We recently got called out on Facebook for using a stock photo of an N95 mask with a exhalation valve. We used that particular image simply because it matched the colors used in the course materials. So it was an aesthetic decision for visual interest and not meant as an endorsement promoting the use of this particular type of mask. The issue around this image stems from the fact that masks with exhalation valves allow some unfiltered air to escape.
With the use of masks becoming mandated in many places in the USA, masks have become the center of attention and are featured frequently in news stories. Unfortunately, it’s difficult to get an understanding of a complex issue in one minute news segments or 500 word articles. The discussion of masks and of reducing risk of COVID-19 transmission is much more nuanced that simply stating that this mask is good or this mask is bad.
We discuss masks in more detail in the Preventing Disease Transmission in a Massage Practice and I’d encourage everyone to get their free copy. However, let’s look at N95 masks, or more accurately “N95 respirators”, a little more closely.
You may have heard that COVID-19 is not currently considered an “airborne” disease, so you may wonder why we have to wear masks. To understand masks or respirators you need to have an understanding of terminology related to disease transmission because it’s a source of confusion. (Refer to “Preventing Disease Transmission in a Massage Practice” for a larger discussion of disease transmission.)
COVID-19 is currently thought to be spread primarily by “droplet” transmission. When you cough, sneeze, sing, or even talk loudly or breathe heavily, saliva and respiratory secretions are expelled from your mouth and nose in the form of droplets. These are rather large heavy particles and they tend to drop to the ground rather quickly, so their spread is somewhat limited. This is why the CDC and WHO has a six foot distancing guideline. Under most circumstances the droplets fall to the ground before they travel those six feet.
It’s believed that COVID-19 is also spread by “fomite” transmission. Fomites are inanimate objects that can become contaminated with infectious agents and serve as a mechanism for transfer between people. For example, an infected person touches a doorknob and leaves traces of virus which can be picked up by an non-infected individual. The most recent research suggests that fomite transmission is not as big a factor in COVID-19 transmission as initially believed, but it is still a concern.
Until recently, the CDC has said that COVID-19 is not an “airborne” disease and this has caused a lot of confusion because the standard definition of airborne is different than the scientific definition of airborne. From a scientific standpoint, airborne transmission is defined as the spread of an infectious agent caused by the dissemination of droplet nuclei (aerosols) that remain infectious when suspended in air over long distances and time. Droplet nuclei or aerosols are extremely small particles of saliva and respiratory secretions. They are produced by normal talking and breathing and through evaporation of larger droplets. Whether or not these aerosolized particles can transmit COVID-19 is contentious, but it is generally recognized as a possible transmission route.
So with that out of the way, let’s look at masks or respirators…
N95 respirators were originally designed for industrial use in sectors such as mining, construction, and painting. They are meant to provide protection from the inhalation of various airborne substances. The “N” stands for “Non-Oil” meaning that if no oil-based particulates are present, then you can use the mask in the work environment. The “95” means that the mask filters 95% of fine particles in the air. In more recent years, the use of these masks has extended from industrial use to medical use.
In the United States, the Occupational Safety and Health Administration (OSHA) requires healthcare workers who are expected to perform patient activities with those suspected or confirmed to be infected with COVID-19 to wear respiratory protection.
The most common type of respiratory protection you’ll see in a medical setting is a surgical mask. They are cheap, readily available, and provide a certain level of protection from droplet transmission of disease. If you’ve worn one of these masks, however, you know that they do not seal to your face and as a result unfiltered air easily moves in and out of the mask. These masks do not provide protection against infectious aerosolized particles.
A higher level of protection is provided by N95 respirators. In the absence of facial hair, they seal more tightly around the face and minimize the movement of unfiltered air, so they do provide protection against aerosolized particles.
KN95 respirators are the Korean and Chinese equivalent of North American N95 masks and provide a similar level of protection. The FDA has recently approved these for use for healthcare workers. KN95 masks are NOT Niosh (National Institute of Occupational Safety and Health) approved N95 masks. The CDC has recently stated however that KN95 masks may be suitable alternative when Niosh N95 masks are not available. KN95 respirators are currently widely available in the USA and are a good alternative to N95 masks for massage professionals.
Some N95 masks have exhalation valves. This is meant to make mask wearing more comfortable and breathing easier, especially for workers who need to wear masks for extended periods of time. The exhalation valves allow air to leave the mask through a vent. As soon as you start to inhale, the vent closes and the protection you get as a wearer is really no different than wearing an unvented N95 mask.
It’s important to note that these masks are designed for the safety and comfort of the person wearing the mask. In medical settings, the primary concern is to prevent disease transmission from patients to healthcare workers. So these ventilated masks have been used in medical settings except in situations where you need a sterile environment, like an operating room. With COVID-19 however, the equation has changed. The concern is not just the protection of the healthcare worker, but also protection of the patients, since healthcare workers need to be considered as possible carriers or the virus. So these masks are not recommended for use in situations where COVID-19 transmission is possible.
So what kind of masks should we wear in our interactions with clients and what masks should they wear?
It’s not a simple question and requires some critical thinking on the part of the therapist. First of all, bear in mind that personal protective equipment (PPE) like masks are only one factor in preventing transmission of COVID-19. More important considerations might include the incidence of infection in your community and the environment of the massage room. It’s also important to note that you cannot eliminate the risk of infection; you can only minimize it to various degrees. And that’s what every guideline offered by various agencies aim to do: Minimize risk.
To put this in context, healthcare workers in hospitals wear eye protection because droplets can enter the eyes and cause infection. But eye protection is not typically talked about in the context of massage simply because the risk infection in this way for massage therapists is extremely low. Note: The Federation of State Massage Therapy Boards guidelines do recommend the use of protective eye equipment (not just eyeglasses) for massage therapists.
If you are in an area where there is a surge of cases and a high rate of infection in the population, you are at an increased risk. There is a higher probability that an infected individual will walk through your door.
A bigger area of concern for massage therapists is the work environment. If we could massage outside in the open air, our risk would be dramatically decreased. Unfortunately, massage rooms are usually small rooms with limited ventilation. We are sharing limited airspace with someone who could be infected, and inversely, our clients are sharing airspace with us and we could be infected.
It’s important that you understand mask use, but it’s equally if not more important that you’re familiar with the wide range of factors that are going to impact the safety of you and your clients. This will allow you to evaluate news stories critically and to move beyond simple guidelines. It will allow you to . No mask provides 100% protection, so you need to take into consideration the full spectrum of factors in disease transmission so you can exercise critical thinking as you reopen practice and make an informed decisions. These factors are discussed in depth in the “Preventing Disease Transmission in a Massage Practice” book, which we are making freely available to the profession.
If you want to read more on the subject, here are some articles of interest. They are all written for consumers and are easy to understand.
Transmission of SARS-CoV-2: implications for infection prevention precautions
This is a recent brief from WHO that outlines current research on modes of transmission and infection prevention.
Why you’re unlikely to get the coronavirus from runners or cyclists
We like this article because it discusses the concepts of viral load and infectious dose in a simple, easy to understand way.
WHO Reviews ‘Current’ Evidence On Coronavirus Transmission Through Air
This is an older article from March 2020 that clarifies some of the confusion around droplet vs. airborne spread of COVID-19.
Should You Wear a Face Mask? The CDC May Be Reconsidering Recommendations
This examines the CDC’s decision to recommend mask wearing for the general public.