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MARCH 22, 2020 -- In the midst of the rapidly spreading COVID-19 pandemic, hospitals and clinics are running out of masks. Healthcare workers are going online to beg for more, the hashtags #GetMePPE and #WeNeedPPE are trending on Twitter, and some hospitals have even put out public calls for mask donations. Health providers are working scared: They know that the moment the masks run out, they're at increased risk for disease. So instead of waiting for mask shipments that may be weeks off, some people are making their own.
At Phoebe Putney Health hospital in Albany, Georgia, staff members and volunteers have been working overtime to make face masks that might provide protection against COVID-19. Using a simple template, they cut green surgical sheeting into half-moons, which they pin and sew before attaching elastic straps. Deaconess Health System in Evansville, Indiana, has posted instructions for fabric masks on their website and asked the public to step up and sew.
Elsewhere, healthcare workers have turned to diapers, maxi pads and other products to create masks. Social media channels are full of tips and sewing patterns. It's an innovative strategy that is also contentious. Limited evidence suggests that homemade masks can offer some protection. But the DIY approach has also drawn criticism for providing a false sense of security, potentially putting wearers at risk.
The conflict points to an immediate need for more protective equipment, says Christopher Friese, PhD, RN, professor of nursing and public health at the University of Michigan, Ann Arbor. Also needed, he says, are new ideas for reducing strain on limited supplies, like adopting gear from other industries and finding innovative ways to provide care so that less protective gear is needed.
"We don't want clinicians inventing and 'MacGyvering' their own device because we don't want to put them at risk if we can avoid it," says Friese, referring to the TV character who could build and assemble a vast array of tools/devices. "We have options that have been tested, and we have experience, maybe not in healthcare, but in other settings. We want to try that first before that frontline doctor, nurse, respiratory therapist decides to take matters into their own hands.
Increasingly, though, healthcare workers are finding they have no other choice — something even the CDC has acknowledged. In new guidelines, the agency recommends a bandana, scarf, or other type of covering in cases where facemasks are not available.
N95 Respirators or Surgical Masks?
There are two main types of masks generally used in healthcare. N95 respirators filter out 95% of airborne particles, including bacteria and viruses. The lighter surgical or medical face-masks are made to prevent spit and mucous from getting on patients or equipment.
Both types reduce rates of infection among healthcare workers, though comparisons (at least for influenza) have yet to show that one is superior to the other. One 2020 review by Chinese researchers, for example, analyzed six randomly controlled trials that included more than 9000 participants and found no added benefits of N95 masks over ordinary surgical masks for healthcare providers treating patients with the flu.
But COVID-19 is not influenza, and evidence suggests it may require more intensive protection, says Friese, who coauthored a blog post for JAMA about the country's unpreparedness for protecting healthcare workers during a pandemic. The virus can linger in the air for hours, suggesting that N95 respirators are healthcare providers' best option when treating infected patients.
The problem is there's not enough to go around — of either mask type. In a March 5 survey, National Nurses United reported that just 30% of more than 6500 US respondents said their organizations had enough PPE to respond to a surge in patients. Another 38% did not know if their organizations were prepared. In a tweet, Friese estimated that 12% of nurses and other providers are at risk from reusing equipment or using equipment that is not backed by evidence.
Physicians and providers around the world have been sharing strategies online for how to make their own masks. Techniques vary, as do materials and plans for how to use the homemade equipment. At Phoebe Putney Health, DIY masks are intended to be worn over N95 respirators and then disposed of so that the respirators can be reused more safely, says Amanda Clements, the hospital's public relations coordinator. Providers might also wear them to greet people at the front door.
Some evidence suggests that homemade masks can help in a pinch, at least for some illnesses. For a 2013 study by researchers in the UK, volunteers made surgical masks from cotton T-shirts, then put them on and coughed into a chamber that measured how much bacterial content got through. The team also assessed the aerosol-filtering ability of a variety of household materials, including scarfs, antimicrobial pillowcases, vacuum-cleaner bags, and tea towels. They tested each material with an aerosol containing two types of bacteria similar in size to influenza.
Commercial surgical masks performed three times better than homemade ones in the filtration test. Surgical masks worked twice as well at blocking droplets on the cough test. But all the makeshift materials — which also included silk, linen, and regular pillowcases — blocked some microbes. Vacuum-cleaner bags blocked the most bacteria, but their stiffness and thickness made them unsuitable for use as masks, the researchers reported. Tea towels showed a similar pattern. But pillowcases and cotton T-shirts were stretchy enough to fit well, thereby reducing the particles that could get through or around them.
Homemade masks should be used only as a last resort if commercial masks become unavailable, the researchers concluded. "Probably something is better than nothing for trained healthcare workers — for droplet contact avoidance, if nothing else," says Anna Davies, BSc, a research facilitator at the University of Cambridge, UK, who is a former public health microbiologist and one of the study's authors.
She recommends that members of the general public donate any stockpiles they have to healthcare workers, and make their own if they want masks for personal use. She is working with collaborators in the US to develop guidance for how best to do it.
"If people are quarantined and looking for something worthwhile to do, it probably wouldn't be the worst thing to apply themselves to," she wrote by email. "My suggestion would be for something soft and cotton, ideally with a bit of stretch (although it's a pain to sew), and in two layers, marked 'inside' and 'outside.' "
The idea that something is better than nothing was also the conclusion of a 2008 study by researchers in the Netherlands and the US. The study enlisted 28 healthy individuals who performed a variety of tasks while wearing N95 masks, surgical masks, or homemade masks sewn from teacloths. Effectiveness varied among individuals, but over a 90-second period, N95 masks worked best, with 25 times more protection than surgical masks and about 50 times more protection than homemade ones. Surgical masks were twice as effective as homemade masks. But the homemade masks offered at least some protection against large droplets.
Researchers emphasize that it's not yet clear whether those findings are applicable to aerosolized COVID-19. In an influenza pandemic, at least, the authors posit that homemade masks could reduce transmission for the general public enough for some immunity to build. "It is important not to focus on a single intervention in case of a pandemic," the researchers write, "but to integrate all effective interventions for optimal protection."
For healthcare workers on the frontlines of COVID-19, Friese says, homemade masks might do more than nothing but they also might not work. Instead, he would rather see providers using construction or nuclear-engineering masks. And his best suggestion is something many providers are already doing: reducing physical contact with patients through telemedicine and other creative solutions, which is cutting down the overwhelming need for PPE.
Homemade mask production emphasizes the urgent need for more supplies, Friese adds.
"The government needs to step up and do a variety of things to increase production, and that needs to happen now, immediately," he says. "We don't we don't want our clinicians to have to come up with these decisions."
Emily Sohn is a freelance journalist in Minneapolis. Her stories have appeared in the Washington Post, NPR, Nature, National Geographic, and many other publications. She can be reached on Twitter @tidepoolsinc.
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