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Research

Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis

Jeffrey D. Smith, Colin C. MacDougall, Jennie Johnstone, Ray A. Copes, Brian Schwartz and Gary E. Garber
CMAJ May 17, 2016 188 (8) 567-574; DOI: https://doi.org/10.1503/cmaj.150835
Jeffrey D. Smith
Public Health Ontario (Smith, MacDougall, Johnstone, Copes, Schwartz, Garber); Department of Medicine (Johnstone), University of Toronto; Dalla Lana School of Public Health (Copes, Schwartz), University of Toronto, Toronto, Ont.; Department of Medicine (Garber), University of Ottawa, Ottawa, Ont.
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Colin C. MacDougall
Public Health Ontario (Smith, MacDougall, Johnstone, Copes, Schwartz, Garber); Department of Medicine (Johnstone), University of Toronto; Dalla Lana School of Public Health (Copes, Schwartz), University of Toronto, Toronto, Ont.; Department of Medicine (Garber), University of Ottawa, Ottawa, Ont.
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Jennie Johnstone
Public Health Ontario (Smith, MacDougall, Johnstone, Copes, Schwartz, Garber); Department of Medicine (Johnstone), University of Toronto; Dalla Lana School of Public Health (Copes, Schwartz), University of Toronto, Toronto, Ont.; Department of Medicine (Garber), University of Ottawa, Ottawa, Ont.
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Ray A. Copes
Public Health Ontario (Smith, MacDougall, Johnstone, Copes, Schwartz, Garber); Department of Medicine (Johnstone), University of Toronto; Dalla Lana School of Public Health (Copes, Schwartz), University of Toronto, Toronto, Ont.; Department of Medicine (Garber), University of Ottawa, Ottawa, Ont.
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Brian Schwartz
Public Health Ontario (Smith, MacDougall, Johnstone, Copes, Schwartz, Garber); Department of Medicine (Johnstone), University of Toronto; Dalla Lana School of Public Health (Copes, Schwartz), University of Toronto, Toronto, Ont.; Department of Medicine (Garber), University of Ottawa, Ottawa, Ont.
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Gary E. Garber
Public Health Ontario (Smith, MacDougall, Johnstone, Copes, Schwartz, Garber); Department of Medicine (Johnstone), University of Toronto; Dalla Lana School of Public Health (Copes, Schwartz), University of Toronto, Toronto, Ont.; Department of Medicine (Garber), University of Ottawa, Ottawa, Ont.
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  • For correspondence: gary.garber@oahpp.ca
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    Figure 1:

    Selection of studies for the meta-analysis.

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    Figure 2:

    Results of meta-analysis to determine effectiveness of N95 respirators versus surgical masks in protecting health care workers against acute respiratory infection. Outcomes were (A) laboratory-confirmed respiratory infection, (B) influenza-like illness and (C) workplace absenteeism. Values less than 1.0 favour N95 respirator. CI = confidence interval, NA = not applicable, RCT = randomized controlled trial.

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    Table 1:

    Characteristics of studies included in the meta-analysis11–17

    StudySettingParticipantsOutcomesInterventionsNotes
    Randomized controlled trials
    Loeb et al., 2009118 hospitals in Ontario, Canada: emergency departments, acute medical units and pediatric units446 nurses; individual-level randomization
    • Laboratory-confirmed respiratory infection, influenza-like illness, workplace absenteeism

    • 5-wk follow-up

    • Intervention: targeted use, fit-tested N95 respirator

    • Control: targeted use, surgical mask

    • Noninferiority trial

    • Detection of influenza A and B, respiratory syncytial virus metapneumovirus, parainfluenza virus, rhinovirus–enterovirus, coronavirus and adenovirus

    MacIntyre et al., 2011/201412,1315 hospitals in Beijing: emergency departments and respiratory wards1441 nurses, doctors and ward clerks; cluster randomization by hospital
    • Laboratory-confirmed respiratory infection, influenza-like illness

    • 5-wk follow-up

    • Intervention 1: continual use, fit-tested N95 respirator

    • Intervention 2: continual use, non–fit-tested N95 respirator

    • Control: continual use, surgical mask

    Detection of influenza A and B, respiratory syncytial virus metapneumovirus, parainfluenza virus, rhinovirus–enterovirus, coronavirus, adenovirus, Streptococcus pneumoniae, Bordetella pertussis, Chlamydophila pneumoniae, Mycoplasma pneumoniae and Haemophilus influenzae type B
    MacIntyre et al., 20131419 hospitals in Beijing: emergency departments and respiratory wards1669 nurses, doctors and ward clerks; cluster randomization by ward
    • Laboratory-confirmed respiratory infection, influenza-like illness

    • 5-wk follow-up

    • Intervention 1: continual use, fit-tested N95 respirator

    • Intervention 2: targeted use, fit-tested N95 respirator

    • Control: continual use, surgical mask

    Detection of influenza A and B, respiratory syncytial virus metapneumovirus, parainfluenza virus, rhinovirus–enterovirus, coronavirus, adenovirus, S. pneumoniae, B. pertussis, C. pneumoniae, M. pneumoniae and H. influenzae type B
    Cohort study
    Loeb et al., 2004152 hospitals in Ontario: coronary care units and ICUs with SARS patients43 nursesLaboratory-confirmed respiratory infection
    • Intervention: N95 respirator

    • Control: surgical mask

    • Retrospective

    • Only 20 nurses reported exposures and consistent use of facial protective equipment

    • Detection of SARS

    Case–control studies
    Seto et al., 2003165 hospitals in Hong Kong: emergency departments and medicine units13 infected (cases) and 241 noninfected (controls) nurses, doctors, health care assistants and domestic staffLaboratory-confirmed respiratory infection
    • N95 respirator

    • Surgical mask

    • Paper mask

    • No cases in N95 respirator or surgical mask groups

    • 143 controls wore either surgical mask or N95 respirator

    • Detection of SARS

    Zhang et al., 20131725 hospitals in Beijing: emergency departments, respiratory wards, ICUs, outpatient departments, technical clinic departments and management51 infected (cases) and 204 noninfected (controls) doctors, nurses, technicians and otherLaboratory-confirmed respiratory infection
    • N95 respirator

    • Surgical mask

    • Cloth mask

    • Cases and controls matched 1:4 by hospital, ward, age and sex

    • 40 cases wore either N95 respirator or surgical mask

    • 159 controls wore either surgical mask or N95 respirator

    • Detection of pandemic H1N1 influenza virus

    • Note: ICU = intensive care unit, SARS = severe acute respiratory syndrome.

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Canadian Medical Association Journal: 188 (8)
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Vol. 188, Issue 8
17 May 2016
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Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis
Jeffrey D. Smith, Colin C. MacDougall, Jennie Johnstone, Ray A. Copes, Brian Schwartz, Gary E. Garber
CMAJ May 2016, 188 (8) 567-574; DOI: 10.1503/cmaj.150835

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Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis
Jeffrey D. Smith, Colin C. MacDougall, Jennie Johnstone, Ray A. Copes, Brian Schwartz, Gary E. Garber
CMAJ May 2016, 188 (8) 567-574; DOI: 10.1503/cmaj.150835
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