Strategies for Optimizing the Supply of Facemasks

Summary of Recent Changes

Audience: These considerations are intended for use by federal, state, and local public health officials; leaders in occupational health services and infection prevention and control programs; and other leaders in healthcare settings who are responsible for developing and implementing policies and procedures for preventing pathogen transmission in healthcare settings.

Purpose: This document offers a series of strategies or options to optimize supplies of facemasks in healthcare settings when there is limited supply. It does not address other aspects of pandemic planning; for those, healthcare facilities can refer to COVID-19 preparedness plans.

Surge capacity refers to the ability to manage a sudden increase in patient volume that would severely challenge or exceed the present capacity of a facility. While there are no commonly accepted measurements or triggers to distinguish surge capacity from daily patient care capacity, surge capacity is a useful framework to approach a decreased supply of facemasks during the COVID-19 response. To help healthcare facilities plan and optimize the use of facemasks in response to COVID-19, CDC has developed a Personal Protective Equipment (PPE) Burn Rate Calculator. Three general strata have been used to describe surge capacity and can be used to prioritize measures to conserve facemask supplies along the continuum of care.

• Conventional capacity: measures consisting of engineering, administrative, and personal protective equipment (PPE) controls that should already be implemented in general infection prevention and control plans in healthcare settings.
• Contingency capacity: measures that may be used temporarily during periods of expected facemask shortages. Contingency capacity strategies should only be implemented after considering and implementing conventional capacity strategies. While current supply may meet the facility’s current or anticipated utilization rate, there may be uncertainty if future supply will be adequate and, therefore, contingency capacity strategies may be needed.
• Crisis capacity: strategies that are not commensurate with U.S. standards of care but may need to be considered during periods of known facemask shortages. Crisis capacity strategies should only be implemented after considering and implementing conventional and contingency capacity strategies. Facilities can consider crisis capacity strategies when the supply is not able to meet the facility’s current or anticipated utilization rate.

CDC’s optimization strategies for facemask supply offer a continuum of options for use when facemask supplies are stressed, running low, or exhausted. Contingency and then crisis capacity measures augment conventional capacity measures and are meant to be considered and implemented sequentially. Once facemask availability returns to normal, healthcare facilities should promptly resume standard practices.

Decisions to implement contingency and crisis strategies are based upon these assumptions:

1. Facilities understand their facemask inventory and supply chain
2. Facilities understand their facemask utilization rate
3. Facilities are in communication with local healthcare coalitions, federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional supplies
4. Facilities have already implemented other engineering and administrative control measures including:
   • Use physical barriers and other engineering controls
   • Limit number of patients going to hospital or outpatient settings
   • Use telemedicine whenever possible
   • Exclude all HCP not directly involved in patient care
   • Limit face-to-face HCP encounters with patients
   • Limit visitors to the facility to those essential for the patient’s physical or emotional well-being and care (e.g., care partner, parent).
   • Cohort patients and/or HCP
5. Facilities have provided HCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform job responsibilities, such as provision of patient care

Once availability of facemasks returns to normal, healthcare facilities should promptly resume conventional practices. Determining the appropriate time to return to conventional strategies can be challenging. Considerations affecting this decision include:

1. The anticipated number of patients for whom a facemask should be worn by HCP providing their care
2. The number of days’ supply of facemasks currently remaining at the facility
3. Whether or not the facility is receiving regular resupply with its full allotment

Conventional Capacity Strategies

Use facemasks according to product labeling and local, state, and federal requirements.

In healthcare settings, facemasks are used by HCP for 2 general purposes:

1. As PPE to protect their nose and mouth from exposure to splashes, sprays, splatter, and respiratory secretions (e.g., for patients on Droplet Precautions). When used for this purpose, facemasks should be removed and discarded after each patient encounter.
2. When recommended for source control while they are in the healthcare facility, to cover one’s mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. When used for this purpose, facemasks may be used until they become soiled, damaged, or hard to breathe through. They should be immediately discarded after removal.

FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures. Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

Contingency Capacity Strategies

Selectively cancel elective and non-urgent procedures and appointments for which a facemask is typically used by HCP as PPE.

Remove facemasks from facility entrances and other public areas. 

Healthcare facilities can consider removing all facemasks from public areas (e.g., entrances, near elevators) and instead keep them in a secure and monitored site where they are distributed at check-in only to patients who do not have their own cloth mask or facemask. This is especially important in high-traffic areas like emergency departments.

Implement extended use of facemasks as PPE.

Extended use of facemasks is the practice of HCP wearing the same facemask as PPE (e.g., for patients on Droplet Precautions) during encounters with several different patients, without removing the facemask between encounters.

• The facemask should be discarded whenever the facemask is removed, and always at the end of each workday.
• The facemask should also be removed and discarded if soiled, damaged, or hard to breathe through.
• HCP must take care not to touch their facemask. If they touch or adjust their facemask, they must immediately perform hand hygiene.
• HCP should leave the patient care area if they need to remove the facemask.

Restrict facemasks for use only by HCP when needed as PPE (e.g., encounters with patients on Droplet Precautions). 

HCP who only require source control may use a cloth mask. Instead of providing a facemask to patients not already wearing their own cloth mask for source control, have them use tissues or other barriers to cover their mouth and nose

Crisis Capacity Strategies

Cancel elective and non-urgent procedures and appointments for which a facemask is typically used by HCP as PPE.

Use facemasks beyond the manufacturer-designated shelf life during patient care activities.

If there is no date available on the facemask label or packaging, facilities should contact the manufacturer. The user should visually inspect the product prior to use and, if there are concerns (such as degraded materials or visible tears), discard the product.

Implement limited re-use of facemasks with extended use.

Pairing limited re-use of facemasks with extended use is the practice of using the same facemask by one HCP for multiple patient encounters but removing it after several encounters and redonning it for further patient encounters. As it is unknown what the potential contribution of contact transmission is for SARS-CoV-2, care should be taken to ensure that HCP do not touch outer surfaces of the mask during care, and that mask removal and replacement be done in a careful and deliberate manner.

• At this time, there is not known a maximum number of uses (donnings) the same facemask could be re-used.
• The facemask should be removed and discarded if soiled, damaged, or hard to breathe through.
• Not all facemasks can be re-used.
  • Facemasks that fasten to the provider via ties may not be able to be undone without tearing and should be considered only for extended use, rather than re-use.
  • Facemasks with elastic ear hooks may be more suitable for re-use.
• HCP should leave patient care area if they need to remove the facemask. Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean sealable paper bag or breathable container.

Prioritize facemasks for selected activities such as:

• For provision of essential surgeries and procedures
• During care activities where splashes and sprays are anticipated
• During unavoidable activities where prolonged face-to-face or close contact with a potentially infectious patient for whom facemask use is recommended
• If respirators are no longer available, during the care of patients with SARS-CoV-2 infection, other infections, or situations for which a respirator is recommended (e.g., during aerosol generating procedures when there is moderate to substantial community transmission of SARS-CoV-2)

When No Facemasks Are Available, Options Include

Exclude HCP at increased risk for severe illness from SARS-CoV-2 infection from contact with patients with suspected or confirmed SARS-CoV-2 infection.
During severe resource limitations, when respirators and facemasks are not available, consider excluding HCP who may be at increased risk for severe illness from SARS-CoV-2 infection, such as those of older age, those with chronic medical conditions, or those who may be pregnant, from caring for patients with confirmed or suspected SARS-CoV-2 infection.

Use a face shield that covers the entire front (that extends to the chin or below) and sides of the face with no facemask.

HCP use of cloth masks:
In settings where neither respirators nor facemasks are available, HCP might use cloth masks as a last resort for care of patients with suspected or confirmed diagnosis for which facemask or respirator use is normally recommended. However, cloth masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Cloth masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.