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Under-mask beard covers achieve an adequate seal with tight-fitting disposable respirators using quantitative fit testing

Open AccessPublished:May 31, 2022DOI:https://doi.org/10.1016/j.jhin.2022.05.015

      Summary

      Background

      Tight-fitting respirators are a critical component of respiratory protection against airborne diseases for health workers. However, they are not recommended for health workers with facial hair. Some health workers are unable to shave for religious or medical reasons. Under-mask beard covers have been proposed as a solution to allow health workers with facial hair to wear tight-fitting respirators. However, studies to date have been limited by their predominant reliance on qualitative rather than quantitative fit testing techniques.

      Aim

      To assess the efficacy of under-mask beard covers in achieving an adequate seal with tight-fitting disposable P2/N95 respirators using quantitative fit testing.

      Methods

      Bearded adult males underwent quantitative fit testing with an under-mask beard cover using either a TSI PortaCount Respirator Fit Tester 8038 or an AccuFit 9000 PRO fit testing device on up to five disposable P2/N95 respirators (3M 1860, 3M 1870+, BYD N95 Healthcare Particulate Respirator, BSN Medical ProShield N-95 Medium and Trident RTCFFP2). The primary outcome was the proportion of subjects that passed or failed quantitative fit testing with an under-mask beard cover.

      Findings

      Thirty subjects were assessed; of these, 24 (80%) passed quantitative fit testing with at least one tight-fitting P2/N95 disposable respirator. Among these subjects, the median best-achieved fit factor was 200 (interquartile range 178–200). None of the subjects had an adverse reaction to the under-mask beard cover.

      Conclusion

      The under-mask beard cover technique may be used to achieve a satisfactory seal with tight-fitting P2/N95 respirators in health workers with facial hair who cannot shave.

      Keywords

      Introduction

      Tight-fitting respirators are a key component of respiratory protection programmes against airborne diseases for health workers (HWs) [
      National Health and Medical Research Council
      Australian guidelines for the prevention and control of infection in healthcare.
      ]. The importance of such respirators has been highlighted during the coronavirus disease 2019 (COVID-19) pandemic, where they have been routinely recommended to reduce the risk of transmission of severe acute respiratory syndrome coronavirus-2 in HWs [
      Australian Government Department of Health
      Guidance on the use of personal protective equipment (PPE) for health care workers in the context of COVID-19.
      ].
      Tight-fitting disposable respirators rely on achieving a complete seal with the wearer's face to minimize the risk of particle transmission through gaps between the wearer's skin and the respirator. Fit testing is a validated quantitative or qualitative process for determining the type and size of respirator that achieves an adequate seal on an individual's face. Fit testing is recommended in manufacturers' instructions for use (IFUs) to ensure adequate HW and patient safety while providing clinical care [
      • Regli A.
      • von Ungern-Sternberg B.S.
      Fit-testing of N95/P2-masks to protect health care workers.
      ]. Following respirator selection via fit testing, HWs perform ‘fit checking’ at each instance of respirator use.
      The manufacturers' IFUs advise that facial hair may compromise the seal between the respirator and the wearer's skin, potentially leaving the HW and patients unprotected. Accordingly, current guidelines recommend that HWs with facial hair cannot use tight-fitting respirators or are required to shave, using a limited number of facial hairstyles that do not interfere with the respirator seal [
      Centers for Disease Control and Prevention
      Facial hairstyles and filtering facepiece respirators.
      ]. This poses a workforce challenge as some HWs with facial hair cannot shave for religious or medical reasons [
      • Talwar R.
      ‘We have to choose between beard or emergency shifts during COVID-19’: Australian Sikh doctors.
      ,
      • Hsieh J.C.
      • Maisel-Campbell A.L.
      • Joshi C.J.
      • Zielinski E.
      • Galiano R.D.
      Daily quality-of-life impact of scars: an interview-based foundational study of patient-reported themes.
      ]. The loss of such critical HWs from frontline clinical roles during the COVID-19 pandemic prompted a review of the guidelines, and a search for viable solutions that permitted affected HWs to continue to work. In response to this challenge, a novel technique (‘Singh Thattha technique’) with under-mask beard covers was described recently and tested in male Sikh HWs [
      • Singh R.
      • Safri H.S.
      • Singh S.
      • Ubhi B.S.
      • Singh G.
      • Alg G.S.
      • et al.
      Under-mask beard cover (Singh Thattha technique) for donning respirator masks in COVID-19 patient care.
      ,
      • Prince S.E.
      • Chen H.
      • Tong H.
      • Berntsen J.
      • Masood S.
      • Zeman K.L.
      • et al.
      Assessing the effect of beard hair lengths on face masks used as personal protective equipment during the COVID-19 pandemic.
      ]. However, these studies were limited by their predominant reliance on qualitative fit testing, use of respirators that are not commonly available in clinical settings, and differences in methodology. In view of the importance of maintaining all available HWs in frontline roles, further analysis in this area is required. The aim of this study was to assess the efficacy of under-mask beard covers in achieving an adequate seal with tight-fitting disposable P2/N95 respirators in HWs with facial hair who cannot shave, using quantitative fit testing.

      Methods

      Subjects

      Sikh males, aged ≥18 years, with facial hair were included in this study. Subjects were not required to be HWs to be enrolled in the study. All subjects were from New South Wales (NSW), Australia.

      Fit testing

      Participants received education on donning and doffing the under-mask beard cover and disposable P2/N95 respirator. The under-mask beard cover or ‘Singh Thattha technique’ requires the use of an elastic resistance band that is tied over the apex of the head to create a smooth surface over the subject's beard, over which the disposable respirator can create a seal (Figure 1A). Subjects used one of two commercially available resistance bands: TheraBand ‘Heavy’ (TheraBand, Akron, OH, USA) or PTP Mediband 5.8 kg resistance (Fitness Systems United, Rosebery, NSW, Australia). Subjects with a latex allergy were advised to use the TheraBand ‘Heavy’ resistance band as it is latex-free. For individuals with a shorter anterior-to-posterior mandibular length, the resistance bands were cut to a narrower width. The ideal width of the band covers the beard completely, without creases or folds in the region where the mask would come into contact with the face (Figure 1B). The appropriately sized band was placed over the subject's beard, and a double knot was tied over the top of the turban to secure it in place, as described by Singh et al. [
      • Hsieh J.C.
      • Maisel-Campbell A.L.
      • Joshi C.J.
      • Zielinski E.
      • Galiano R.D.
      Daily quality-of-life impact of scars: an interview-based foundational study of patient-reported themes.
      ]. Subjects were tested on up to five disposable P2/N95 respirators depending on local availability: 3M 1860 (3M Australia, North Ryde, NSW, Australia), 3M 1870+ (3M Australia), BYD N95 Healthcare Particulate Respirator (BYD Australia, Lane Cove West, NSW, Australia), BSN Medical ProShield N-95 (BSN Medical, Mulgrave, Victoria, Australia) and Trident RTCFFP2 (Industree Group, West Gosford, NSW, Australia).
      Figure 1
      Figure 1Under-mask beard cover. (A) The resistance band provides a smooth surface for the respirator to create a seal. Subject shown with 3M 1860. (B) The ideal width of the band covers the beard completely, without creases or folds in the region where the mask contacts the face. In this subject, the band was trimmed to reduce its width. Subject photos included with permission.
      A quantitative fit testing protocol was used in the ambient particle counting mode using either a TSI PortaCount Respirator Fit Tester 8038 or an AccuFit 9000 PRO fit testing device. The Occupational Safety Health Administration Modified FAST quantitative fit testing protocol was used [
      • Prince S.E.
      • Chen H.
      • Tong H.
      • Berntsen J.
      • Masood S.
      • Zeman K.L.
      • et al.
      Assessing the effect of beard hair lengths on face masks used as personal protective equipment during the COVID-19 pandemic.
      ]. All fit testers were trained and approved, working either within the NSW government public hospital system or as a private approved fit tester. The fit testers were independent from trial investigators. An independent observer from the Clinical Excellence Commission (CEC), the lead agency supporting safety improvement in the NSW government health system, was also present at all fit testing sessions, ensuring that correct protocols were followed during testing.
      The corresponding results for each aspect of the fit test and the overall fit factor were recorded. The fit factor pass result was set at 100. The maximum recorded fit factor by the testing protocol was 200. The process was repeated for all respirators in a similar manner. The testing was performed at five different sites on five separate days.

      Outcomes

      The primary outcome was the proportion of subjects that passed or failed quantitative fit testing with the under-mask beard cover. Secondary outcomes were the median best-achieved fit factor amongst subjects that passed fit testing, and adverse reactions to the under-mask beard cover (discomfort, skin irritation or allergic reaction) during and immediately after fit testing.

      Statistical analysis

      Categorical variables were reported as frequency and percentage. Continuous variables with a normal distribution were reported as mean and standard deviation (SD). Continuous variables with a non-normal distribution were reported as median and interquartile range (IQR). Statistical analysis was performed using RStudio Desktop 2022.02.0+443.

      Ethics and funding

      This study was approved by the Northern Sydney Human Research Ethics Committee (2021/ETH12307). No external funding was received. In-kind support was received from NSW-CEC who facilitated and observed the fit testing.

      Results

      Thirty adult males were enrolled over 5 days. All subjects had facial hair classified as ‘full beard’, ‘Garabaldi’ or ‘Bandholz’, as defined by the Centers for Disease Control and Prevention [
      Centers for Disease Control and Prevention
      Facial hairstyles and filtering facepiece respirators.
      ]. Eighteen (60%) subjects were currently employed as HWs.
      Twenty-four (80%) subjects passed quantitative fit testing with at least one tight-fitting P2/N95 disposable respirator (Table I). Among these subjects, the median best-achieved fit factor was 200 (IQR 178–200).
      Table IQuantitative fit testing results by subject
      BYD N95 Healthcare Particulate RespiratorBSN Medical ProShield N-95 Medium3M 18603M 1870+Trident RTCFFP2
      Subject 1FF137F-
      Subject 2F174200--
      Subject 3--126--
      Subject 4FFFFF
      Subject 5154F110F-
      Subject 6FFFF-
      Subject 7FF116--
      Subject 8FF155199-
      Subject 9FFFF200
      Subject 10FFFF186
      Subject 11FF132FF
      Subject 12FFF200-
      Subject 13FFFFF
      Subject 14FFFFF
      Subject 15--200174200
      Subject 16F-FFF
      Subject 17--FF104
      Subject 18--FFF
      Subject 19--200FF
      Subject 20--184200188
      Subject 21--F188193
      Subject 22---152200
      Subject 23FF198-200
      Subject 24FF200-200
      Subject 25187F--200
      Subject 26FFF200119
      Subject 27FFF-200
      Subject 28F120200-200
      Subject 29200-F-200
      Subject 30FF126-200
      F, fail; -, not tested.
      Subjects were tested on a median of 4 (IQR 3–4) tight-fitting P2/N95 disposable respirators. Subjects that passed quantitative fit testing with at least one tight-fitting P2/N95 respirator were tested on a median of 4 (IQR 3–4) respirators. Those who did not pass were tested on a median of 4.5 (IQR 4–5) respirators.
      The Trident RTCFFP2 respirator had the highest pass rate, with 15 of 22 (68%) subjects achieving a pass. It also had the highest median fit factor [200 (IQR 191–200)] amongst those who passed (Table II).
      Table IIQuantitative fit testing results by respirator
      Passed n/N (%)Median (IQR) fit factor for those who passed
      BYD N95 Healthcare Particulate Respirator3/22 (14)187 (171–194)
      BSN Medical ProShield N-95 Medium2/20 (10)147 (134–161)
      3M 186014/28 (50)170 (128–200)
      3M 1870+7/20 (35)199 (181–200)
      Trident RTCFFP215/22 (68)200 (191–200)
      IQR, interquartile range.
      The respirator with the lowest pass rate was the BSN Medical ProShield respirator, with two of 20 (10%) subjects achieving a pass. The median fit factor was 147 (IQR 134–161) amongst those who passed.
      No subjects reported any adverse reactions to the under-mask beard cover during or immediately after the test.

      Discussion

      The under-mask beard cover technique was first described in 2020 during the COVID-19 pandemic by Singh et al. [
      • Singh R.
      • Safri H.S.
      • Singh S.
      • Ubhi B.S.
      • Singh G.
      • Alg G.S.
      • et al.
      Under-mask beard cover (Singh Thattha technique) for donning respirator masks in COVID-19 patient care.
      ]. In that study of 27 HWs, 26 (93%) passed qualitative fit testing using an under-mask beard cover technique similar to the technique used in the present study. However, the study was limited by the reliance on mainly qualitative rather than quantitative fit testing. All five (19%) subjects who underwent quantitative fit testing passed. Another limitation of the study was the use of respirators which are not commonly available in healthcare settings. The strength of the present study was its ability to address both of these limitations. The present study used independent quantitative fit testing using disposable tight-fitting P2/N95 respirators that are readily available in healthcare settings. Prince et al. [
      • Prince S.E.
      • Chen H.
      • Tong H.
      • Berntsen J.
      • Masood S.
      • Zeman K.L.
      • et al.
      Assessing the effect of beard hair lengths on face masks used as personal protective equipment during the COVID-19 pandemic.
      ] also demonstrated an overall >95% quantitatively assessed fit efficacy in their study of one subject using the resistance band beard cover technique when tested with a 3M 8210 respirator.
      It is important to note that this study was not designed to assess the relative pass rate of respirators against each other. Hence, the higher pass rate with the Trident RTCFFP2 should not be interpreted as a recommendation of this respirator over the others. Similarly, these results should not be interpreted as disapproval of respirators that had a lower pass rate, such as the BYD N95 Healthcare Particulate Respirator and BSN Medical ProShield N-95.
      The limitations of this study include that not all subjects underwent testing with all five tight-fitting P2/N95 respirators. Of the six (20%) subjects who did not pass quantitative fit testing, three did not undergo testing with all five respirators due to limited respirator availability. It is possible that the pass rate and median fit factor may have improved had all subjects been tested with all five respirators. In addition, only a limited sample of P2/N95 respirators were tested in this study. It is possible that some of the subjects who failed quantitative fit testing in this study may have passed in a more comprehensive study of all available respirators. Furthermore, subjects only received brief training on the under-mask beard cover technique. If more comprehensive training had been provided, the pass rate may have further improved. In addition, the study was not designed to assess the predictors of passing quantitative fit testing. Finally, the study only assessed comfort during and immediately after fit testing with the under-mask beard cover. None of the subjects developed skin irritation or pressure injury at the time of the test. Future studies should address this by comparing the comfort of different under-mask beard covers with extended use and in actual clinical scenarios.
      As a result of this study, NSW-CEC developed comprehensive guidance and videos demonstrating the technique, which may be accessed online [
      New South Wales Government Clinical Excellence Commission
      Respiratory protection program manual.
      ,
      New South Wales Government Clinical Excellence Commission
      Education, training, posters and videos.
      ].
      In conclusion, the under-mask beard cover technique may be used to achieve a satisfactory seal with tight-fitting disposable P2/N95 respirators in HWs with facial hair who are unable to shave.

      Acknowledgements

      The authors wish to thank NSW-CEC for their assistance supervising fit testing.

      Conflict of interest statement

      The authors DDSB, KSB, TS, APSS, GS, AB and NS were subjects in the study. Importantly, none of the authors performed any of the fit testing.

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