may help improve patient care.

OBJECTIVE

To review systematically the evidence for the influence of race/ethnicity on the prevalence of endometriosis.

SEARCH STRATEGY

CENTRAL, MEDLINE, PubMed, Embase, LILACS, SCIELO, and CINAHL databases, as well as the grey literature, were searched from date of inception until September 2017.

SELECTION CRITERIA

Randomised control trials and observational studies reporting on prevalence and/or clinical presentation of endometriosis.

DATA COLLECTION AND ANALYSIS

Twenty studies were included in the review and 18 studies were used to calculate odds ratio (OR) with 95% confidence interval (CI) through a random effects model. Methodological quality was assessed using the Newcastle-Ottawa risk of bias scale (NOS).

MAIN RESULTS

Compared with White women, Black woman were less likely to be diagnosed with endometriosis (OR 0.49, 95% CI 0.29-0.83), whereas Asian women were more likely to have this diagnosis (OR 1.63, 95% CI 1.03-2.58). Compared with White women, there was a statistically significant difference in likelihood of endometriosis diagnosis in Hispanic women (OR 0.46, 95% CI 0.14-1.50). Significant heterogeneity (I2  > 50%) was present in the analysis for all racial/ethnic groups but was partially reduced in subgroup analysis by clinical presentation, particularly when endometriosis was diagnosed as self-reported, CONCLUSIONS: Prevalence of endometriosis appears to be influenced by race/ethnicity. Most notably, Black women appear less likely to be diagnosed with endometriosis compared with White women. There is scarce literature exploring the influence of race/ethnicity on symptomatology, as well as treatment access, preference, and response.

TWEETABLE ABSTRACT

Prevalence of endometriosis may be influenced by race/ethnicity, but there is limited quality literature exploring this topic.

Correlation between nicotine-induced inhibition of hematopoiesis and decreased CD44 expression on bone marrow stromal cells

This study demonstrates that in vivo exposure to cigarette smoke (CS) and in vitro treatment of long-term bone marrow cultures (LTBMCs) with nicotine, a major constituent of CS, result in inhibition of hematopoiesis. Nicotine treatment significantly delayed the onset of hematopoietic foci and reduced their size. Furthermore, the number of long-term culture-initiating cells (LTC-ICs) within an adherent layer of LTBMCs was significantly reduced in cultures treated with nicotine. Although the production of nonadherent mature cells and their progenitors in nicotine-treated LTBMCs was inhibited, this treatment failed to influence the proliferation of committed hematopoietic progenitors when added into methylcellulose cultures. Bone marrow stromal cells are an integral component of the hematopoietic microenvironment and play a critical role in the regulation of hematopoietic stem cell proliferation and self-renewal. Exposure to nicotine decreased CD44 surface expression on primary bone marrow-derived fibroblastlike stromal cells and MS-5 stromal cell line, but not on hematopoietic cells. In addition, mainstream CS altered the trafficking of hematopoietic stem/progenitor cells (HSPC) in vivo. Exposure of mice to CS resulted in the inhibition of HSPC homing into bone marrow. Nicotine and cotinine treatment resulted in reduction of CD44 surface expression on lung microvascular endothelial cell line (LEISVO) and bone marrow-derived (STR-12) endothelial cell line. Nicotine treatment increased E-selectin expression on LEISVO cells, but not on STR-12 cells. These findings demonstrate that nicotine can modulate hematopoiesis by affecting the functions of the hematopoiesis-supportive stromal microenvironment, resulting in the inhibition of bone marrow seeding by LTC-ICs and interfering with stem cell homing by targeting microvascular endothelial cells.

Evidence for the presence of idiotype-bearing regulatory T cells in which idiotype expression does not show linkage to either IgH alleles or the MHC

An anti-idiotypic antiserum was raised in rabbits to a monoclonal antibody with specificity for one of the two antigenic determinants on the ferredoxin (Fd) molecule. The monoclonal antibody (Fd-B2) was derived from fusion of spleen cells from Fd-immune B10.BR (H-2k, Ighb). Examination of an extensive number of samples of Fd-immune serum from B10.BR and other mouse strains established that the Fd-B2 idiotype is essentially never present in such sera in detectable concentrations (greater than 30 ng/ml). Administration of the anti-idiotypic antibody (anti-Fd-B2) i.v. to B10.BR mice, or treatment of B10.BR T cell-enriched populations with anti-Fd-B2 + C prior to adoptive transfer to irradiated B10.BR recipients followed by challenge with Fd resulted in a significant increase in the production of anti-Fd antibodies. This effect was specific and was not reflected by a change in expression of the Fd-B2 idiotype in the antibody produced. Similarly, injection of 10 micrograms of Fd-B2 into B10.BR mice resulted in an enhanced anti-Fd response. When similar experiments were carried out using B10.D2 mice (H-2d, Ighb), which are genetic non-responders to Fd, it was observed that treatment which anti-Fd-B2 followed by challenge with Fd resulted in production in treated animals of significant levels of antibody to Fd. Again, the antisera thus produced did not contain detectable levels of the Fd-B2 idiotype. Further experiments using high responder (H-2k) mice with Igh allotypes differing from the B10 strains (C57/BR, Igha, and RF/J, Ighc), showed that treatment of these animals with anti-Fd-B2 also resulted in a highly significant enhancement of the anti-Fd response. These data imply that the anti-idiotypic antiserum (anti-Fd-2B) is exerting its influence by acting on an id + population of T cells and that the expression of this id is not dependent on genetic linkage to either the H-2 or the Igh loci.

Identification of an idiotypic marker of a major regulatory T cell of the immune response in B10.BR mice to ferredoxin. The relationship of idiotypic regulation to conventional hapten-carrier effects

An anti-idiotypic antiserum was raised in rabbits to a monoclonal antibody (Fd-1) with specificity for one (the N epitope) of the two antigenic epitopes found on the ferredoxin (Fd) molecule. The anti-idiotypic antiserum (anti-Fd-1) was used to demonstrate that the Fd-1 idiotype was expressed at significant levels in most anti-Fd antisera raised in B10.BR mice. Examination of antisera raised in other mouse strains demonstrated that expression of this idiotype mapped to the IgH gene complex and was found in the antisera of all mouse strains examined with the Ig-1 allotype. When splenocytes from Fd-immune B10.Br mice were treated with anti-Fd-1 and transferred to irradiated syngeneic recipients, the adoptive secondary response was significantly higher in animals receiving treated cells as opposed to control animals, which received normal rabbit serum-treated cells. This response produced a net increase in antibody to both determinants, and the relative amount of Fd-1 idiotype was not significantly altered. Further studies with separated cell populations showed that the overall increase of anti-Fd antibody produced was attributable to the effects of the anti-idiotypic serum on a population(s) of T cells. Treatment of mice with the Fd-1 monoclonal antibody (which should react with anti-idiotypic cells) had an analogous effect to that of the anti-idiotype, in that mice so treated produced higher concentrations of anti-Fd antibodies when they were immunized and these antibodies exhibited net increases to both determinants. A model is presented to explain these results.

Regulation of L-amino acid oxidase and of D-amino acid oxidase in Neurospora crassa

Neurospora crassa possesses an inducible L-amino acid oxidase that is expressed only when cells are derepressed for nitrogen in the presence of an amino acid. Enzyme synthesis requires both induction by an amino acid and simultaneous nitrogen catabolite derepression. Carbon limition in the presence of an amino acid does not permit induction of L-amino acid oxidase. The nit-2 gene is a major regulatory locus which is believed to mediate nitrogen catabolite repression in Neurospora. Mutants of nit-2 are repressed for L-amino acid oxidase activity under conditions which lead to good enzyme induction in wild type and nit-2 revertants. The loss of the enzyme in nit-2 mutants does not result from inducer exclusion, which suggests that the nit-2 gene product has a direct role in controlling the expression of this enzyme. Substantial amounts of L-amino acid oxidase were detected in the growth medium as well as in cell extracts of the wild type strain. Biochemical data indicates that the intracellular and the extracellular L-amino acid oxidases are identical. Inhibitors of protein and of RNA synthesis block accumulation of L-amino acid oxidase, suggesting that enzyme expression is controlled at the level of transcription. D-amino acid oxidase can be detected in cell extracts of Neurospora grown in the presence of a D-amino acid. The enzyme is present in cys-3 mutants and is not repressed by high concentrations of sulfate or nitrogen indicating that D-amino acid oxidase is not a member of the sulfur or nitrogen regulatory circuits of this organism.

The use of unideterminant fragments of ferredoxin in the genetic mapping of determinant specificity of the immune response

The ferredoxin (Fd) molecule is a small non-mammalian immunogenic protein containing 55 amino acid residues with only two major antigenic determinants located with the NH2-terminal heptapeptide and the COOH-terminal pentapeptide. Selective enzyme cleavages of Fd with either trypsin or carboxypeptidase A result in the inactivation of the antigenic determinants by the removal of a tripeptide at the NH2-terminal and two amino acid residues at the COOH-terminal, effectively leaving 52 and 53 amino acid fragments respectively, each containing a single antigenic determinant. Fd digested with both enzymes yielded a 50 amino acid peptide with both determinants inactivated. Purity of these digests was assessed using monoclonal antibodies in standard and antigen-blocking ELISAs. The doubly digested peptide had virtually no reactivity with anti-Fd sera, reconfirming that the central cysteine-rich region is serologically silent. It was found that the sum of the reactivities of the N- and C-determinant-bearing peptides as equal to that of the native Fd and that the ratio of the reactivities could be used to assess determinant selectivity in the response to Fd in congenic recombinant strains of mice. This method was used in mapping the determinant selectivity in the antibody response to the MHC of mice to the left of the I-B subregion. Use of the B10.HTT strain indicated that separate genes mapping to the same subregion code for the magnitude of the antibody response and the determinant selectivity of the response.

Identification and isolation of actin from Neurospora crassa

Crude cell extracts of Neurospora crassa contained an abundant protein that was identified as actin by a number of criteria. The protein, either in cell extracts or in pure form, co-migrated with rabbit skeletal muscle actin in polyacrylamide gels. The N. crassa actin was purified by DEAE-cellulose and DNAase I-Sepharose chromatography and had the expected property of inhibiting DNAase I activity. Although N. crassa actin could polymerize and depolymerize, purification based entirely on this characteristic was ineffective. The actin was susceptible to proteolytic degradation, and under certain conditions, a breakdown product of defined size was observed.

The immune response to ferredoxin: characterization of a major idiotype in serum using monoclonal antibody derived by cell fusion

Ferredoxin (Fd) is a low mol. wt protein (6000 d) isolated from Clostridium pasteurianum. This antigen possess two non-cross-reactive antigenic determinants and engenders a restricted antibody response in selected strains of mice. Immunochemical studies of Fd have shown that antibody responses are confined to two sequences of between five and seven amino acids in extent located at the NH2-and COOH-termini of the molecule. Serum antibodies from responder strains of mice bind these epitopes in proportions which are regulated by genes mapping in the Ir-region of the H-2 complex. A hybrid cell line secreting monoclonal Fd-binding antibody has been isolated from an immune mouse through fusion with the SP2/0 myeloma cell line. The resulting antibody binds to a single determinant located at the nH2-terminal of the molecule. An anti-idiotype antibody to this monoclonal antibody was raised in rabbits. After appropriate absorptions, its specificity for the paratopic regions of the hybridoma antibody was established by demonstrating its displacement from reaction with the idiotype by Fd. Analysis of the distribution of the hybridoma idiotype in serum antibodies from congenic mouse strains indicates that it is a major idiotype expressed in different inbred strains sharing identity at the Igh-1 locus.

The use of the enzyme-linked immunosorbent assay (ELISA) for the detection and quantification of specific antibody from cell cultures

The solid phase enzyme linked immunosorbent assay (ELISA) has been used to quantify anti-keyhole limpet haemocyanin (anti-KLH) antibody in the serum of KLH-immune C57Bl/6 mice. When spleen cells from immune mice were cultured overnight in ELISA microtitre wells to which KLH had been adsorbed it was found that easily quantifiable amounts of anti-KLH antibody were synthesized and were detectable. It was found further that spleen cells from KLH-primed mice, when cultured in vitro in the presence of KLH, transferred to KLH-labelled ELISA plates, and cultured overnight, also produced detectable levels of antibody. Levels of antibody were detectable only after 4 and 5 days of in vitro stimulation. A comparison was made between detectable numbers of plaque forming cells to sheep red blood cells (SRBC) in SRBC primed CBA mice and levels of antibody detected by the ELISA procedure. It was found that the sensitivities of the two tests were comparable. The applications of this technique to the study of in vitro antibody synthesis using soluble antigens are discussed.