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CME / ABIM MOC / CE

Is Masking Still Best Practice to Reduce COVID-19 Transmission in Clinical Settings?

  • Authors: News Author: Jay Croft; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 6/16/2023
  • Valid for credit through: 6/16/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for infectious disease clinicians, nurses, nurse practitioners, pharmacists, physician’s assistants and clinicians of all specialties.

The goal of this activity is for members of the healthcare team to be better able to describe N95, surgical, and cloth mask effectiveness in community and healthcare settings for preventing SARS-CoV-2 infection, based on an updated evidence synthesis incorporating a recent randomized clinical trial and other new studies.

Upon completion of this activity, participants will:

  • Assess N95, surgical, and cloth mask effectiveness in community and healthcare settings for preventing SARS-CoV-2 infection, based on an updated evidence synthesis
  • Determine the clinical and public health implications of N95, surgical, and cloth mask effectiveness in community and healthcare settings for preventing SARS-CoV-2 infection, based on an updated evidence synthesis
  • Outline implications for the healthcare team


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Jay Croft

    Freelance writer, Medscape

    Disclosures

    Jay Croft has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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CME / ABIM MOC / CE

Is Masking Still Best Practice to Reduce COVID-19 Transmission in Clinical Settings?

Authors: News Author: Jay Croft; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/16/2023

Valid for credit through: 6/16/2024, 11:59 PM EST

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Clinical Context

Preventive measures, including masks (N95 respirators, surgical, and cloth), are recommended to reduce risk for COVID-19. Mask types vary in filtration efficacy, fluid resistance, and fit.

Factors affecting SARS-CoV-2 transmission and potentially affecting mask effectiveness include viral transmission levels, circulating variants, degree of immunity, use of other personal protective equipment (PPE) and infection control measures, and exposures in different settings. A review in June 2020 found insufficient evidence to determine the effects of masks on SARS-CoV-2 infection.

Study Synopsis and Perspective

A new study urges people to continue wearing protective masks in medical settings, even though the US public health emergency declaration around COVID-19 has expired.

Masks continue to lower the risk of catching the virus during medical visits, says the study, published online May 16 in the Annals of Internal Medicine.[1] And there was not much difference between wearing surgical masks and N95 respirators in healthcare settings.

Researchers reviewed 3 randomized trials and 21 observational studies to compare the effectiveness of those masks and cloth masks in reducing COVID-19 transmission.

“[M]asking in interactions between patients and health care personnel should continue to receive serious consideration as a patient safety measure,” says an opinion article accompanying the study.[2]

“In our enthusiasm to return to the appearance and feeling of normalcy, and as institutions decide which mitigation strategies to discontinue, we strongly advocate not discarding this important lesson learned for the sake of our patients’ safety,” the opinion authors write.

Surgical masks limit the spread of aerosols and droplets from people who have influenza, coronaviruses, or other respiratory viruses, CNN reported. And although masks are not 100% effective, they substantially lower the amount of virus put into the air via coughing and talking.

Ann Intern Med. Published online May 16, 2023.

Study Highlights

  • Reviewers searched MEDLINE, EMBASE, medRxiv (June 3, 2022-January 2, 2023), and reference lists for randomized clinical trials (RCTs; n=3) of interventions to increase mask use and risk for SARS-CoV-2 infection and observational studies (n=21) of mask use, controlling for potential confounders.
  • On the basis of 3 RCTs and 7 observational studies, mask use vs no mask use in community settings may be associated with a small reduced risk for SARS-CoV-2 infection.
  • “Of 10 prior observational studies, 9 found mask use (any or unspecified type) associated with decreased SARS-CoV-2 infection versus nonuse (adjusted risk estimates ranged from 0.04 to 0.86),” the authors write.
  • In community settings, the authors add, “[t]he strength of evidence remained low for reduced risk for SARS-CoV-2 infection with surgical masks versus no mask on the basis of 2 prior RCTs (adjusted prevalence ratio, 0.89 [CI, 0.78 to 0.997] and [odds ratio], 0.82 [CI, 0.52 to 1.23]) and 2 observational studies and insufficient for N95 respirators versus no mask or cloth mask versus no mask.”
  • “In routine patient care settings,” they note, “surgical masks and N95 respirators may be associated with similar risk for SARS-CoV-2 infection, on the basis of 1 new randomized trial with some imprecision and 4 observational studies” (2 of which were new).
  • In the RCT, “[s]urgical masks were noninferior to N95s for risk for [polymerase chain reaction]-confirmed SARS-CoV-2 infection ([hazard ratio], 1.14 [CI, 0.77 to 1.69]) on the basis of a prespecified noninferiority margin of up to a doubling of risk.”
  • “N95 masks were associated with a nonstatistically significant increased risk for mask-related adverse events (13.6% vs 10.8%; risk ratio, 1.25 [CI, 0.87 to 1.79]), primarily due to increased discomfort and headaches.”
  • Withdrawals for adverse events were few (3 with N95s and 1 with surgical masks).
  • “Two new fair-quality case-control studies (2607 and 2045 cases) from France and Canada each found N95 respirators associated with decreased risk for SARS-CoV-2 versus surgical masks, although estimates were imprecise” (adjusted OR, 0.85; CI, 0.55-1.29).
  • "On the basis of the new RCT, the strength of evidence was changed from insufficient to low for similar effects of N95 and surgical masks when providing routine patient care in health care settings.”
  • The evidence from the observational studies was not sufficient to assess comparisons of other masks as a result of methodological limitations and inconsistency.
  • Limitations of this review were few RCTs, methodological limitations and some imprecision of studies, suboptimal adherence and pragmatic aspects of RCTs potentially attenuated benefits, very limited evidence on harms, uncertain applicability to Omicron-variant-predominant era, heterogeneity precluding meta-analysis, inability to formally assess for publication bias, and restriction to English-language articles.
  • The investigators concluded that updated evidence suggests that mask use in community settings may be associated with a small reduction in SARS-CoV-2 infection risk.
  • In routine patient care settings, surgical masks and N95 respirators may be associated with similar infection risk, but a benefit of N95 respirators could not be ruled out.
  • Additional reasons for masking in medical settings are that healthcare personnel often continue to work while ill, and that transmission between patients and staff is still possible, but rare, when both are masked.
  • Observational studies of masks versus no masks consistently found masks to be associated with decreased risk for SARS-CoV-2 infection, but had methodological limitations and some imprecision.
  • "The evidence on surgical versus cloth masks or more versus less consistent mask use remained insufficient.”
  • Evidence on harms remained very limited, but did not indicate serious harms.
  • "There remains no evidence on extended or reuse of N95 respirators and risk for SARS-CoV-2 infection.”
  • Further research should address comparative effectiveness of masks to prevent SARS-CoV-2 infection, have adequate statistical power for primary and stratified analyses, use appropriate diagnostic methods, describe key mask characteristics, evaluate adherence, and assess harms as well as benefits.
  • An accompanying opinion article recommended prioritizing patient safety over the desire to return to the appearance and feeling of normalcy and continuing to give serious consideration to masking in interactions between patients and healthcare personnel.
  • Surgical masks, albeit not 100% effective, limit aerosol and droplet spread from people infected with influenza, coronaviruses, or other respiratory viruses and substantially lower viral load released into the air via coughing and talking.
  • Real-world experience shows that mask wearing in clinical settings is effective against SARS-CoV-2 and other respiratory viruses.
  • Because of universal masking and use of other personal protective equipment, healthcare personnel have been at far greater risk for acquiring COVID-19 from community than occupational exposures.
  • Presymptomatic transmission of respiratory viruses, particularly SARS-CoV-2, offers additional support for continued use of masking in clinical settings.
  • Alternatives to universal masking could include masking only during respiratory virus season, masking on wards housing patients at higher risk for serious sequelae of respiratory virus infections, or masking staff and visitors but allowing optional masking for patients (1-way masking).
  • However, exposing patients unnecessarily to infections that are preventable by masking seems directly contrary to the principles of patient safety.
  • The authors therefore recommend remaining masked during patient interactions.

Clinical Implications

  • Mask use in community settings may be associated with a small reduction in SARS-CoV-2 infection risk.
  • In routine patient care settings, surgical masks and N95 respirators may be associated with similar infection risk, but a benefit of N95 respirators could not be ruled out.
  • In order to prioritize patient safety over a desire to return to the appearance and feeling of normalcy, it is recommended that members of the healthcare team are continue the practice of masking.
 

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