Filtering Facepiece Respirator (N95 Respirator) Reprocessing
Authors: Max A. Schumm, Joseph E. Hadaya, Nisha Mody, Bethany A. Myers, Melinda Maggard-Gibbons
Journal: JAMA (2021)

<h3>Importance</h3> 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. <h3>Objective</h3> To perform a systematic review to evaluate the evidence on effectiveness and feasibility of different processes used for decontaminating N95 respirators. <h3>Evidence Review</h3> 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. <h3>Findings</h3> 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/cm<sup>2</sup>effectively sterilized most pathogens on N95 respirators (&gt;10<sup>3</sup>reduction in influenza virus [4 studies], MS2 bacteriophage [3 studies],<i>Bacillus</i>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/cm<sup>2</sup>may be needed based on 2 studies demonstrating greater than 10<sup>3</sup>reduction in SARS-CoV-2. Vaporized hydrogen peroxide eradicated the pathogen in all 7 efficacy studies (&gt;10<sup>4</sup>reduction in SARS-CoV-2 [3 studies] and &gt;10<sup>6</sup>reduction of<i>Bacillus</i>and<i>Geobacillus stearothermophilus</i>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 10<sup>4</sup>(2 studies), vesicular stomatitis virus (1 study), and<i>Escherichia coli</i>(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 10<sup>3</sup>(influenza virus [2 studies], MS2 bacteriophage [3 studies], and<i>Staphylococcus aureus</i>[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). <h3>Conclusions and Relevance</h3> 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.