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Table 1.  Demographic Characteristics of Study Participants
Demographic Characteristics of Study Participants
Table 2.  Bivariate and Multivariable Analysis of Factors Associated With Visual Mask Fit Test Pass
Bivariate and Multivariable Analysis of Factors Associated With Visual Mask Fit Test Pass
1.
Gunia  A. There aren’t enough medical masks to fight coronavirus: here's why it's not going to get better anytime soon. Time. February 27, 2020. Accessed April 28, 2020. https://time.com/5785223/medical-masks-coronavirus-covid-19/
2.
Cummings  KJ, Cox-Ganser  J, Riggs  MA, Edwards  N, Kreiss  K.  Respirator donning in post-hurricane New Orleans.   Emerg Infect Dis. 2007;13(5):700-707. doi:10.3201/eid1305.061490PubMedGoogle ScholarCrossref
3.
Lin  M. Emergency starter kits delivered to all households. The Straits Times. May 14, 2014. Accessed April 28, 2020. https://www.straitstimes.com/singapore/emergency-starter-kits-delivered-to-all-households
4.
3M Singapore. How to wear a 3M VFlex N95 respirator. YouTube; 2014. Accessed April 28, 2020. https://www.youtube.com/watch?v=sIkbyfJ5YRQ
5.
Desai  AN, Mehrotra  P.  Medical masks.   JAMA. 2020;323(15):1517-1518. doi:10.1001/jama.2020.2331PubMedGoogle ScholarCrossref
6.
Harber  P, Boumis  RJ, Su  J, Barrett  S, Alongi  G.  Comparison of three respirator user training methods.   J Occup Environ Med. 2013;55(12):1484-1488. doi:10.1097/JOM.0000000000000010PubMedGoogle ScholarCrossref
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    1 Comment for this article
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    Policy implications?
    Ashok Srinivasan, PhD | University of West Florida
    The authors mention that their results support the public health recommendation against the use of N95 by the general public. The testing methodology followed from [2] does not measure leakage due to improper fit; it measures the number of errors in the fit. N95 masks were reported as around a factor 50 better than homemade masks by Sande et al [A] based on leakage measurements. Does leakage due to improper fit overwhelm this advantage? The results in this article do not address this issue.

    Reference:

    [A] Sande et al, (2008) Professional and Home-Made Face Masks
    Reduce Exposure to Respiratory Infections among the General Population. PLoS ONE 3(7): e2618. doi:10.1371/journal.pone.0002618
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    Public Health
    May 20, 2020

    Assessment of Proficiency of N95 Mask Donning Among the General Public in Singapore

    Author Affiliations
    • 1University Medicine Cluster, National University Hospital, Singapore
    • 2Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge
    • 3Division of Medical Oncology, National Cancer Centre Singapore, Singapore
    • 4Division of Medicine, Singapore General Hospital, Singapore
    • 5Saw Swee Hock School of Public Health, National University of Singapore, Singapore
    JAMA Netw Open. 2020;3(5):e209670. doi:10.1001/jamanetworkopen.2020.9670
    Introduction

    With the advent of the coronavirus disease 2019 (COVID-19) pandemic, mask-wearing among the general public has become commonplace, leading to a worldwide shortage.1 However, there is little data on mask-wearing proficiency in the general public. A single study performed in the US after Hurricane Katrina, when individuals donned masks for mold remediation, found that only 24% of participants demonstrated proper technique.2 Incorrectly worn masks may not confer effective protection against COVID-19.

    We conducted this cross-sectional study to evaluate the proficiency of members of the Singapore public in wearing N95 masks, which the local government distributed to households in 2014 as part of an emergency preparedness program3 targeted at episodes of haze. The duck-bill foldable N95 mask (3M VFlex 9105) was selected for ease of mailing and was distributed along with pictorial instructions.

    Methods

    The institutional review board of the National University of Singapore granted approval for our study. Verbal informed consent was obtained from all participants, and a participant information sheet was provided. This study is reported following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    We conducted a cross-sectional study in the Jurong district in Singapore from February 9 to 15, 2015. Participants were recruited by simple random sampling without replacement. Inclusion criteria were Singapore citizens or permanent residents aged 21 years or older who lived in Singapore in June through July 2013 (during a severe episode of transboundary haze) and who were physically able to independently don the N95 mask. N95 masks, with accompanying multilingual pictorial instructions, were given to respondents. These masks and instruction sheets were of the same model as those mailed out to Singapore residents in 2014. The participant was then asked to put on the mask, with no prompting to refer to the instruction sheet. Interviewers administered a visual mask fit (VMF) test2 and a user seal check following the manufacturer’s instructions.4 Our primary outcome was passing the VMF test.

    Pearson χ2 tests and Welch t test were used for bivariate analyses, and a log-binomial regression model was used for multivariable analyses. Data were analyzed using R statistical software (R Project for Statistical Computing). P values were 2-sided, and statistical significance was set at .05. Analysis was conducted from February to March 2015.

    Results

    The survey was administered to 2499 households. Of these, 268 households were excluded because they did not meet the inclusion criteria. Among the remaining 2231 households, 714 (32.0%) completed the survey, 541 (24.2%) declined to be surveyed, and 976 (43.7%) did not respond. There were slightly more women participants (382 women [53.5%]). Most participants were aged 41 to 65 years (356 participants [49.9%]) and were of Chinese ethnicity (514 participants [72.0%]) (Table 1). Only 90 participants (12.6%; 95% CI, 10.3%-15.3%) passed the VMF test. The most common mask-fit criteria performed incorrectly were strap placement (521 participants [73.0%; 95% CI, 69.6%-76.2%]), leaving a visible gap between the mask and skin (442 participants [61.9%; 95% CI, 58.2%-65.5%]), and tightening the nose-clip (431 participants [60.4%; 95% CI, 56.7%-64.0%]). Younger age (adjusted prevalence ratio per 1-year increase in age, 0.95; 95% CI, 0.94-0.96; P < .001) and previous mask-fit training (adjusted prevalence ratio, 2.25; 95% CI, 1.54-3.30; P < .001) were independently associated with higher pass rates (Table 2). The use of the instruction leaflet provided, ownership of N95 masks, and previous mask use were not significantly associated with passing the VMF test.

    Discussion

    Our study found a low N95 VMF pass rate of 12.6%. The observation that reading pictorial instructions was not associated with increased VMF pass rates may suggest an inherent complexity to N95 mask wearing. Limitations of this study include nonresponse and recall bias.

    These findings support ongoing recommendations against the use of N95 masks by the general public during the COVID-19 pandemic.5 N95 mask use by the general public may not translate into effective protection but instead provide false reassurance. Beyond N95 masks, proficiency among the general public in donning surgical masks needs to be assessed. Policy measures that encourage mask use in the general public must be coupled with effective training materials beyond instruction leaflets, which our study and a 2013 study by Harber et al6 found to be inadequate. Other public health measures, such as social distancing, handwashing, and self-isolation when ill, are also critical.

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    Article Information

    Accepted for Publication: April 25, 2020.

    Published: May 20, 2020. doi:10.1001/jamanetworkopen.2020.9670

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Yeung W et al. JAMA Network Open.

    Corresponding Author: Wesley Yeung, MBBS, University Medicine Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074 (wesley_yeung@nuhs.edu.sg).

    Author Contributions: Drs Yeung and Ng had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Yeung, Ng, and Fong contributed equally to this work.

    Concept and design: Yeung, Ng, Fong, Sng, Chia.

    Acquisition, analysis, or interpretation of data: Yeung, Ng, Fong, Tai.

    Drafting of the manuscript: Yeung, Ng, Fong.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Yeung, Ng, Tai.

    Obtained funding: Yeung.

    Administrative, technical, or material support: Yeung, Ng, Chia.

    Supervision: Yeung, Sng.

    Conflict of Interest Disclosures: Dr Tai reported receiving personal fees from Boehringer Ingelheim and Wiley Blackwell outside the submitted work. No other disclosures were reported.

    Funding/Support: 3M Singapore provided 800 3M VFlex 9105 N95 masks for use in the study.

    Role of the Funder/Sponsor: 3M Singapore had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: Alex Lua, MBBS; Amanda Chin, MBBS; Cheryl Lie, MBBS; Claudia Chong, MBBS; Julia Ann-Lee, MBBS; Liang Sai, MBBS; Xin Qi Look, MBBS; Yun Hao Leong, MBBS, Abigail Lee, MBBS; Alexandra Yung, MBBS; Bing Howe Lee, MBBS; Bochao Jiang, MBBS; Cheryl Lam, MBBS; Deborah Lim, MBBS; Fiona Ng, MBBS; George Tan, MBBS; Jasmine Chang, MBBS; Jiaquan Chaung, MBBS; Jia Long Chua, MBBS; Kai Yun Ang, MBBS; Kevin Lim, MBBS; Kristabella Low, MBBS; Lorraine Yong, MBBS; Lyria Hoa, MBBS; Marcus Tan, MBBS; Marianne Tsang, MBBS; Michael Chee, MBBS; Nicholas Ngiam, MBBS; Nicole Chan, MBBS; Nicole Chew, MBBS; Ren Wei Liu, MBBS; Ryan Lee, MBBS; Shaina Neo, MBBS; and Zhao Kai Low, MBBS; provided help in the conduct of this study. They were not compensated for their contribution.

    References
    1.
    Gunia  A. There aren’t enough medical masks to fight coronavirus: here's why it's not going to get better anytime soon. Time. February 27, 2020. Accessed April 28, 2020. https://time.com/5785223/medical-masks-coronavirus-covid-19/
    2.
    Cummings  KJ, Cox-Ganser  J, Riggs  MA, Edwards  N, Kreiss  K.  Respirator donning in post-hurricane New Orleans.   Emerg Infect Dis. 2007;13(5):700-707. doi:10.3201/eid1305.061490PubMedGoogle ScholarCrossref
    3.
    Lin  M. Emergency starter kits delivered to all households. The Straits Times. May 14, 2014. Accessed April 28, 2020. https://www.straitstimes.com/singapore/emergency-starter-kits-delivered-to-all-households
    4.
    3M Singapore. How to wear a 3M VFlex N95 respirator. YouTube; 2014. Accessed April 28, 2020. https://www.youtube.com/watch?v=sIkbyfJ5YRQ
    5.
    Desai  AN, Mehrotra  P.  Medical masks.   JAMA. 2020;323(15):1517-1518. doi:10.1001/jama.2020.2331PubMedGoogle ScholarCrossref
    6.
    Harber  P, Boumis  RJ, Su  J, Barrett  S, Alongi  G.  Comparison of three respirator user training methods.   J Occup Environ Med. 2013;55(12):1484-1488. doi:10.1097/JOM.0000000000000010PubMedGoogle ScholarCrossref
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