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Editorial
March 28, 2020

Sourcing Personal Protective Equipment During the COVID-19 Pandemic

Author Affiliations
  • 1Dr Livingston and Dr Berkwits are Deputy Editors and Dr Desai is Fishbein Fellow, JAMA
JAMA. 2020;323(19):1912-1914. doi:10.1001/jama.2020.5317

As the coronavirus disease 2019 (COVID-19) pandemic accelerates, global health care systems have become overwhelmed with potentially infectious patients seeking testing and care. Preventing spread of infection to and from health care workers (HCWs) and patients relies on effective use of personal protective equipment (PPE)—gloves, face masks, air-purifying respirators, goggles, face shields, respirators, and gowns. A critical shortage of all of these is projected to develop or has already developed in areas of high demand. PPE, formerly ubiquitous and disposable in the hospital environment, is now a scarce and precious commodity in many locations when it is needed most to care for highly infectious patients. An increase in PPE supply in response to this new demand will require a large increase in PPE manufacturing, a process that will take time many health care systems do not have, given the rapid increase in ill COVID-19 patients.

In its current guidance to optimize use of face masks during the pandemic, the Centers for Disease Control and Prevention (CDC) identifies 3 levels of operational status: conventional, contingency, and crisis.1 During normal times, face masks are used in conventional ways to protect HCWs from splashes and sprays. When health care systems become stressed and enter the contingency mode, CDC recommends conserving resources by selectively canceling nonemergency procedures, deferring nonurgent outpatient encounters that might require face masks, removing face masks from public areas, and using face masks for extended periods if feasible.

When health systems enter crisis mode, the CDC recommends cancellation of all elective and nonurgent procedures and outpatient appointments for which face masks are typically used, use of face masks beyond the manufacturer-designated shelf life during patient care activities, limited reuse, and prioritization of use for activities or procedures in which splashes, sprays, or aerosolization are likely. When face masks are altogether unavailable, the CDC recommends use of face shields without masks, taking clinicians at high risk for COVID-19 complications out of clinical service, staffing services with convalescent HCWs presumably immune to SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), and use of homemade masks, perhaps from bandanas or scarves if necessary.

Many communities in the US and globally are rapidly entering crisis mode. Popular news outlets report unconventional solutions for PPE at local hospitals, such as plastic garbage bags for gowns and plastic water bottle cutouts for eye protection.2 Plans for resupply through the repurposing of industrial capacity and other means are welcome but seem unlikely to solve the shortage quickly enough as supply chains become more dysfunctional in the pandemic.3 The Department of Health and Human Services’ Strategic National Stockpile was created to solve precisely this problem, but its inventory is not transparent and news reports suggest its supplies are being distributed unevenly or are insufficient to meet demand.4

HCWs need supplies and solutions for these shortages now, and for that reason JAMA issued a call for ideas for how to address the impending PPE shortage.5 In the week since publication the article received more than 100 000 views and generated more than 250 comments. In addition, many additional ideas were sent directly to JAMA editors. The Box organizes the major themes of the contributions and the following discussion reviews several of them.

Box Section Ref ID
Box.

Summary of Recommendations for PPE Conservation and Management

Import
  • Purchase from international suppliers: China proposed as a primary market given manufacturing capacity, experience with and decline in COVID-19 incidence

Reclaim
  • Dentists, farmers, construction, high schools, universities, veterinarians, salons, manufacturing, aerospace, industrial “clean labs”

    • Individual HCW procurement in towns and communities

    • Charitable movements

    • Public or private buybacks

    • Public or private bounties

Reuse
  • Rotate through 72-h cycles given current understanding of surface viability

  • Reusable elastomeric respirators (have exchangeable filter cartridges)

  • Disinfectants

    • Heat (eg, autoclave), UV, ozone, ethylene oxide, hydrogen peroxide, bleach, isopropyl alcohol, gamma or e-beam radiation, microwave, copper sulfate, methylene blue with light, sodium chlorine, iodine, zinc oxide impregnation (gowns), hypochlorous acid, commercial laundering (for cloth)

Repurpose
  • Prefabricated masks: snorkel and scuba, 3D printed, welder’s, civilian military grade gas masks, ski buffs

  • Eye and face shields: sports eye protectors, motorcycle helmets with visors, balaclavas

  • Gowns: plastic ponchos or poly bags, bedbug sheet material

  • Adhesive bandage as nasal PPE

Create supply
  • Sewn fabric masks and gowns, coffee filter masks, home HVAC filter masks

Extend supply
  • Plastic face shields (water bottle cutouts, thermoplastic sheets, A4 acetate sheets, Ziploc bags) to preserve face masks and eyewear

Reduce nonessential services
  • Cancel elective and ambulatory procedures; reduce questionable contact and isolation precautions (eg, MRSA/VRE, influenza, cellulitis)

Reduce patient contact
  • Utilize mobile and out-of-room monitoring and device controls, e-consults, extended dwell IVs, batching medications or self-administration, barrier visits

Alter staffing
  • Reduce student and trainee patient contacts

Use nonhuman services
  • Nonhuman services (drones and robots) for delivery of test kits for self-testing, robots for equipment movement within hospitals, decontamination protocols

Stratify use by patient risk
  • Cohort patients and reduce PPE use for those at low risk (ideally requires testing to accurately stratify low and high risk)

Employ immune workers
  • HCWs recovered from clinical illness or with demonstrated immunity care preferentially for COVID-19 patients without PPE

Use government solutions
  • Regionalize care and supply, import international supply, ration supply, loosen import regulations, commandeer business to accelerate supply

Manage supply
  • Reduce bulk packaging, Pyxis-like controlled distribution, nongovernment regional coordination of PPE distribution

Miscellaneous
  • Convert RV trailers to negative pressure spaces; phase change material to improve comfort and reduce reuse of gowns

Abbreviations: COVID-19, coronavirus disease 2019; HCW, health care worker; HVAC, heating, ventilating, and air-conditioning; MRSA, methicillin-resistant Staphylococcus aureus; PPE, personal protective equipment; VRE, vancomycin-resistant Enterococcus.

A frequent proposal was to acquire PPE from existing supplies in non–health care industries and settings such as construction, research laboratories, nail salons, dentists, veterinarians, and farms, and redirect them to the health care system via charitable appeals, community organizing, financial incentives, or government mandate. One endeavor is Project N95, a national COVID-19 medical equipment clearinghouse to identify high-need regions and to source and distribute PPE and other equipment where it is needed most.6

Numerous proposals suggested sterilization of used PPE with agents ranging from ethylene oxide, UV or gamma irradiation, ozone, and alcohol. There were also novel proposals such as mask-fiber impregnation with copper or sodium chloride. These are not new ideas; work was performed after prior viral epidemics to determine the feasibility of sterilizing PPE.7 Most commenters acknowledged uncertainty about the effects of these sterilizing agents on the structural integrity of PPE, and there is some evidence the fibers in masks and respirators that filter viral particles can degrade and lose their efficacy with PPE reprocessing.7

A few people advocated for use of positive pressure airflow helmets; proposals ranged from creating devices from plastic bags insufflated using compressed air and nasal cannula tubing to adoption of commercially available devices used in the welding industry. An advantage of this approach is that by not relying on filters, positive airflow devices can be cleaned and reused indefinitely.

Many proposals reflect an era when PPE was made of cloth and laundered.8 Health care might be made greener if reusable PPE was employed where feasible. Cloth gowns and masks are easily created and stored, and laundry capacity could easily be expanded by recruiting commercial launderers that service hotels and other large organizations who currently sit idle. Many contributors wrote of sewing masks, creating them out of clothing, using novel materials to make them, and using cloth sleeves to extend the use of N95 respirators. As with re-sourced material, most commenters acknowledged uncertainty about the ability of these handmade solutions to filter infectious agents and weather repeated cleaning, although common sense suggests they are better than no PPE at all.

High-grade filters used in respirators such as N95 devices exist in many commercial products. Some ideas involved creating masks from air-conditioning filters or vacuum cleaner bags. These plentiful and commercially available household antiallergen filters have a MERV (minimum efficiency reporting value) rating for their filtering efficiency of 13 or 14, meaning they will reduce the flow of particles larger than 0.3 μm by 50% or 75% respectively. N95 respirators are 95% efficient for these particles and equivalent to a MERV 16 filter. Although the SARS-CoV-2 particle is smaller than 0.2 μm, the water droplets carrying it are larger and largely blocked by these filters. Several commentators suggested using snorkel masks and tubes, which are easily cleaned and reused, and could efficiently use home-sourced filter material placed on the end of the tubing for added protection.

Conservation of existing PPE is important, as recommended by the CDC. Some commenters called for suspending practices that consume large amounts of PPE and are of uncertain effectiveness, such as contact precautions for some infectious diseases, to free up supplies.9,10 The idea of using HCWs who have recovered from clinical illness or who have stayed healthy but test positive and are presumed immune and are no longer infectious is an age-old and appealing solution. Hoarding of PPE and other supplies has occurred during the current COVID-19 pandemic, and some proposals suggested rationing or controlling the supply chain through limited, controlled allocation of supplies, a Pyxis-like administration system or regional coordination, for example.

These and scores of other comments are insightful, many have references, provide links to websites and videos with illustration and instructions, and readers should spend time determining which, if any, might best fit their needs and situations. But the ingenuity displayed in the contributions needs to be placed in context. First, few of the ideas can be successful independent of the broader health care enterprise and its vulnerabilities. The commonly suggested process of cohorting low-risk patients for PPE preservation, for example, requires rapid testing to be accurate and efficient, a requirement regrettably not yet met in most US health systems. More important, PPE shortages are a problem for HCWs, but not a problem HCWs are trained to address or should be expected to solve; it’s become cliché to point out that firefighters are not asked to source their own equipment before entering burning buildings. Hospital administrators, health system media relations departments, university leadership, elected officials, and government agencies have a role to play in reaching out to suppliers and organizing a response and develop a reliable supply system. Hospitals successful at procuring supplies should employ rational use of PPE. Better-resourced institutions and some clinician advocates have considered policies requiring all staff to wear face masks in public spaces regardless of high-risk exposures, despite little evidence that this is a judicious use of resources.

JAMA will continue to offer commenting on COVID-19 articles so that clinicians may share their experiences and ideas regarding how to best get through the COVID-19 crisis. When health systems pass this stress test, the operations, organizations, and profession will have learned a thing or two, and be stronger for it.

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Article Information

Corresponding Author: Edward Livingston, MD, JAMA (edward.livingston@jamanetwork.org).

Published Online: March 28, 2020. doi:10.1001/jama.2020.5317

Conflict of Interest Disclosures: None reported.

References
1.
Strategies for optimizing the supply of facemasks. Centers for Disease Control and Prevention. Published March 17, 2020. Accessed March 27, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html
2.
Bowden  E, Campanile  C, Golding  B. Worker at NYC hospital where nurses wear trash bags as protection dies from coronavirus. New York Post. March 25, 2020. Accessed March 27, 2020. https://nypost.com/2020/03/25/worker-at-nyc-hospital-where-nurses-wear-trash-bags-as-protection-dies-from-coronavirus/
3.
Morris  C. Some Amazon Prime shipments won’t arrive for a month due to coronavirus. Fortune. March 23, 2020. Accessed March 27, 2020. https://fortune.com/2020/03/23/amazon-prime-delays-coronavirus/
4.
Trexler  P, Tarpley  T. Strategic National Stockpile fails to quench Ohio’s need for medical supplies. MSN. March 26, 2020. Accessed March 27, 2020. https://www.msn.com/en-us/news/us/strategic-nation-stockpile-fails-to-quench-ohios-need-for-medical-supplies/ar-BB11HVZw
5.
Bauchner  H, Fontanarosa  PB, Livingston  EH.  Conserving Supply of personal protective equipment—a call for ideas.   JAMA. Published online March 20, 2020. doi:10.1001/jama.2020.4770PubMedGoogle Scholar
6.
Project N95. the national COVID-19 medical equipment clearinghouse. Accessed March 27, 2020. https://www.projectn95.org/
7.
Reusability of facemasks during an influenza pandemic: facing the flu. National Academies of Sciences, Engineering, and Medicine; 2006. https://www.nap.edu/catalog/11637/reusability-of-facemasks-during-an-influenza-pandemic-facing-the-flu
8.
Vozzola  E, Overcash  M, Griffing  E.  Environmental considerations in the selection of isolation gowns: a life cycle assessment of reusable and disposable alternatives.   Am J Infect Control. 2018;46(8):881-886. doi:10.1016/j.ajic.2018.02.002PubMedGoogle ScholarCrossref
9.
Harris  AD, Pineles  L, Belton  B,  et al; Benefits of Universal Glove and Gown (BUGG) Investigators.  Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.   JAMA. 2013;310(15):1571-1580. doi:10.1001/jama.2013.277815PubMedGoogle Scholar
10.
Rubin  MA, Samore  MH, Harris  AD.  The importance of contact precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci.   JAMA. 2018;319(9):863-864. doi:10.1001/jama.2017.21122PubMedGoogle ScholarCrossref
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    8 Comments for this article
    EXPAND ALL
    Lessons learned from the shortage of PPE.
    Gladwin Das, MD | Retired from the University of Minnesota
    The PPE shortage crisis is self inflicted. The companies that supply these items have contracted with largely Chinese manufacturers and are in fact middlemen.

    Does the US military outsource its manufacturing of ammunition, missiles, tanks, aircraft to China ? PPE is not less important.

    Short term strategy : Cloth/fabric gowns, masks , drapes etc. These can be easily manufactured in the USA in large quantities.

    All US hospitals/clinics should physically have a 2 week supply of fabric gowns, masks, caps, drapes as an emergency supply for disruptions of the supply chain.

    Long term strategy : All
    PPE must be manufactured in the USA.

    It is time Congress passed a law to enable this. The AMA and ANA leadership need to demand permanent solutions from the President and Congress. We need to drive the process and not be mute bystanders.This should never ever happen again.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    PPE and Testing
    William Harrell, MD | Private physician
    Some of my commercial lab test submissions have returned within three days and others have been up to nine days or more. Hence, unusable for screening---only useful for statistics.

    An office PPE order to a major medical supplier over a month ago was cancelled. What few we have to screen febrile patients were obtained from members of the community.

    Our large medical building has ruled that we must not perform tests in the building at all. Tests performed on the grounds outside are only allowed with special permission on a limited time basis. County and
    City screening sites turn sick patients away when they are overwhelmed on a daily basis.
    CONFLICT OF INTEREST: None Reported
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    Multi-threaded PPE Sourcing Pipeline
    Sophia Boettcher, BSCS | PPEforHCP.org
    In less than a week since posting a comment on the preceding “Call for Ideas” (regarding conservation of PPE) I was able to implement this very idea and singlehandedly outsourced 20,000 masks and level-iib isolation suits from China as well as leverage a coalition of local sewers (using the Deaconess/Providence templates). I worked with Momentum.Space to develop 3D printed shields and also partnered with a bus company for hand sanitizers using the FDA’s temporary guidance on hand sanitizers. I am currently working on re-outfitting clothing factories to produce face masks per the FDA’s guidelines.

    It can be done. As
    a group of volunteer doctors and engineers we are busily responding to hospitals across the country now to send them free PPE and to map shortage outbreaks. There is friction/absence of willingness among administrators to actually set up this pipeline themselves however—understandably due to the burden of dealing with the crisis on the ground.

    Thousands of Americans across the country want to help and we’ve been able to quickly find traction. Hospitals need to proactively reach out and not penalize HCPs for doing so, especially now.

    REFERENCES

    https://www.fda.gov/regulatory-information/search-fda-guidance-documents/enforcement-policy-face-masks-and-respirators-during-coronavirus-disease-covid-19-public-health

    https://www.fda.gov/media/136289/download

    https://jamanetwork.com/journals/jama/fullarticle/2763590

    https://www.deaconess.com/How-to-make-a-Face-Mask

    https://www.deaconess.com/How-to-make-a-Face-Mask

    https://budmen.com/

    https://www.prusa3d.com/covid19/

    https://www.medscape.com/viewarticle/927541

    https://www.medscape.com/viewarticle/927590

    https://www.medscape.com/viewarticle/927528

    https://www.wsna.org/about/press-area/2020/wsna-state-ment-on-firing-of-dr-ming-lin-and-silencing-of-nurses-and-doctors
    CONFLICT OF INTEREST: None Reported
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    Need for expert consulation and direction
    Kristin Morrison, MD | Hotel Dieu Hospital, Kingston, Ontario
    Thank you for a concise summary of the issues and your concluding statements regarding the inappropriateness of frontline workers having to source or create our own solutions. However in the midst of this current crisis, having access to a diverse group of experts who could review and respond to the most common questions and suggestions would save countless hours of searching and experimentation by those desperate individuals. Having this information centralized and readily available would be an essential service to us all. For example - the information provide about the effects of different methods of decontaminating N95 masks was invaluable, however I am still unclear as to how many of these methods work to kill off pathogens other than the SARS-CoV-2 virus. So what might be appropriate for someone working in a medical COVID ward - such as hanging a mask for 4 days, might not be appropriate for someone working in ICU where there is a higher risk of other secondary infections etc. I live in Canada so probably less concern re litigation - but surely in the current crisis, this could be managed in a way to limit liability especially if we are able to get expert consensus on best practices in desperate situations.
    CONFLICT OF INTEREST: None Reported
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    Simple ideas that may help during COVID-19 pandemic
    Ali Al-Shanqeeti, MD | Saudi Arabia
    We are all watching this pandemic unfold with massive impact on human lives. Desperate times call for desperate measures. The CDC recommendations during situations of crisis (recently reviewed in a perspective published online in New England Journal of Medicine) are an example of how to suggest ideas even if based on "thin" evidence.

    Therefore I would like to share with everyone this idea that may help with protecting healthcare workers (and potentially the public) especially since the world is now facing a potential shortage of N95 masks and other PPE items. Here is the summary of the idea
    and the suggested steps:

    1. Viruses (including the corona family of viruses) can be deactivated when they come in contact with surfaces covered with sodium chloride (table salt) . This can be explained by physical destruction of virus during recrystallization of coated salts. When the salt-coated surface is exposed to virus aerosols, salt crystals below the aerosol droplet dissolve to increase osmotic pressure to virus. Due to evaporation, the salt concentration of the droplet significantly increases and reaches the solubility limit, leading to recrystallization of salt. As a consequence, virus particles are exposed to increasing osmotic pressure during the drying process and are physically damaged by crystallization (1) .
     
    2. Many of the widely available consumables have pore sizes that are significantly smaller than the size of COVID-19 virus which is 60-140 nm in diameter (2). For example; the 3M Micropore surgical tape has pores that are 2nm in diameter. Therefore, the virus is not expected to pass through the pores of the 3M micropore surgical tape acting as a physical barrier to the virus.

    The implications for PPE conservation: 

    a) Healthcare workers must wear gloves at all times. These gloves must be sprayed with hypertonic saline (HTS) immediately after wearing them. The wet gloves are then allowed to air dry (few to several minutes) thus creating a layer of dried salt crystals on the gloves surfaces. This way, if a virus containing droplet / droplets come(s) in contact with the gloves surfaces; the salt crystals on these surfaces will dry the virus particles and inactivate the virus (see 1 above) rendering them non-infective.

    b) Similarly both sides of a regular surgical mask are sprayed with HTS and allowed to air dry. A standard surgical mask spayed with HTS and allowed to air dry is to be used by all healthcare workers all the time. The open peripheral edges of the mask are taped to the face of the care provider to seal the mask to the face. This way, the virus particles will not pass through the sides of the mask (tape pores are smaller than the size of the virus) and the virus will be inactivated on both the outer and inners surfaces of the mask (because of the salt crystals)

    This is an idea that in my opinion carries no additional risk, is cheap, affordable and one will lose anything trying it in such desperate times. It can also be adopted for public use.

    REFERENCES 

    1. Quan, F., Rubino, I., Lee, S. et al. Universal and reusable virus deactivation system for respiratory protection. Sci Rep 7, 39956 (2017). https://doi.org/10.1038/srep39956

    2. Cascella M, Rajnik M, Cuomo A, et al. Features, Evaluation and Treatment Coronavirus (COVID-19) [Updated 2020 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK554776/
    CONFLICT OF INTEREST: None Reported
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    Plastics Manufacturing
    Trevor Orrick |
    We are a manufacturer of plastic components in California. We are on the strategic manufacturing list. We make other non-medical items. We have done research and can build tooling in 7 days to manufacture 1000+ plastic face shields a day. We just don't know if there is a need for these? We know there are different types of these, disposable versus reusable, closed or open on sides. If there is a need and we could get some direction we are all ears.

    Thanks

    Trevor Orrick
    805 471
    3951
    trevor@trevororrick.com
    CONFLICT OF INTEREST: None Reported
    READ MORE
    In use in Seattle: DIY plastic isolation gown for <$0.50
    Scott Veirs, Marine science | Seattle
    We are between contingency and crisis modes in Seattle.

    Until official gowns can be provided to health care providers, please share with your colleagues this guide for making a DIY isolation gown from plastic sheeting and a clothes iron.

    My wife's pediatric clinic in Seattle is using these after running out of $1 rain ponchos from Amazon. Each of these costs less than 50 cents to make and a takes my teenagers a couple of minutes to make.

    Step-by-step guide (aka as an Instructable)  is at https://www.instructables.com/id/DIY-Plastic-PPE-Gown/
    CONFLICT OF INTEREST: None Reported
    Challenging the principle of ‘reasonably practicable’ by the flooding of counterfeit and fake face masks during the COVID-19 pandemic
    Simon Ching Lam, PhD, RN, FHKAN | Squina International Center for Infection Control, School of Nursing, The Hong Kong Polytechnic University.
    Thank you for a concise and comprehensive summary of the captioned and the insightful conclusive statements. As in other regions in the world, this shortage of personal protective equipment (PPE) (i.e., gloves, face masks, air-purifying respirators, goggles, face shields, respirators, and gowns) has been unfolding in Hong Kong as well as Mainland China on mass and/or social media online. Such shortage added pressure to the hospital administrators and infection control officers to re-adjust infection control guidelines so they were “reasonably practicable” for different “job tasks” (1). These adjustments (e.g., prudent use of PPE, and extended use of PPE) were generally based on World Health Organization’s interim guidance regarding rational use (2). As a consequence, in this case, it is noteworthy that the quality of PPE should be up to described/documented standard because there is no room to allow the increased infection risk due to fake material.

    For the quality of face masks, it was reported that hundreds of thousands of fake masks appeared in the markets because coronavirus depletes the global supplies (3). With reference to ASTM F2299-03 (4), our centre has established a particle filtration efficiency (PFE) system to preliminary assess the filtration performance of face masks by the use of artificial aerosols 0.3 micron and 1.0 micron under the flow rate of 15 L/min. We have received 66 brands masks with different sources and countries from many regional enquires. Surprisingly, in the midst of this current pandemic, we have come across about 45% low quality face masks (i.e., PFE of 1 micron range from 44%-94%). Some face masks (~4.5%) were the counterfeit of some international well-known brands on mask manufacturers, where the difference in PFE was 48.97% (fake) versus 99.99% (genuine). About 35% of face masks claimed an ASTM level 1 standard (i.e., PFE > 95% on 0.1 micron, with provided certification or printed description on box) demonstrated insufficient filtration performance on even 0.3 micron (range = 6.74% - 94.4%). Furthermore, 1.5% of sampled masks were made of tissue paper as the inner filter that was totally un-waterproofed. Indeed, the PFE of a mask is unable to be estimated by inspection. However, most of the hospitals do not have time and equipment to test the purchased face masks before use. This result is alarming and adds great uncertainty to the infection prevention and control in both clinical and community settings towards the COVID-19 outbreak. This may also turn the infectious pandemic to a new hybrid disaster (natural and man-made events) mode (5), particularly the application of ‘reasonably practicable’ now.

    References:
    1. Health and Safety Executive (HSE). (n.d.). Risk management: ALARP at a glance. Accessed April 02, 2020. http://www.hse.gov.uk/risk/theory/alarpglance.htm
    2. World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19): Interim guidance, 27 February 2020. Accessed April 02, 2020. https://apps.who.int/iris/handle/10665/331498
    3. Daragahi B. ‘Total disregarded for people’s lives’: Hundreds of thousands of fake masks flooding markets as coronavirus depletes world supplies. 25 March, 2020. The Independent. Accessed April 02, 2020. https://www.independent.co.uk/news/health/coronavirus-face-mask-fake-turkey-medical-supply-shortage-covid-19-a9423426.html
    4. ASTM F2299 / F2299M-03. Standard Test Method for Determining the Initial Efficiency of Materials Used in Medical Face Masks to Penetration by
    CONFLICT OF INTEREST: None Reported
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