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Filtering Facepiece Respirator (N95 Respirator) ReprocessingA Systematic Review

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What methods of filtering facepiece respirator decontamination are effective and feasible?

Findings  Five decontamination processes and 42 studies were reviewed. Ultraviolet germicidal irradiation, moist heat, and microwave-generated steam processing were effective for pathogen removal, preserved respirator filtration, and had short treatment times and readily available equipment. Vaporized hydrogen peroxide is a suitable alternative with longer decontamination durations and is more expensive. Ethylene oxide may leave toxic residues and is less easily implemented.

Meaning  Ultraviolet germicidal irradiation, moist heat, and microwave-generated steam processing of filtering facepiece respirators are effective means for decontamination and are simple to implement.


Importance  The COVID-19 pandemic has resulted in a persistent shortage of personal protective equipment; therefore, a need exists for hospitals to reprocess filtering facepiece respirators (FFRs), such as N95 respirators.

Objective  To perform a systematic review to evaluate the evidence on effectiveness and feasibility of different processes used for decontaminating N95 respirators.

Evidence Review  A search of PubMed and EMBASE (through January 31, 2021) was completed for 5 types of respirator-decontaminating processes including UV irradiation, vaporized hydrogen peroxide, moist-heat incubation, microwave-generated steam, and ethylene oxide. Data were abstracted on process method, pathogen removal, mask filtration efficiency, facial fit, user safety, and processing capability.

Findings  Forty-two studies were included that examined 65 total types of masks. All were laboratory studies (no clinical trials), and 2 evaluated respirator performance and fit with actual clinical use of N95 respirators. Twenty-seven evaluated UV germicidal irradiation, 19 vaporized hydrogen peroxide, 9 moist-heat incubation, 10 microwave-generated steam, and 7 ethylene oxide. Forty-three types of N95 respirators were treated with UV irradiation. Doses of 1 to 2 J/cm2 effectively sterilized most pathogens on N95 respirators (>103 reduction in influenza virus [4 studies], MS2 bacteriophage [3 studies], Bacillus spores [2 studies], Escherichia virus MS2 [1 study], vesicular stomatitis virus [1 study], and Middle East respiratory syndrome virus/SARS-CoV-1 [1 study]) without degrading respirator components. Doses higher than 1.5 to 2 J/cm2 may be needed based on 2 studies demonstrating greater than 103 reduction in SARS-CoV-2. Vaporized hydrogen peroxide eradicated the pathogen in all 7 efficacy studies (>104 reduction in SARS-CoV-2 [3 studies] and >106 reduction of Bacillus and Geobacillus stearothermophilus spores [4 studies]). Pressurized chamber systems with higher concentrations of hydrogen peroxide caused FFR damage (6 studies), while open-room systems did not degrade respirator components. Moist heat effectively reduced SARS-CoV-2 (2 studies), influenza virus by greater than 104 (2 studies), vesicular stomatitis virus (1 study), and Escherichia coli (1 study) and preserved filtration efficiency and facial fit for 11 N95 respirators using preheated containers/chambers at 60 °C to 85 °C (5 studies); however, diminished filtration performance was seen for the Caron incubator. Microwave-generated steam (1100-W to 1800-W devices; 40 seconds to 3 minutes) effectively reduced pathogens by greater than 103 (influenza virus [2 studies], MS2 bacteriophage [3 studies], and Staphylococcus aureus [1 study]) and maintained filtration performance in 10 N95 respirators; however, damage was noted in least 1 respirator type in 4 studies. In 6 studies, ethylene oxide preserved respirator components in 16 N95 respirator types but left residual carcinogenic by-product (1 study).

Conclusions and Relevance  Ultraviolet germicidal irradiation, vaporized hydrogen peroxide, moist heat, and microwave-generated steam processing effectively sterilized N95 respirators and retained filtration performance. Ultraviolet irradiation and vaporized hydrogen peroxide damaged respirators the least. More research is needed on decontamination effectiveness for SARS-CoV-2 because few studies specifically examined this pathogen.

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Article Information

Corresponding Author: Max A. Schumm, MD, Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Ave, 72-227 CHS, Los Angeles, CA 90095 (mschumm@mednet.ucla.edu).

Accepted for Publication: February 11, 2021.

Published Online: March 3, 2021. doi:10.1001/jama.2021.2531

Author Contributions: Dr Schumm had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Schumm, Hadaya, Mody, Myers.

Acquisition, analysis, or interpretation of data: Schumm, Hadaya, Maggard-Gibbons.

Drafting of the manuscript: Schumm, Hadaya.

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

Statistical analysis: Schumm, Hadaya.

Supervision: Maggard-Gibbons.

Conflict of Interest Disclosures: None reported.

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