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      Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta‐analysis

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          Abstract

          Objective

          Previous meta‐analyses concluded that there was insufficient evidence to determine the effect of N95 respirators. We aimed to assess the effectiveness of N95 respirators versus surgical masks for prevention of influenza by collecting randomized controlled trials (RCTs).

          Methods

          We searched PubMed, EMbase and The Cochrane Library from the inception to January 27, 2020 to identify relevant systematic reviews. The RCTs included in systematic reviews were identified. Then we searched the latest published RCTs from the above three databases and searched ClinicalTrials.gov for unpublished RCTs. Two reviewers independently extracted the data and assessed risk of bias. Meta‐analyses were conducted to calculate pooled estimates by using RevMan 5.3 software.

          Results

          A total of six RCTs involving 9 171 participants were included. There were no statistically significant differences in preventing laboratory‐confirmed influenza (RR = 1.09, 95% CI 0.92‐1.28, P > .05), laboratory‐confirmed respiratory viral infections (RR = 0.89, 95% CI 0.70‐1.11), laboratory‐confirmed respiratory infection (RR = 0.74, 95% CI 0.42‐1.29) and influenzalike illness (RR = 0.61, 95% CI 0.33‐1.14) using N95 respirators and surgical masks. Meta‐analysis indicated a protective effect of N95 respirators against laboratory‐confirmed bacterial colonization (RR = 0.58, 95% CI 0.43‐0.78).

          Conclusion

          The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory‐confirmed influenza. It suggests that N95 respirators should not be recommended for general public and nonhigh‐risk medical staff those are not in close contact with influenza patients or suspected patients.

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          Most cited references31

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          Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial.

          Benjamin Cowling, Kwok-Hung Chan, Vicky J. Fang … (2009)
          Few data are available about the effectiveness of nonpharmaceutical interventions for preventing influenza virus transmission. To investigate whether hand hygiene and use of facemasks prevents household transmission of influenza. Cluster randomized, controlled trial. Randomization was computer generated; allocation was concealed from treating physicians and clinics and implemented by study nurses at the time of the initial household visit. Participants and personnel administering the interventions were not blinded to group assignment. (ClinicalTrials.gov registration number: NCT00425893) Households in Hong Kong. 407 people presenting to outpatient clinics with influenza-like illness who were positive for influenza A or B virus by rapid testing (index patients) and 794 household members (contacts) in 259 households. Lifestyle education (control) (134 households), hand hygiene (136 households), or surgical facemasks plus hand hygiene (137 households) for all household members. Influenza virus infection in contacts, as confirmed by reverse-transcription polymerase chain reaction (RT-PCR) or diagnosed clinically after 7 days. Sixty (8%) contacts in the 259 households had RT-PCR-confirmed influenza virus infection in the 7 days after intervention. Hand hygiene with or without facemasks seemed to reduce influenza transmission, but the differences compared with the control group were not significant. In 154 households in which interventions were implemented within 36 hours of symptom onset in the index patient, transmission of RT-PCR-confirmed infection seemed reduced, an effect attributable to fewer infections among participants using facemasks plus hand hygiene (adjusted odds ratio, 0.33 [95% CI, 0.13 to 0.87]). Adherence to interventions varied. The delay from index patient symptom onset to intervention and variable adherence may have mitigated intervention effectiveness. Hand hygiene and facemasks seemed to prevent household transmission of influenza virus when implemented within 36 hours of index patient symptom onset. These findings suggest that nonpharmaceutical interventions are important for mitigation of pandemic and interpandemic influenza. Centers for Disease Control and Prevention.
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            N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel

            Lewis Radonovich, Michael S. Simberkoff, Mary Bessesen … (2019)
            Clinical studies have been inconclusive about the effectiveness of N95 respirators and medical masks in preventing health care personnel (HCP) from acquiring workplace viral respiratory infections.
            Article 0 comments Cited 206 times – based on 0 reviews     Review now
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              Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial.

              Mark Loeb, Nancy Dafoe, James Mahony … (2009)
              Data about the effectiveness of the surgical mask compared with the N95 respirator for protecting health care workers against influenza are sparse. Given the likelihood that N95 respirators will be in short supply during a pandemic and not available in many countries, knowing the effectiveness of the surgical mask is of public health importance. To compare the surgical mask with the N95 respirator in protecting health care workers against influenza. Noninferiority randomized controlled trial of 446 nurses in emergency departments, medical units, and pediatric units in 8 tertiary care Ontario hospitals. Assignment to either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season. The primary outcome was laboratory-confirmed influenza measured by polymerase chain reaction or a 4-fold rise in hemagglutinin titers. Effectiveness of the surgical mask was assessed as noninferiority of the surgical mask compared with the N95 respirator. The criterion for noninferiority was met if the lower limit of the 95% confidence interval (CI) for the reduction in incidence (N95 respirator minus surgical group) was greater than -9%. Between September 23, 2008, and December 8, 2008, 478 nurses were assessed for eligibility and 446 nurses were enrolled and randomly assigned the intervention; 225 were allocated to receive surgical masks and 221 to N95 respirators. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and in 48 (22.9%) in the N95 respirator group (absolute risk difference, -0.73%; 95% CI, -8.8% to 7.3%; P = .86), the lower confidence limit being inside the noninferiority limit of -9%. Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza. clinicaltrials.gov Identifier: NCT00756574
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                Author and article information

                Contributors
                Jin Huang: michael_huangjin@163.com
                Liang Du: duliang0606@vip.sina.com
                Journal
                Journal ID (nlm-ta): J Evid Based Med
                Journal ID (iso-abbrev): J Evid Based Med
                Journal ID (doi): 10.1111/(ISSN)1756-5391
                Journal ID (publisher-id): JEBM
                Title: Journal of Evidence-Based Medicine
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Electronic): 1756-5391
                Publication date (Electronic): 13 March 2020
                Electronic Location Identifier: 10.1111/jebm.12381
                Affiliations
                [ 1 ] Chinese Evidence‐Based Medicine Center West China Hospital Sichuan University Chengdu P.R. China
                [ 2 ] West China School of Medicine Sichuan University Chengdu P.R. China
                [ 3 ] School of Clinical Medicine Chengdu University of Traditional Chinese Medicine Chengdu P.R. China
                [ 4 ] West China Hospital Sichuan University Chengdu P.R. China
                Author notes
                [*] [* ] Correspondence

                Liang Du, West China Hospital, Sichuan University, Guoxuexiang 37, Chengdu 610041, P.R. China.

                Email: duliang0606@ 123456vip.sina.com

                Jin Huang, West China Hospital, Sichuan University, Guoxuexiang 37 Chengdu 610041, P.R. China.

                Email: michael_huangjin@ 123456163.com

                Article
                Publisher ID: JEBM12381
                DOI: 10.1111/jebm.12381
                PMC ID: 7228345
                PubMed ID: 32167245
                SO-VID: 05d2aa09-e230-4fd1-b3b6-98fc0f50070d
                Copyright © © 2020 Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd
                License:

                This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

                History
                Date received : 03 February 2020
                Date accepted : 12 February 2020
                Page count
                Figures: 7, Tables: 3, Pages: 9, Words: 4108
                Funding
                Funded by: Science and technology project supported by West China Hospital of Sichuan University for tackling COVID‐19: HX‐2019‐nCoV‐024
                Funded by: National Natural Science Foundation of China , open-funder-registry 10.13039/501100001809;
                Award ID: 81873197
                Award ID: 81403276
                Funded by: Key Program of Sichuan Provincial Science and Technology Department
                Award ID: 2019YFS0194
                Categories
                Subject: Article
                Subject: Articles
                Custom metadata
                source-schema-version-number 2.0
                edited-state corrected-proof
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.0 mode:remove_FC converted:16.04.2020

                ScienceOpen disciplines: Medicine
                Keywords: influenza,masks,n95 respirator,respiratory protective devices,respiratory tract infections,surgical mask
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: influenza, masks, n95 respirator, respiratory protective devices, respiratory tract infections, surgical mask

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