FFP3 Reusable Respirators; the respiratory Personal Protective Equipment (PPE) that Health and Social Care Workers Need, Want and Deserve.

Dear Editor,

We agree with Dr Zhang et al. in their concern regarding the catastrophic environmental repercussions of single -use Personal Protective Equipment (PPE)[1].

By law, PPE "should be the last line of defense"; occupational environmental controls and ventilation design optimisations for inhaled hazardous substances should be mandatory to reduce spread of COVID-19. However, the precautionary principle must apply[2] and therefore PPE is likely to be a mainstay in the healthcare landscape from now on.

The World Health Organisation have declared climate change as one of the greatest risks to human health. They predict that between 2030-2050, 250,000 additional deaths per year will occur due to climate change, in part, secondary to infectious diseases.[3] This must be taken into account by policy makers and NHS stake holders when investing in PPE.

However, Dr Zhang et al. state that "single use PPE is vital to prevent infection and control disease in healthcare settings[1]" and this is categorically not the case.

Reusable options are not only better for the environment, but are a widely available option that are vastly superior for the wearer and the system they work within, on a number of levels.

For instance, using the example of the reusable FFP3 respirator; this form of respiratory protection can be easily decontaminated. Multiple Healthboards throughout the UK have already adopted this wise approach, since April 2020. Standard Operating Procedures (SOP) can easily be developed[4] and reusable PPE decontaminated using autoclave, UV light,[5] or immersion in 70% alcohol[6-8], depending on manufacturer advice, microbiology protocols and the cleaning equipment locally available. In the UK, there are factories which already manufacture reusable respiratory protection and others who could retool to facilitate this, simply and rapidly. Local procurement would reduce the carbon footprint of delivery to front line UK services and have the additional benefits of reducing reliance upon precarious international supply chains, and increase investment into local economies during this time of crisis. Some countries already undertook a system-wide review of the manufacture, procurement and supply of PPE following the MERS epidemic, and elected to invest in manufacture of high-quality PPE within their borders, resulting in assured resilience of supply chain[9].

Reusable full face and half mask respirators provide optimum respiratory protection for the health or social care worker; the protection is far superior to that even of disposable FFP3 masks[10]. Surgical masks, in addition to being disposable, do not protect the wearer from SARS-CoV-2 respirable aerosol particles, [11] produced when the patient breathes, speaks or coughs. With a wider seal (10-20mm)[10], the reusable respirators achieve the airtight seal required in a greater number of people, this includes in smaller faced individuals who have failed fit testing on disposable masks. The improved fit offered by reusable options is particularly pertinent as females and those of Asian ethnicity have highest fit test failure rates[12]; females make up 75% of the NHS workforce[13], and death rates from COVID-19 are significantly higher in individuals of Black and Asian ethnicity[14]. The wider and face conforming seal also makes reusable masks more comfortable to wear.

Reusable respiratory protection has vast economic advantages; patient facing staff often require multiple mask changes per day. A disposable mask costs ~£5, whereas a reusable FFP3 respirator can cost as little as ~£15, requiring cartridge changes after each pandemic wave[15] (~£5-10 for 100 pairs of cartridges) or as per specific manufacturer and local Infection Control instructions. Use of reusable FFP3 respirator masks could produce annual cost savings of 84% annually, compared to single use masks[16]. Use of reusable respiratory protection such as a power air purifying respirators (PAPR) or full face reusable mask would negate the requirement for the time consuming and expensive task of fit testing. Fit testing removes staff from their vital roles for a minimum of 30 minutes and the precious PPE resource is disposed of in the process. By January 2021, the UK Government had spent ~£15.2 billion on PPE for the COVID-19 pandemic,[17] the majority of which is single use, and will now be in landfill, in the ocean or in the atmosphere post incineration[18].

The British Medical Association (BMA) and Royal College of Nursing (RCN) are demanding FFP3 respiratory protection to protect all front line workers against airborne transmission of COVID-19[19 20]. There is a large desire from front line staff to use reusable FFP3 respirators. Med Supply Drive UK (charity no. 1190337) found that 95% of 487 frontline staff surveyed wanted to use a reusable FFP3 respirator. Feedback included;

"Yep. Already have. It's brilliant. Very comfortable and I feel protected from potential mask shortages in future. Also way better for the environment"

"I failed the fit test so was given a half face respirator. It's good for two years, the filters are good for six months. It's probably cheaper in the long run as well."[21]

Reusuable FFP3 respirators are already recommended for use by Public Health England, Public Health Wales, Health Protection Scotland, the Public Health Agency, the Academy of Royal Medical Colleges and the National Health Service[22]. The Confederation of British Surgeons released a statement in support of reusable PPE[23] and the Chair People of all UK Surgical Specialties and Anaesthetists (FSSA) support the use of reusable respiratory protection. Yet, the majority of health and social care workers are still issued inferior, single use PPE.

Therefore, not only is reusable PPE a solution to the devastating environmental repercussions of continuing to use of disposable PPE, it is also highly safe, economical and practical in the long term. Reusable FFP3 respirators are a solution that provides health and social care workers with the optimal life saving equipment that they want, need and deserve.

MedSupplyDrive UK is a charity (charity no. 1190337) established by volunteer healthcare professionals, medical students and allies. They work to procure, produce and advocate for high quality, sustainable PPE to protect the UK Health and Social Care workforce from COVID-19. MedSupplyDrive UK support Health and Social Care workers in demanding reusable FFP3 respirators from their workplaces, to allow them to care for patients safely. MedSupplyDrive UK are launching a campaign to protect workers by supplying reusable FFP3 respirators, free of charge. For more information visit www.medsupplydrive.org.uk. or email: [email protected].

References1. Zhang EJ, Aitchison LP, Phillips N, et al. Protecting the environment from plastic PPE. BMJ 2021;372:n109 doi: 10.1136/bmj.n109[published Online First: Epub Date]|.2. Great Britain H, Staff SE, Health GB, et al. Respiratory Protective Equipment at Work: A Practical Guide: HSE Books, 2013.3. World Health Organization. Climate change and health. Secondary Climate change and health 2018. https://www.who.int/news-room/fact-sheets/detail/climate-change-and-heal....4. Bessesen MT, Adams JC, Radonovich L, et al. Disinfection of reusable elastomeric respirators by health care workers: a feasibility study and development of standard operating procedures. American journal of infection control 2015;43(6):629-345. Department for Homeland Security. Disinfection and Reuse of Personal Protective Equipment Secondary Disinfection and Reuse of Personal Protective Equipment 2020. https://www.dhs.gov/sites/default/files/publications/respiratoryprotecti....6. Sundström. Pandemic flu kit, SR 100. Secondary Pandemic flu kit, SR 100 2020. https://www.srsafety.com/pub/media/wysiwyg/srsaftey/CompCentre/Articles/....7. 3M. Respiratory Protection for Airborne Exposures to Biohazards, Technical Bulletin. Secondary Respiratory Protection for Airborne Exposures to Biohazards, Technical Bulletin 2020. https://multimedia.3m.com/mws/media/409903O/respiratory-protection-again....8. 3M. Decontamination of 3M Filtering Facepiece Respirators, such asN95 Respirators, in the United States - Considerations. Secondary Decontamination of 3M Filtering Facepiece Respirators, such asN95 Respirators, in the United States - Considerations 2020. https://multimedia.3m.com/mws/media/1824869O/decontamination-methods-for....9. Gereffi G. What does the COVID-19 pandemic teach us about global value chains? The case of medical supplies. Journal of International Business Policy 2020;3(3):287-301 doi: 10.1057/s42214-020-00062-w[published Online First: Epub Date]|.10. Gawn J, Clayton M, Makison C, et al. Evaluating the protection afforded by surgical masks against influenza bioaerosols: gross protection of surgical masks compared to filtering facepiece respirators. Health Safety Exec 200811. Douglas J, McLean N, Horsley C, et al. COVID-19: smoke testing of surgical mask and respirators. Occupational Medicine 2020;70(8):556-6312. Regli A, Sommerfield A, von Ungern‐Sternberg B. The role of fit testing N95/FFP2/FFP3 masks: a narrative review. Anaesthesia 2021;76(1):91-10013. Bissett J. PPE respirator masks often fail to fit women and Asian healthcare workers. Secondary PPE respirator masks often fail to fit women and Asian healthcare workers 2020. https://www.dental-nursing.co.uk/news/ppe-respirator-masks-often-fail-to....14. Office for National Statistics. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 15 May 2020. Secondary Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 15 May 2020 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri....15. 3M. 3M™ Reusable Half Masks for use in the Healthcare Industry. Secondary 3M™ Reusable Half Masks for use in the Healthcare Industry 2020. https://www.3m.co.uk/intl/uk/ohes/segments/healthcare/(9666a)OH_ReusableTechBulletin_lft.pdf16. Iacobucci G. Promoting reusable PPE: five minutes with . . . Jasmine Ho. BMJ 2021;372:n270 doi: 10.1136/bmj.n270[published Online First: Epub Date]|.17. https://www.instituteforgovernment.org.uk/publication/whitehall-monitor-....18. Rizan C, Reed M, Bhutta MF. Environmental impact of Personal Protective Equipment supplied to health and social care services in England in the first six months of the COVID-19 pandemic. medRxiv 2020:2020.09.21.20198911 doi: 10.1101/2020.09.21.20198911[published Online First: Epub Date]|.19. Tonkin T. Call for enhanced PPE. Secondary Call for enhanced PPE 2021. https://www.bma.org.uk/news-and-opinion/call-for-enhanced-ppe.20. Royal College of Nursing. Public Health England must urgently review whether current PPE and ventilation guidance is still adequate. . Secondary Public Health England must urgently review whether current PPE and ventilation guidance is still adequate. 2021. https://www.rcn.org.uk/news-and-events/news/uk-higher-level-ppe-protect-....21. Medsupplydrive. Medsupplydrive. Secondary Medsupplydrive 2021. https://www.medsupplydrive.org.uk/news.22. Public Health England. Recommended PPE for healthcare workers by secondary care inpatient clinical setting, NHS and independent sector. Secondary Recommended PPE for healthcare workers by secondary care inpatient clinical setting, NHS and independent sector 2020. https://associationofbreastsurgery.org.uk/media/252021/t1_poster_recomme....23. Confederation of British Surgeons. NEW STUDY: CURRENT PPE NOT FIT FOR PURPOSE. Secondary NEW STUDY: CURRENT PPE NOT FIT FOR PURPOSE 2020. https://www.cbsgb.co.uk/news/36/new_study_current_ppe_not_fit_for_purpose.

Competing interests: No competing interests