Last updated Friday 18 April 2020

 

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 changes frequently. Following is some of the most recent information to be used as a guide for you to make decisions in your practice. For the most up to date Australian information look at the Department of Health website.

The Department of Health, in their document titled “Distribution of face masks through PHNs
released 08.04.2020 stated “There is no need for the general public or health care workers to wear masks unless they are dealing with symptomatic patients.”

The updated advice from organisations in the eye sector specifically, 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 changed their advice on the 6th April 2020 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”;

“There is currently no evidence that wearing a mask (whether medical or other types) by healthy persons in the wider community setting, including universal community masking, can prevent them from infection with respiratory viruses, including COVID-19.

Medical masks should be reserved for health care workers. The use of medical masks in the community may create a false sense of security, with neglect of other essential measures, such as hand hygiene practices and physical distancing, and may lead to touching the face under the masks and under the eyes, result in unnecessary costs, and take masks away from those in health care who need them most.”

And also warn;

“Wearing a medical mask is one of the prevention measures that can limit the spread of certain respiratory viral diseases, including COVID-19. However, the use of a mask alone is insufficient to provide an adequate level of protection, and other measures should also be adopted. Whether or not masks are used, maximum compliance with hand hygiene and other IPC measures is critical to prevent human-to-human transmission of COVID-19”

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;

Further, the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) released a statement on the 16th of April 2020 titledClinical eye care” which says;

“When face-to-face consultations are required, ophthalmologists are advised to use their own judgement regarding use of PPE in asymptomatic, routine patients. They should be able to assess infection risk on a case-by-case basis, taking into consideration RANZCO guidance about how to assess patients, and be permitted to wear their own PPE, if they feel this is clinically justified. Any decision should acknowledge the need to preserve critically low supplies of PPE in Australia and New Zealand.”

For more information and their full statement, including justification, please see the link.

The Royal College of Ophthalmologists UK updated their statement on the 30th of March entitled Protecting Patients, Protecting Providers to say;

A) Patients with no respiratory symptoms and no COVID-19 risk factors:
– Clinicians may wish to wear standard surgical masks, whilst recognising that they are of uncertain benefit. Gowns and gloves are not recommended
– Plastic breath shields attached to slit lamps may 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 surface s
– Avoid speaking at the slit lamp
B) Patients with suspected or proven COVID-19 infection;
– Patients should be seen in a designated area within the eye department
– Clinicians should wear a fluid repellent mask, gown, gloves and eye protection (face shield or goggles)

The College of Optometrists UK on the 17th of April in a document titled COVID-19 College Updates advised;

 “For the direct care or assessment (within 2 metres) of a patient or resident that is not currently a possible or confirmed COVID-19 case they should wear (and change between each patient)

  • Single Use Gloves
  • Single use disposable plastic apron
  • Fluid resistant surgical mask (sessional use, based on risk assessment)
  • Reusable face or eye protection (sessional use, based on risk assessment)

Finally, the American Academy of Ophthalmology also released a statement updated on the 17 of April 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;

“For in-office procedures that require close physical proximity to the patient (e.g., intravitreal injection, lateral tarsorrhaphy), we recommend the patient wear a surgical mask or a cloth face covering if surgical masks are in short supply, and that the surgeon wear a surgical mask and eye protection. In regions with high prevalence of COVID-19, an N95 mask for the surgeon can be considered when available.”

We also encourage Australian optometrists to review the Australian Department of Health’s “Interim recommendations for the use of personal protective equipment (PPE) during hospital care of people with Coronavirus Disease 2019 (COVID-19)”, updated 5th March and “Revised advice on non-inpatient care of people with suspected or confirmed COVID-19, including use of personal protective equipment”:

Further information

On the use of PPE for suspect and confirmed COVID-19 cases, the Australian Department of Health advises in “Revised advice on non-inpatient care of people with suspected or confirmed COVID-19, including use of personal protective equipment” updated 7th of April 2020:

“If a person, who fulfils epidemiological criteria and is in quarantine or under investigation, needs medical attention for any reason (e.g. symptoms compatible with COVID-19 or other illness/injury) they are requested:
• to telephone their doctor or hospital emergency department (ED) before presenting
• if they experience severe symptoms, to call 000 and advise the operator that they are in self-quarantine because of COVID-19 risk.

Upon presentation to a healthcare setting (general practice or other community care setting, hospital ED or pathology collection centre), of a person who is under quarantine or investigation or is a suspect case:
• 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.  o If a single room is unavailable, an area separate from other patient areas should be designated for assessment of suspected COVID-19 patients. 
If this is the first contact with a healthcare provider, contact the local public health unit or state/territory communicable disease branch for advice if you are uncertain about the need for testing.”

And for assessment of persons with suspected or confirmed COVID-19

“For clinical consultation with clinical examination: perform hand hygiene 
• use gown, gloves, surgical mask and eye protection (safety glasses or face shield).”

RANZCO has released the following guidelines on the 16th of April 2020 “Clinical Eye Care” that suggests triaging for patients with suspected COVID-19 as follows;

How do I manage confirmed, probable or suspected COVID-19 patients?

Ophthalmologists seeing a patient with an emergent or urgent eye problem who is at risk or has symptoms suggestive of COVID-19 will need to use their discretion to triage the relative urgency of each condition. To ensure the appropriate triage of patients during the COVID-19 pandemic, the College has adapted the Moorfields Eye Hospital Guidelines to suit our context. These adapted triage guidelines can be accessed to inform your clinical decision making. See below for guidance on immediate management of non-urgent and emergent/urgent eye conditions:

i.) Non-urgent eye problem should have their eye appointment postponed for 14 days until COVID-19 has been excluded.

ii.) Emergent and Urgent eye problems

a. If the eye condition can wait, the patient should be referred to an appropriate clinical centre for testing

b. If the eye condition cannot wait, the current interim advice from the Australian Government Department of Health should be followed including:

  • Immediately give the patient a N95/P2 (surgical if N95/P2 is not available) 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.
  • Standard precautions, including hand hygiene (5 Moments), should be observed for all patients. Patients and staff should observe cough etiquette and respiratory hygiene.
  • Contact and droplet precautions should be used for clinical assessment and collection of specimens from a patient under investigation.
  • Perform hand hygiene before putting on Personal Protective Equipment (PPE): gown, gloves, eye protection (goggles or face shield) and N95/P2 (surgical if N95/P2 is not available) mask. All assistants should do the same.
  • To collect eye swabs, stand slightly to the side of the patient to avoid exposure to respiratory secretions should the patient cough or sneeze.
  • After the consultation, remove PPE and perform hand hygiene.
  • Any contacted/contaminated surfaces should be wiped with detergent/disinfectant by a person wearing gloves, surgical mask and eye protection.
  • Note that for droplet precautions, a negative pressure room is not required and the room does not need to be left empty after sample collection.
  • Any patient with severe symptoms suggestive of pneumonia should be transferred to and managed in hospital. Call 000 and advise the operator that the patient is in self-quarantine because of COVID-19 risk.”

Q) Do I need to wear a N95/P2 Respirator Mask?

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/P2 respirators only for HCP who need protection from both airborne and fluid hazards (e.g., splashes, sprays). If needed but unavailable, use face shield over standard N95 respirator.

The Australian Department of Health, in a Coronavirus disease (COVID-19) document updated on 7th of April “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;

Standard precautions, including hand hygiene (5 Moments), should be observed for all patients. Patients and staff should observe cough etiquette and respiratory hygiene.
Transmission-based precautions:
• Contact and droplet precautions should be observed for routine care of patients in quarantine or under investigation or with suspected or confirmed COVID-19 infection.
• Contact and airborne precautions should be observed when performing aerosol generating procedures (see Appendix 1), and care of patients with severe respiratory symptoms”

However, if you suspect a patient has a possibility of COVID infection, contact the local public health unit or state/territory communicable disease branch before treating the patient for advice.

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 the 6th of March 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.”

 

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/P2 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 on the 31st of March 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.”

Professor Mary-Louise McLaws, a Professor of Epidemiology of Hospital Infection and Infectious Diseases Control at the University of New South Wales and a member of the World Health Organization (WHO) Health Emergencies Program Experts Advisory Panel for infection Prevention and Control Preparedness also answered this issue with the following on the 9th of April 2020;

“During the SARS 2003 outbreak healthcare workers reused their own masks because of the surge in demand for masks associated with the high number of SARS patients and the high number of procedures that required the healthcare worker to wear a mask. They placed their N95 mask into a labelled bag and re-used it the following day until the mask was moist or damp and then they replaced it with a new one. This is not an ideal situation but is an emergency response to severe disruption to the supply chain.

We can’t yet safely reprocess N95 masks because research has reported reprocessing degrades the strands within the mask. The World Health Organization (WHO) is right now working with global experts to identify the safest method of extending the use of masks until a reprocessing method that does not degrade the mask is identified.”

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;

Other universal shields:

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 but supply lines seem to be improving as many factories overseas and locally pivot to making PPE.  Online suppliers selling surgical masks as at 14 May 2020, still  have stock available from Australia for quick delivery.

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.

  • Aviva & Mann Optical group has face masks arriving shortly
  • ANSIC has surgical and N95 masks, many of which are TGA / FDA approved
  • Kogan Australia has multiple sellers providing masks, many of which are TGA / FDA approved
  • PPE Masks Australia has sanitiser plus surgical and N95 masks, many of which are TGA / FDA approved.  They have offered a discounted rate to OA members. You will need to enter a password: (staysafe) to enter site and at the checkout use your AHPRA number when registering and discount code OPTOM2020. Pricelist available here and guide to mask selection here.

 

Q) Should I make my own mask?

Professor Mary-Louise McLaws, a Professor of Epidemiology of Hospital Infection and Infectious Diseases Control at the University of New South Wales and a member of the World Health Organization (WHO) Health Emergencies Program Experts Advisory Panel for infection Prevention and Control Preparedness answered this issue with the following on the 9th of April 2020;

“No. The production of masks is complex, for example some masks are made up of polypropylene central layers that are charged to prevent penetration of particles and designed to fit the face to provide a seal to prevent small particles from entering the mask. Both N95 and surgical masks are lab tested to ensure they filter at least 95-98% of lab particles (referred to as the ‘most penetrating particle’).

It is understandable that people in places like New York City where the COVID-19 infection rate is very high are nervous and may resort to making their own masks. While a mask made out of cotton may provide a small amount of protection from droplets, it is incredibly important that this does not give people a false sense of security. If you want to wear a mask, remember it may not be hospital grade. If you wear a mask don’t forget to hand hygiene, avoid touching your face and apply social distancing as these simple actions are still the best ways to avoid being infected with COVID-19 even while wearing a non-hospital grade mask.”

 And the CDC on the 17th of March 2020 in their release titled “Strategies for Optimising the supply of facemasks” stated;

“In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.”

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 Centers 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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