Last updated Friday 3 April 2020

With the emergence of COVID-19 across many countries, there is a global shortage of personal protective equipment (PPE), including surgical masks and P2/N95 respirators. As a first step in releasing PPE from the National Medical Stockpile, the Australian Government has provided a limited supply of surgical masks and P2/N95 respirators for general practices (including Aboriginal Community Controlled Health Services) and community pharmacies with a demonstrated need. We continue to advocate for optometry access to this stock.

Further guidance on the use of surgical masks can be found on the Department of Health website.

Do I need to wear a face mask while seeing patients?

Information regarding face masks for general consulting in non-COVID suspicious patients has been conflicting, confusing and often changes daily. Following is some of the most recent information to be used as a guide for you to make decisions in your practice. For most up to date information look at the Department of Health website.

The updated advice from organisations in the eye sector seems to be that whilst the use of masks in non-suspicious patients has no specific evidence, optometric practitioners may wish to use one given the close proximity to patients. The following is a collection of the most recent information for you to use to make a decision in your clinical practice.

The World Health Organisation states in their document “Advice on the use of masks in the community during home care and in healthcare settings in the context of the novel coronavirus” published on 19th March 2020;

“Wearing medical masks when not indicated may result in unnecessary costs and procurement burdens and create a false sense of security that can lead to the neglect of other essential measures, such as hand hygiene practices. Further, using a mask incorrectly may hamper its effectiveness in reducing the risk of transmission.” “Health care workers should:  Wear a medical mask when entering a room where patients with suspected or confirmed COVID-19 are admitted;”

The World Health Organisation, in a document entitled “Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19)” Published 19.03.2020 gave a table;

The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) on the 2nd of April commented on their website; “where practical, doctors, staff and patients should wear masks. This may be very difficult given the limited availability of masks. “Doctors and staff should use gloves when seeing patients.”

Further, the Royal College of Ophthalmologists UK released a statement titled “Protecting patients, protecting staff during COVID-19 pandemic currently on their website which says;.

“Clinicians may wish to wear standard surgical masks, whilst recognising that they are of uncertain benefit. Gowns and gloves are not recommended” – 25th March 2020

But further documents available from the College of Optometrists UK on 1st April 2020“The Royal College of Ophthalmologists guidance to ophthalmologists” states that the College is advising the following approach to the use of PPE:

  • “Patients with no respiratory symptoms and no COVID-19 risk factors:
  • Clinicians should wear standard surgical masks, when examining or treating patients at the slit lamp. Gowns and gloves are not recommended
  • Plastic breath shields attached to slit lamps provide some protection but must be disinfected between patients because studies show that the COVID-19 virus is viable for up to 72 hours on plastic surfaces
  • Avoid speaking at slit lamp
  • Wear a surgical mask when examining or treating patients at the slit lamp.  Note: The same surgical mask may be worn for examining multiple patients, but you must be fastidious to avoid transmitting the virus on the front of the mask via your hands or your clothes. Do not take the mask on and off between patients and do not allow it to dangle on your chest.

Finally, the American Academy of Ophthalmology also released a statement on the 31st of March 2020, describing that

“U.S. hospital guidance has varied from forbidding physicians from wearing masks except in high-risk interactions, presumably for fear of shortages, to mandating all hospital staff wear surgical or N-95 masks. The Academy relies on expert guidance from the CDC with regards to indications for extended mask wear and reuse. The use of masks during ophthalmic examinations is a rapidly evolving issue.” 

And have suggested that when seeing asymptomatic patients;

  • “Standard precautions apply.
  • Added precaution of not speaking during slit-lamp biomicroscopic examinations is appropriate.
  • In the setting of adequate PPE supplies, use of surgical mask and eye protection for the clinician as well as surgical mask for the patient may reduce asymptomatic and presymptomatic transmission.” 

We also encourage Australian optometrists to review the Australian Department of Health’s “Interim advice on non-inpatient care of persons with suspected or confirmed Coronavirus disease (COVID19), including use of personal protective equipment (PPE)”, updated 5th March

Further information

On the use of PPE for suspect and confirmed COVID-19 cases, the Australian Department of Health advises:

Suspect case

A suspect case is a patient whom has any one of the following;

  • Recent travel to, including transit though, another country
  • Close or casual contact within the last 14 days with a confirmed case of COVID-19
  • Respiratory illness symptoms

Patients whom are suspect cases should defer any non-emergent optometric care until post the 14 days of quarantine.

If they present to a practice, immediately give the patient a surgical mask and ensure they put it on correctly. Direct them to a single room, whether or not respiratory symptoms are present.

If this is the first contact with a health care provider, contact the local public health unit or state/territory communicable disease branch for advice if you are uncertain about the need for testing.

All staff and practitioners should wear a mask.

Confirmed cases

A confirmed case is a person who tests positive to a specific SARS-CoV-2 PCR test or has the virus identified by electron microscopy or viral culture, at a reference laboratory.

Patients should defer any non-emergent optometric care until post the 14 days of quarantine, and they are declared well. Recommend referral to a local COVID treatment centre. “As there may be transmission through the ocular surface in patients with conjunctivitis, and the close proximity during slit lamp examination, optometrists would require Gloves, Gowns, Eye protection and masks (e.g. an N-95 mask) to protect the mouth, nose and eyes.”

Q) Do I need to wear a N95 Respirator?

The CDC in a document called “Checklist for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during the COVID-19 Response

Use surgical N95 respirators only for HCP who need protection from both airborne and fluid hazards (e.g., splashes, sprays). If needed but unavailable, use faceshield over standard N95 respirator.

The Australian Department of Health, in a Coronavirus disease (COVID-19) document updated on 5th of March “Interim advice on non-inpatient care of persons with suspected or confirmed Coronavirus disease (COVID19), including use of personal protective equipment (PPE)”

In patients with a confirmed COVID diagnosis; “As there may be transmission through the ocular surface in patients with conjunctivitis, and the close proximity during slit lamp examination, optometrists would require Gloves, Gowns, Eye protection and masks (e.g. an N-95 mask) to protect the mouth, nose and eyes.”

RANZCO’s FAQ’s, last updated 27th March 2020 states;

The N95/P2 masks are thought to be helpful but given they are in short supply, they need to be reserved for those cases with definite or suspected COVID.

Q) If I need to wear a mask, what should I do?

“Medical masks are surgical or procedure masks that are flat or pleated (some are like cups); they are affixed to the head with straps.”

The following information from the World Health Organisation on correct use of medical masks derives from the practices in health-care settings:

  • “Place the mask carefully, ensuring it covers the mouth and nose, and tie it securely to minimize any gaps between the face and the mask.
  • Avoid touching the mask while wearing it.
  • Remove the mask using the appropriate technique: do not touch the front of the mask but untie it from behind.
  • After removal or whenever a used mask is inadvertently touched, clean hands using an alcohol-based hand rub or soap and water if hands are visibly dirty.
  • Replace masks as soon as they become damp with a new clean, dry mask.
  • Do not re-use single-use masks.
  • Discard single-use masks after each use and dispose of them immediately upon removal.
  • Cloth (e.g. cotton or gauze) masks are not recommended under any circumstances.”

 

There is a CDC guide on appropriate facial hair for maintaining a tight seal on NIOSH filtering facepiece respirators. The CDC made a statement on Feb 28th 2020 highlighting that this is not in relation to the general public when wearing face masks, but rather specific advice published 2017 for people who require airborne hazard protection. See the graph here. This may be important if you are actively dealing with diagnosed COVID-19 patients.

Wearing a N95 mask fitting advice from Health NSW’s Procedure for putting on a P2/N95 face mask and conducting a fit check:

  1. Remove glasses and hats. Tie back long hair so it does not become tangled in the straps of the respiratory protection
  2. Put the mask on your face, ensuring the nos​e piece is at the top of the mask
  3. Place the headband or ties over the head and at the base of the neck
  4. Compress the mask against the face to ensure a seal across the bridge of the nose
  5. Compress the mask to ensure a seal across the cheeks and the face; and
  6. Conduct a fit check: check the seal of the mask by gently inhaling. If the mask is not drawn in towards the face, or air leaks around the face seal, readjust the mask and repeat process or check for defects in the mask. If the mask still leaks you may need to try a different size or style of mask.

Note: People with beards should shave before using a P2 mask as a good seal between the mask and the wearer’s face cannot be guaranteed if they have facial hair.”

Q) Can you re-use masks? Can they be sterilised?

The CDC also have released advice on the use of face masks during an epidemic, where stocks are potentially low as a strategy for optimising the supply of facemasks.

“Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters.

  • The facemask should be removed and discarded if soiled, damaged, or hard to breathe through.
  • HCP must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene.
  • HCP should leave the patient care area if they need to remove the facemask.”

The Royal Australian and New Zealand College of Ophthalmology (RANZCO) released a statement saying;

“Standard Surgical masks have not been specifically noted to be helpful for ophthalmologists, ophthalmic assistants or other healthcare workers as there is no evidence of their usefulness against virus transmission to the healthcare worker. However, we would understand that you might want to wear one if you feel it will help you avoid touching your face during clinic. If you do decide to wear one, it would be sensible to keep it on the whole clinic rather than taking it on and off which could transfer virus to hands.” 27th March 2020 – Read more.

The World Health Organisation has also answered this question on disposable face masks; stating that:

“Disposable medical face masks are intended for a single use only. After use they should be removed using appropriate techniques (i.e. do no touch the front, remove by pulling the elastic ear straps or laces from behind) and disposed of immediately in an infectious waste bin with a lid, followed by hand hygiene.”

However, there are multiple contradicting sources regarding the re-use of N95 masks:

The National Academies of Sciences, Engineering, and Medicine reports that, in a pandemic situation where masks are in short supply, “use and store the respirator in such a way that the physical integrity and efficacy of the respirator will not be compromised.” You shouldn’t keep it in your pocket, wallet, purse, or handbag.

The Centers for Disease Control and Prevention (CDC) website suggests that you “hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses.” This is for pandemic situations where the supply of N95 masks is significantly compromised.

Q) Where can I get slit lamp shields from?

All optometrists should use slit lamp shields to reduce droplet transmission during close encounter patient examinations.

Some options for commercial slit lamp shields;

  • One option is from: https://slitlampshield.com/ Australian designed and has large area and side wings: $80.
  • Contact your slit lamp manufacturer
  • https://www.guldenophthalmics.com/products/index.php/slit-lamp-breath-shield.html

Q) Can I make my own slit lap shield?

Yes. Qld Member Helen Flohr passed on a helpful tip for creating a temporary breath shield by putting an empty sheet through the laminator and then cutting a hole for the slit lamp eye pieces. It is again larger than many conventional breath shields. Please be aware these may be more difficult to disinfect between patients than commercial shields.

Q) Will optometrists be able to access the government stockpile of masks?

Optometry Australia continues to remain in contact with the Department of Health concerning emergency supply of masks through Primary Health Networks (PHNs) advocating for optometry access to the supplies being made available from the national stockpile.

The Department of Health advised on March 8th that it had obtained a further 54 million masks for the National Stockpile. The direction of the Australian Department of Health is for PHNs to distribute masks to GPs and community pharmacies within their area with demonstrated need.

Please note that in general circumstances, each practice is only being sent a single box of 50 masks (and that this is for emergency situations where there is no local supply available commercially and is not intended as ongoing supply).

At this stage, PHN’s are not authorised to supply surgical masks to allied health professions, including optometry but we understand that this situation is being monitored daily and Optometry Australia remains in contact with the Australian Department of Health.

Q) Where can I get masks?

Simply type ‘Surgical Mask’ or ‘P2 / N95 mask’ into your online search bar to see what is available.

Amidst a huge increase in demand the answer to this question changes daily and conventional surgical and medical suppliers are reporting limited supplies.  Online suppliers selling surgical masks still seem to, as at 25th March 2020, have stock available from Australia for quick delivery, but since the start of March prices have been increasing steadily and supply dwindling even on sites like eBay and Amazon.

It may be worth splitting orders with different suppliers (rather than putting all your eggs in one basket) as members are reporting some orders being cancelled and refunded or transit and shipping delays.  You may wish to consider P2 masks for yourself and staff and surgical masks for patients.

Here are some suppliers that have let us know that they have masks available, or we have been alerted that members have been successful in getting orders. Optometry Australia does not endorse, or have any corporate relationship with any of the following companies, nor guarantee quality or supply. If you know of any available suppliers (or are one) that should be added to this rapidly changing list, please let us know.

Q) How do I know the quality of my mask, or if it is appropriate for clinical use?

There have been multiple rumors about inadequate masks entering the Australian market, and deciding if a product is suitable for clinical use is challenging. The following is not an exhaustive list, but some recommendations include:

  1. Look for TGA, FDA or CE certification where possible.  Please be aware the ‘China Export’ mark and  European standards logo “CE” look very similar.
  2. Check how many layers do the surgical masks have?
  3. Is it from Australian stock or being sent from overseas and what is the estimated delivery window (often months away)
  4. Is it a reputable seller?
  5. The ABC reported on the 1st of April 2020 that the Australian Border Force had seized up to 800,000 counterfeit or otherwise faulty masks
  6. How fluid repellent is the mask? Halyard has this infographic to explain the different standard of masks (Note: Halyard does retail masks)
  7. According to the Australian Department of Health “Safe Use of PPE”, The P2 mask is the Australian equivalent of the United States’ N95 mask. Both masks are designed with a high filtration capacity and essentially provide the same level of protection.
  8. For in depth description of how masks were developed the American Center for Disease Control and Prevention recently put out this extensive blog.

Support for our members

We realise this is a difficult and uncertain time for all of us. Optometry Australia’s optometry advisor helpdesk  offers our members dedicated experienced optometrists ready to provide confidential support.

Optometry Australia’s advisor helpdesk
Email: national@optometry.org.au
Phone: (03) 9668 8500
Operating hours: Monday to Friday, 9.00am to 5.00pm AEST

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