12:00 PM

430 - Face Mask Primer 2022, HPV Re-Vax?, Words Creating Worlds

Take 3 – Practical Practice Pointers©

From the Literature and the CDC

 1)  Optimizing Face Mask Fit


To limit the transmission of SARS-CoV-2, the CDC recommends wearing a face mask that is multi-layered, covers the nose and mouth, and forms a tight seal against the face.  Face masks provide a physical barrier to the expulsion of both aerosols and droplets and offer limited personal respiratory protection against aerosols that may enter through the nose and mouth. 

 The presence of face seal leaks enables respiratory aerosols to escape out rather than pass through the filtering materials of the mask, consequently reducing the benefits of wearing a face mask for source control. Because medical and cloth masks tend to fit more loosely than a fitted respirator, recent attention has been given to modifications that improve mask fit.

 Modifications such as mask braces, earloop straps, knotting and tucking, and double masking have been proposed to improve mask fit, however the data on source control are limited.  This recently published study evaluated various modifications that aimed to improve the fit of a medical or cloth face mask and reduce the amount of expelled aerosols during simulated coughs and exhalations as well as limit particle exposure with inhalation.  Fit tests were done on human subjects and simulator manikins by performing machine generated simulated coughs and exhalations with a test aerosol solution (particle size range from 0-20 μm in diameter).  A 3M 1860 N95 respirator was used as a source control for metric comparisons.

 The authors found that medical masks without modification blocked ≥56% of cough aerosols and ≥42% of exhaled aerosols. Modifying fit by crossing the earloops or placing a bracket under the mask did not increase performance.  Increasing tension to the earloops with an adjustable strap significantly improved the collection efficiencies of medical masks to >72%.  Modifications to the earloops by adding toggles or by knotting and tucking achieved similar increases in source control performance to > 74%. The most effective modifications for improving source control performance were double masking and using a mask brace. Placing a cloth mask over a medical mask blocked ≥85% of cough aerosols and ≥91% of exhaled aerosols. Placing a brace over a medical mask blocked ≥95% of cough aerosols and ≥99% of exhaled aerosols.

 Simulated particle inhalation exposure studies showed significant increases in particle blocking were obtained when the source simulator wore a medical mask fit modified with earloop toggles, knotted and tucked earloops, or a mask brace. Results show that greater than 98% of the particle mass was blocked by a medical face mask fit modified with a brace and were comparable to the N95 respirator.

 The authors concluded that fit modifications can greatly improve the performance of face masks as source control devices for respiratory aerosols. 

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 Mark’s Comments:

While perhaps at the start of the pandemic, “just cover your mouth and nose with something” may have seemed appropriate, the science has continued to advance, and neither healthcare nor society at large have really kept up.  An N95 mask would still be considered the “gold standard,” but on a population scale these are not practical, and when you consider these numbers from a public health perspective, the potential impact of some of these modifications is enormous.  And while the “mask brace” device is not easy to come by (and they didn’t measure “comfort” so I can’t comment), double masking with cloth over surgical and even the “knot and tuck” (instructional video reference below) are simple modifications that could easily be universally implemented.


With the likelihood that face masks of some form will likely become more commonly used in the healthcare setting post-pandemic, studies such as this will help guide the science as to how we can best utilize these tools to optimize effectiveness and safety. 


·       Blanchere F, et al.  Face mask fit modifications that improve source control performance.  Am J Infect Control.  Published online 15 December, 2021.  Article

·       CDC:  “How to knot and tuck your mask to improve fit.”  15 April 2021.  Video

·       CDC:  “Your Guide to Masks.”  Updated 25 October, 2021.  Link

Question from a Colleague

 2)  Re-vaccination with the Human Papilloma Virus (HPV) Vaccine?


A reader asks, “If my patient has had a quadrivalent HPV (HPV-4) vaccine in the past, should we worry about the five serogroups that weren’t covered by the HPV-4? Does my patient need testing or re-vaccination?”

 In short, no. But a bit of a refresher first:

·       In the mid-2000s, two HPV vaccines were approved by the US Food and Drug Administration (FDA): Cervarix (HPV-2) and Gardasil (HPV-4).

·       HPV-2 vaccine had antigens for HPV types 16 and 18, which cause @ 2/3 of cervical cancers. Cervarix did not compete well with Gardasil, and ultimately was taken off the market in the US.

·       HPV-4 covered types 16 & 18 as well as 6 and 11, which cause most genital warts.

·       Uptake of HPV vaccination has consistently lagged that of other vaccines due mostly to hesitancy about a vaccine against a sexually transmitted disease.

·       The CDC’s Advisory Committee on Immunization Practices (ACIP) has gradually broadened the age and gender indications for this vaccination to reduce HPV-associated cancers (cervical, vulvo-vaginal, penile, anal, and oropharyngeal).

·       In 2016, a two-dose schedule for HPV-9 was approved due to high and persisting immunogenicity from the vaccine if given prior to age 15.

·       The HPV vaccine recommendations today:

o   Males and females 9-26, with catch up immunization recommended through age 26. Only two doses are needed (separated by six months) if the series is completed prior to age 15.

o   Shared decision making for vaccinating males and females from 27-45 (focusing on those at high risk due to multiple sexual partners, HIV, etc.) mainly because the expected benefit would be small for the general population.

 The ACIP notes that no antibody testing or HPV testing is indicated prior to any HPV vaccination. They also note, without much comment, that an incomplete HPV-4 series can be completed using HPV-9 without additional vaccination, and that re-vaccination with HPV-9 is not recommended if someone had completed the HPV-4 series.

 John’s Comments:

The ACIP has often suggested re-vaccination with newer/broader vaccination products (e.g., the pneumococcal series, varicella-zoster vaccines), so the reader’s question is a very reasonable one. The effectiveness of the both the HPV-4 and -9 immunization in preventing the most oncogenic strains of the virus (16 and 18) likely obviates the need for re-vaccination. The public health effort would be better spent increasing immunization in the unvaccinated populations.


·       ACIP HPV Vaccine Recommendations | CDC. Published August 16, 2019. Accessed January 6, 2022. Link

·       Ask the Experts about Human Papillomavirus (HPV) Vaccines - CDC experts answer Q&As. Accessed January 6, 2022. Link

From PeerRxMed (www.PeerRxMed.com)


3)  Let Your “Word” Help Create Your World in 2022


“Words create worlds.”  Attributed to many

 I believe words matter.   Apparently, so do many others who make one of their New Year’s rituals to pick their “word for the year.”  This is a word or short phrase that represents a personal and/or professional aspiration and can help serve as a guide, anchor, or “theme” for the upcoming year.  Mine has been a “made-up” word that symbolizes values that I want to focus on and becomes a compass to help keep me aligned with my stated priorities – it helps me create my world for the year.  

 Indeed, words are symbols for thoughts and ideas, and we personalize them according to the meaning we associate with them.  Consider some pandemic-related words that have taken on a whole new meaning in the past 2 years, such as zoom, distancing, hero, mask, lockdown, quarantine, incubation, vaccination, transmission, booster and even cloth!  Each of these words now have a newly acquired “emotional charge” attached to them, and depending on your perspective, symbolize different meanings, and those differences have indeed often created “different worlds.”   

 In the past 3 years, my self-created words have been “zilience,” “reslove,” and in 2021, “cor,” and last week I wrote how living into my understanding of “cor” helped shape my year in powerful way.  For this year, my word is “bemusedament,” and I intend that it will help me tap into the creative spirit around my core values of connection, wonder, love, growth, and fun, and in particular, will inform and inspire my writing in 2022.  

 How about you?  What might be your word or words to help you frame the year?  Consider picking one or more and sharing their meaning with those close to you.  Last year one of my PeerRxMed buddies also adopted “cor” as his word, and for him it symbolized a year for which he made self-care a priority.  Embracing a common meaning can help strengthen your community and provide an opportunity for accountability and encouragement. 

 What kind of world do you want to create in 2022?  Well, it can all start with one word.  Choose wisely ….


Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org