Abstract
Background:
Face masks are essential components of personal protective equipment widely used in infection control. However, improper use can expose patients and healthcare workers (HCWs) to opportunistic infections.
Objective:
This study aimed to evaluate the extent of fungal contamination in masks worn by HCWs and the contributing factors.
Methods:
In this study, 400 HCWs from various clinical settings (wards, intensive care units (ICUs), emergency rooms, and outpatient department (OPD)) from hospitals in an Indian city were assessed for fungal contamination in used masks along with the working environment. The fungal contaminations were studied and identified using standard microbial techniques. A predesigned questionnaire was adapted to record personal mask hygiene, work patterns, and demographic profiles.
Results:
Most HCWs were females, 267 (66.8%), with a mean age of 30.8 ± 9.6 years. Fungal contamination was detected in 56% of the mask samples, with colony counts ranging from 1 to 100 per mask. The most common fungal species identified in masks (>90%) was Aspergillus, followed by Fusarium and Rhizopus, which correlated with those identified in the working environment. Multivariate quasi-Poisson regression analysis showed a significant association between the fungal colony count in the mask and variables like the duration of mask usage (RR (relative risk) = 1.06, 1.04–1.08, P < 0.001), the clinical setting (RR = 1.64, 1.06–2.48, P = 0.023), and disinfecting hands after touching the mask (RR = 0.55, 0.32–0.88, P = 0.017).
Conclusion:
The present study highlights the significance of HCWs adhering to stringent mask hygiene protocols and targeted interventions to mitigate fungal contamination in indoor hospital settings that pose health risks to healthcare personnel and immunocompromised patients.
Keywords: Aspergillus, face masks, healthcare workers, hygiene practice, indoor air quality, mask hygiene
INTRODUCTION
In an era of continuous threat from emerging and reemerging infections, using personal protective equipment (PPE) is crucial to mitigate the risk of infection in any healthcare setting. Face masks are an important component of PPE and are currently widely used as a part of infection control strategy for all hospitals.[1,2] Face masks mitigate microbial transmission by limiting its spread via droplets and aerosols (source control) and reducing the inhalation of respiratory pathogens (wearer protection), supporting widespread advocacy for their use, especially during the pandemic.[3,4] Interim guidelines by the World Health Organization (WHO), published in December 2020 and 2021, recommend universal mask usage and duration of mask usage as 6 hours while caring for coronavirus disease 2019 (COVID-19) patients. Some of the developed countries recommend only 2–4 hours of mask use.[5,6,7] However, there are no specific guidelines for healthcare workers (HCWs) regarding the duration of mask use in different clinical settings, like OPD or general wards, suitable for the Indian context. In the absence of specific guidelines, there has been reuse and extended use of masks, which could further result in contamination.[6,8] Used medical masks can harbor respiratory pathogens, increasing the risk of self-contamination, particularly with prolonged use and frequent clinical contact. A recent comprehensive systematic review and meta-analysis has concluded the presence of various respiratory pathogens, including fungi, on the outer surfaces of medical masks used by HCWs. Masks are susceptible to fungal colonization if they are not handled or stored properly because they can come into contact with several kinds of environmental surfaces and are exposed to moisture from breath.[9]
In recent years, there has been a growing concern about fungal contamination and opportunistic infections, particularly among immunocompromised individuals who are more susceptible to serious health complications.[10,11] A study conducted among forensic HCWs detected fungal contamination on the surfaces of used medical masks, with Alternaria spp., Penicillium spp., and Aspergillus spp. being the most prevalent fungi identified.[8] Fungi, which are ubiquitous in the environment, can enter the human body through wounds, burns, and respiratory routes. Inhalation of spores can cause infections, especially in those with asthma or chronic lung conditions, triggering allergic reactions.[12] A study conducted among ICU patients in a tertiary care center in India showed 15% prevalence of invasive fungal infections with a mortality rate of 73%.[13] Proper hygiene, including hand washing before and after touching the mask and avoiding frequent adjustments, is crucial for protecting HCWs as well as patients in healthcare settings.[3] However, there exists a gap in the literature on the contamination of masks of HCWs and associated factors, including mask hygiene, from developing country settings.[5,14] Most of the studies were either undertaken among patients or in community settings from developed countries.[4,15] In this background, the current study aimed to assess the fungal contamination in used masks by HCWs and its associated factors, such as demographics (age, gender), occupational factors (work experience, occupation, patient contacts/day, clinical setting of work), working environment, and mask hygiene practices.
METHODOLOGY
Study population and sample size
The study was conducted among HCWs in seven selected hospitals in a metropolitan city in India. Institutional Ethics and Research Committee approval was obtained before the implementation of the project, and written informed consent was obtained from participants. HCWs working in different clinical settings (OPD, ICU, ward, emergency) who had direct contact with patients were recruited from these selected hospitals for the study. This study was part of a broad study exploring microbial contamination in the hospital setting. As published literature on similar objectives from India was not available, assuming a 50% prevalence of fungal contamination in used masks with 5% precision at a 95% confidence interval (CI), our sample size was calculated to be 384, rounded off to 400.
Sample collection and analysis
An interview schedule was developed to collect information on sociodemographic variables, occupational history such as clinical setting of work, work experience, current occupation, and number of patient contacts per day (“patient contact” refers to the number of individual patients seen by a HCW), information on the type of mask used and mask hygiene practices such as duration of use of current mask (which was given for sampling) and disinfection of hands based on WHO guidelines was also included in the schedule. To assess the fungal contamination, masks worn by the HCWs at the time of the interview were collected aseptically in ziplock bags from HCWs in different clinical settings. It was transported to the lab in a cold storage box at 2–8°C and processed immediately. The inside and outside area of the face mask was directly imprinted on trypticase soy agar. All the agar plates were incubated at 25°C for fungal counts for 5 days. After collecting used masks, a new mask was given to the healthcare worker (either an N95 or surgical mask, based on the preference of the healthcare worker). Simultaneously, fungal presence was assessed in the working environment of HCWs using a settle plate (i.e., the sedimentation or depositional method). Environmental samples were collected from 52 areas. Petri dishes with media were placed on four corners and in the center of the room, and allowed air to settle on solid culture media using the 1/1/1 Scheme (expose for 1 hour, 1 meter above the ground and 1 meter away from the wall).[16] After incubation, the fungal colonies were counted and calculated to express as colony-forming unit/plate (cfu/plate) and colony-forming unit/mask. The grown colonies were subcultured to get a pure culture on the respective media. Fungal culture was studied for colony characteristics, and a microscopic study for morphology was carried out with lactophenol cotton blue stain to identify fungi.
Statistical analysis
The data collected were coded and entered into Microsoft Excel. Statistical analysis was performed using R software version 4.2.3 (R Core Team, 2024). Descriptive statistics were calculated using the mean (standard deviation (SD)), median (interquartile range (IQR)), frequencies, and percentages. The outcome variable considered in the study was the number of fungal colonies in the mask. The average count of fungal colonies was compared across levels of potential risk factors. For statistical significance, univariate quasi-Poisson regression was used, and relative risk, 95% CI, and related P values were reported. A stepwise regression technique was used to select the best set of predictors, including the number of fungal colonies, and then, a multivariate quasi-Poisson regression was applied. Adjusted relative risk (ARR), 95% CI, and P values were reported. We considered a statistically significant P value to be less than 0.05.
RESULTS
Distribution of demographic and occupational characteristics
A total of 400 HCWs from different clinical settings were included in the study. Most healthcare workers, 267 (66.8%), were females with a mean age of 30.8 ± 9.6 years. Nearly 70% of the healthcare workers who have direct contact with patients are less than 35 years of age. Nearly one-third, 144 (36%), of the study participants were doctors, followed by nursing aids and nurses. Almost half of the healthcare workers had a working experience of 5 years or more. Among the participants, 294 (73.5%) worked for 8 hours or more per day. Details are shown in Table 1. Out of 400 participants, 39 (9.8%) reported having suffered from ARI during the time of the interview, and 31 (7.8%) were on antibiotics.
Table 1.
Distribution of demographic and occupational characteristics in the study sample
| Demographic and occupational characteristics (n=400) | Male | Female | Total number |
|---|---|---|---|
| Age group (in years) | |||
| ≤25 | 59 (39.3%) | 91 (60.7%) | 150 |
| 26–35 | 36 (27.7%) | 94 (72.3%) | 130 |
| 36–45 | 25 (28.7%) | 62 (71.3%) | 87 |
| >45 | 13 (39.4%) | 20 (60.6%) | 33 |
| Occupation | |||
| Doctors | 56 (38.9%) | 88 (61.1%) | 144 |
| Nurses | 26 (23.6%) | 84 (76.4%) | 110 |
| Nursing aid | 39 (31.7%) | 84 (68.3%) | 123 |
| Others | 12 (52.2%) | 11 (47.8%) | 23 |
| Work experience | |||
| <5 years | 76 (36.5%) | 132 (63.5%) | 208 |
| ≥5 years | 57 (29.7%) | 135 (70.3%) | 192 |
| Department of work | |||
| ICU | 29 (29.0%) | 71 (71.0%) | 100 |
| Emergency | 41 (41.0%) | 59 (59.0%) | 100 |
| OPD | 34 (34.0%) | 66 (66.0%) | 100 |
| Ward | 29 (29.0%) | 71 (71.0%) | 100 |
| Patient contact per day | |||
| <25 | 42 30.0% | 98 (70.0%) | 140 |
| 25–49 | 41 38.3% | 66 (61.7%) | 107 |
| ≥ 50 | 50 32.7% | 103 (67.3%) | 153 |
ICU=Intensive care unit; OPD=Outpatient department
Fungal contamination of masks
Fungal contamination was observed in 224 (56%) mask samples collected from the participants. Contamination was observed in the outer surface of 194, 48.5% of the samples and the inner surface of 115, 28.7% of the samples. Fungal colonies in contaminated masks ranged from 1 to 100 colonies/mask. The most common fungi identified from masks were Aspergillus species (>90%)—Aspergillus niger, Aspergillus fumigatus, and Aspergillus flavus—followed by Fusarium and Rhizopus. Fungal growth was detected in more than 75% of the environmental samples from the OPD/ward and in all samples collected from the emergency/ICU. Fungal species identified in the masks correlated with those identified in the working environment of healthcare workers, with Aspergillus being the most common species. The presence of more than one type of fungus was also noticed in the same sample shown in Table 2.
Table 2.
Distribution of fungal characteristics in the study sample
| Area sampled | Presence of fungi n (%) | Fungi isolated and frequency of isolates | Fungal colonies/plate range | |
|---|---|---|---|---|
|
| ||||
| Genus and species identified | n (%)* numbers not mutually exclusive | |||
| Inner side of the mask | 115 (28.7%) | Aspergillus Niger | 73 (63.47) | 1 to 50 colonies/plate |
| (n=400) | Aspergillus Fumigatus | 27 (23.4) | ||
| Aspergillus Flavus | 19 (16.5) | |||
| Fusarium | 6 (5.2) | |||
| Rhizopus | 2 (1.7) | |||
| Outer side of the mask | 194 (48.5%) | Aspergillus Niger | 112 (57.73) | 1 to 50 colonies/plate |
| (n=400) | Aspergillus Fumigatus | 49 (25.25) | ||
| Aspergillus Flavus | 27 (13.91) | |||
| Fusarium | 9 (4.63) | |||
|
| ||||
| Working environment of HCWs | ||||
|
| ||||
| Ward (n=17) | 13 (76.5%) | Aspergillus Niger | 9 (69.23) | 1 to 19 colonies/plate |
| Aspergillus Fumigatus | 4 (30.76) | |||
| Aspergillus Flavus | 3 (23.07) | |||
| Fusarium | 2 (15.38) | |||
| OPD (n=14) | 13 (92.9%) | Aspergillus Niger | 6 (46.15) | 1 to >50 colonies/plate |
| Aspergillus Fumigatus | 3 (23.07) | |||
| Aspergillus Flavus | 2 (15.38) | |||
| Fusarium | 1 (7.69) | |||
| Rhizopus | 1 (7.69) | |||
| Emergency (n=11) | 11 (100%) | Aspergillus Niger | 8 (72.72) | 1 to 23 colonies/plate |
| Aspergillus Fumigatus | 2 (18.18) | |||
| Aspergillus Flavus | 2 (18.18) | |||
| Fusarium | 2 (18.18) | |||
| ICU (n=10) | 10 (100%) | Aspergillus Niger | 5 (50) | 1 to 16 colonies/plate |
| Aspergillus Fumigatus | 2 (20) | |||
| Aspergillus Flavus | 4 (40) | |||
| Fusarium | 2 (20) | |||
HCW=Healthcare worker; ICU=Intensive care unit; OPD=Outpatient department
Prevalence, risk factors, and associated variables among healthcare workers
Among all 400 samples, 56% of masks were contaminated with at least one fungal colony, and the number of colonies ranged from 1 to 100. Among the fungal-contaminated masks, the mean number of colonies was 3.4 ± 7.9, and the median was 2, with IQR.[1,3] The average number of colonies was observed to be higher among age <30 years (2.18 vs. 1.56) and 1.4 (95% CI: 0.76–2.69, P value: 0.298) times higher number of colonies observed compared to age 30 years and above. Similarly, the average number of colonies was lower among males than females (1.36 vs 2.19) with RR 0.62 (95% CI: 0.29, 1.21, P value: 0.187). The average number of colonies was higher in doctors and nurses who had direct/frequent contact with patients than in other groups of health professionals. While comparing the clinical setting of work, the average number of colonies was lowest among ICU staff compared to those working in the ward, with RR 3.2 (95% CI: 1.2–9.5, P value: 0.024). Staff who used a mask for a duration of 6 hours or more had 2.3 times higher number of colonies compared to those who used less than 6 hours (P value: 0.002). Also, the average number of colonies was less among those who disinfected their hands after touching the mask. Details are shown in Table 3.
Table 3.
Estimated average fungal count across levels of different risk factors with unadjusted RR estimated by univariate quasi-Poisson regression
| Variables | Levels | n | Mean | SD | 95% LCL | 95% UCL | Unadjusted RR (95% CI) | P |
|---|---|---|---|---|---|---|---|---|
| Age | Age>30y | 173 | 1.56 | 2.54 | 1.18 | 1.94 | ||
| Age< = 30y | 227 | 2.18 | 7.9 | 1.15 | 3.21 | 1.40 (0.76,2.69) | 0.298 | |
| Sex | Female | 267 | 2.19 | 7.42 | 1.29 | 3.08 | ||
| Male | 133 | 1.36 | 2 | 1.02 | 1.7 | 0.62 (0.29,1.21) | 0.187 | |
| Occupation | Others | 146 | 1.27 | 2.2 | 0.91 | 1.63 | ||
| Doctor/nurse | 254 | 2.28 | 7.56 | 1.35 | 3.21 | 1.79 (0.93,3.73) | 0.098 | |
| Clinical setting | ICU | 100 | 0.89 | 1.18 | 0.66 | 1.12 | ||
| Emergency | 100 | 1.88 | 2.84 | 1.32 | 2.44 | 2.1 (0.8,6.6) | 0.164 | |
| OPD | 100 | 2.07 | 10.01 | 0.08 | 4.06 | 2.3 (0.9,7.2) | 0.111 | |
| Ward | 100 | 2.81 | 6.52 | 1.52 | 4.1 | 3.2 (1.2,9.5) | 0.024 | |
| Work experience | > = 5 years | 192 | 1.53 | 2.56 | 1.16 | 1.89 | ||
| <5 years | 208 | 2.27 | 8.21 | 1.15 | 3.39 | 1.49 (0.82,2.79) | 0.203 | |
| Type of mask | Surgical | 285 | 1.76 | 4.02 | 1.3 | 2.23 | ||
| Others | 115 | 2.28 | 9.66 | 0.49 | 4.06 | 1.29 (0.66,2.40) | 0.433 | |
| Duration of mask use | < = 6 hrs | 303 | 1.45 | 2.31 | 1.19 | 1.71 | ||
| >6 hrs | 97 | 3.35 | 11.8 | 0.97 | 5.73 | 2.31 (1.37,3.84) | 0.002 | |
| Patient contact per day | <50 pts | 247 | 1.59 | 4.33 | 1.04 | 2.13 | ||
| > = 50 pts | 153 | 2.44 | 8.33 | 1.11 | 3.77 | 1.54 (0.83,2.82) | 0.165 | |
| Disinfecting hands before wearing the mask | No | 204 | 1.92 | 3.17 | 1.48 | 2.35 | ||
| Yes | 196 | 1.91 | 8.23 | 0.75 | 3.07 | 1.00 (0.52,1.89) | 0.989 | |
| Disinfecting hands before wearing the mask | No | 186 | 1.79 | 2.56 | 1.42 | 2.16 | ||
| Yes | 214 | 2.02 | 8.12 | 0.93 | 3.11 | 1.13 (0.61,2.14) | 0.707 | |
| Disinfecting hands after touching the mask | No | 272 | 2.17 | 6.62 | 1.38 | 2.96 | ||
| Yes | 128 | 1.38 | 5.12 | 0.48 | 2.27 | 0.63 (0.28,1.29) | 0.236 |
CI=Confidence interval; LCL=Lower control limit; RR=Relative risk; SD=Standard deviation; UCL=Upper control limit
Further, stepwise multivariate quasi-Poisson regression identified the best predictor set as duration of mask use, practice hand hygiene after touching the mask, clinical setting of work, and number of patient contacts >50/day. It estimated a 6% (95% CI: 4–8%, P value < 0.001) increase in the number of colonies per hour use of mask; a 65% (95% CI: 12–685, P value: 0.017) reduction in colony count was observed with regular practice of hand hygiene after touching the mask. In the ward, 1.64 (95% CI: 1.06–2.48, P value: 0.023) times higher colonies were observed than in other clinical settings of work. HCWs who had contact with more than 50 patients showed a 1.31-fold higher colony count (95% CI: 0.86–2.0, P = 0.201) compared to those with 50 or fewer patient contacts. [Table 4]. The adjusted association of fungal colony count and duration of mask use is shown in Figure 1.
Table 4.
ARR estimated by multivariate quasi-Poisson regression
| Variable | RR | 95% LCL | 95% UCL | P |
|---|---|---|---|---|
| Duration of mask usage hours) | 1.06 | 1.04 | 1.08 | <0.001 |
| Practice hand hygiene after touching the mask | 0.55 | 0.32 | 0.88 | 0.017 |
| Clinical setting of work ward | 1.64 | 1.06 | 2.48 | 0.023 |
| Number of patient contacts >50/day | 1.31 | 0.86 | 2 | 0.201 |
ARR=Adjusted relative risk; LCL ower control limit; RR = Relative risk; UCL = Upper control limit
Figure 1.
Association between duration of mask use and the number of fungal counts/mask
DISCUSSION
This study’s main focus was on fungal contamination in masks worn by medical professionals in a variety of clinical settings, along with the contributing factors. Wearing masks in healthcare settings has become essential for preventing the spread of infections, particularly in light of the COVID-19 pandemic. However, questions have been raised concerning the safety and effectiveness due to the possibility of microbiological contamination of masks, particularly fungi.[1,8] The study revealed that fungal contamination was present in almost 56% of the mask samples, with Aspergillus being the most frequently observed species. The results are comparable with a similar study conducted in Algeria among forensic HCWs, where 48% of the mask samples were contaminated.[8] Nosocomial fungal infections, including invasive aspergillosis, mucormycosis, and candidiasis, pose a significant risk in terms of mortality and healthcare costs, particularly for critically ill and immunocompromised patients. Several studies highlight that higher fungal colony counts can increase the risk of exposure to potentially pathogenic fungi, particularly for immunocompromised individuals.[1,8,12,17,18] Another study conducted on patients at AIIMS Delhi, India, revealed that 70% of the masks had fungal contamination, with Aspergillus being the most common species found in mask samples.[17] In contrast to our study, a Japanese study observed a higher prevalence of fungal contamination (>80%) in mask samples from volunteers during COVID-19.[19] Given that patients and volunteers were chosen for these studies rather than healthcare professionals might have resulted in a higher rate of contamination in masks. Our present study also supports the finding on the association between a longer duration of mask use and an increase in fungal colony count in masks, as shown in the existing literature. According to a recent study among HCWs, using masks for 1–2 hours and 5–6 hours was linked to <5% and 36% fungal contamination, respectively.[8,19] Fungal spores, in contrast to bacteria, are not easily dried out, which can happen at night when there is little moisture and no masks on. As a result, while wearing the mask, fungi tend to grow and accumulate.[20]
We have observed that poor mask hygiene practices are significantly associated with fungal contamination in masks. Interim guidelines by WHO published in December 2020 and 2021 highlighted that the appropriate mask usage and hygiene are more critical than the type of mask to ensure effectiveness and reduce the risk of transmission of infections.[6,13] As masks can act as a direct source of infection to the digestive tract, respiratory tract, and skin, it is crucial to maintain mask hygiene to prevent infections among HCWs and patients.[19,20] However, despite their significant importance, these aspects are frequently ignored in several research investigations, and we could not find a similar study from India to compare our results. One of the reasons postulated for the unprecedented increase in mucormycosis cases amid COVID-19 in India was the use of unsanitary face masks in hot and humid weather.[21] Surgical mask samples were observed to have more fungal contamination compared to other type of masks in this study, which correlate with study findings of research conducted among HCWs of a university hospital in Algeria.[8] Another factor that was significantly associated with mask contamination is the type of clinical setting where the HCW is working. Masks collected from the emergency, ward, and OPD were more contaminated compared to those collected from the ICU. Nevertheless, all environmental samples and almost half of the masks were contaminated even in the ICU. Given the risk factors for aspergillosis, which include impaired mucosal clearance and mechanical ventilation, this is a very serious concern among ICU patients. According to a study conducted at a tertiary care facility in India, 15% of ICU patients had invasive fungal infections, such as invasive aspergillosis and invasive mucormycosis.[12] Even though no literature compares fungal contamination in different clinical settings, a hospital-based study has observed that nearly 25% of the inanimate objects in emergency departments were contaminated even after manual decontamination.[22] Higher levels of contamination may be caused by the nature of work conducted by healthcare professionals in an emergency, which could compromise mask hygiene practices and appropriate mask usage. The study further identified an association between the contamination of masks used by male and younger healthcare personnel, which aligns with our study findings, even though this association was not statistically significant in our study.
Even though a few studies are exploring fungal contamination in inanimate objects from hospital settings, to the best of our knowledge, this is the first study conducted in India exploring fungal contamination in masks of healthcare workers and their associated factors in detail.[21] Our study has a few limitations as well. The potential health risks associated with this contamination to patients or healthcare personnel have not been thoroughly investigated. This study was restricted to evaluating the fungal contamination of masks. The current study excludes other types of PPE.
CONCLUSION AND RECOMMENDATIONS
This study revealed a significant prevalence of fungal contamination in masks worn by HCWs, underscoring the potential risks they pose as sources of infection to both HCWs and immunocompromised patients. The detection of fungal colonies in samples from healthcare environments, including ICUs, underscores the urgent need to enforce robust indoor infection control strategies in healthcare settings. Adherence to proper mask hygiene practices, including regular replacement of masks and avoiding prolonged usage, is essential to mitigate the risk of fungal contamination. Additionally, targeted interventions, such as active fungal surveillance in clinical environments, can play a pivotal role in identifying and addressing potential sources of contamination early. Furthermore, educating HCWs about the risks associated with improper mask handling and promoting routine disinfection practices, such as hand hygiene after touching masks, are key to reducing contamination.[23] Ultimately, prioritizing these preventive measures can safeguard both healthcare personnel and vulnerable patient populations, ensuring safer healthcare environments.
Ethics approval
Obtained from the Regional Occupational Health Centre (Southern), IEC/IRB No: BR/IRB/06.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
The investigators would like to acknowledge the support given by the Director and staff of ICMR-National Institute of Occupational Health, Regional Occupational Health Centre, and Bangalore Medical College and Research Institute for this study. We also extend our sincere appreciation to the healthcare workers for their time and effort, especially given the demanding nature of their work.
Funding Statement
This research was funded by the ICMR- National Institute of Occupational Health, Ahmedabad, Gujarat, India, under intramural research projects.
REFERENCES
- 1.Keri VC, Kumar A, Singh G, Mandal A, Ali H, Ranjan P, et al. Pilot study on burden of fungal contamination in face masks: Need for better mask hygiene in the COVID-19 era. Infez Med. 2021;29:557–61. doi: 10.53854/liim-2904-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ong JJY, Chan ACY, Bharatendu C, Teoh HL, Chan YC, Sharma VK, et al. Headache Related to PPE Use during the COVID-19 Pandemic. Curr Pain Headache Rep. 2021;25:53. doi: 10.1007/s11916-021-00968-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Chen YJ, Qin G, Chen J, Xu JL, Feng DY, Wu XY, et al. Comparison of face-touching behaviours before and during the Coronavirus Disease 2019 pandemic. JAMA Netw Open. 2020;3:1–10. doi: 10.1001/jamanetworkopen.2020.16924. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Delanghe L, Cauwenberghs E, Spacova I, De Boeck I, Van Beeck W, Pepermans K, et al. Cotton and Surgical Face Masks in Community Settings: Bacterial Contamination and Face Mask Hygiene. Front Med (Lausanne) 2021;8:732047. doi: 10.3389/fmed.2021.732047. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.World Health Organisation. Rational use of personal protective equipment for COVID-19 and considerations during severe shortages: Interim guidance, 23 December 2020a. Available from: https://www.who.int/publications/i/item/rational-use-of-personal-protective-equipment-for-coronavirus-disease-(covid-19)-and-considerations-during-severe-shortages .
- 6.WHO. WHO recommendations on mask use by health workers, in light of the Omicron variant of concern. World Health Organisation. December 2021. doi: 10.1101/2021.05.30.21258080. [Google Scholar]
- 7.Guan X, Lin J, Han J, Gao X, Zhang Y, Hu B, et al. Prolonged use of surgical masks and respirators affects the protection and comfort for healthcare workers. Materials (Basel) 2022;15:7918. doi: 10.3390/ma15227918. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Merad Y, Belmokhtar Z, Hadjazi O, Belkacemi M, Matmour D, Merad Z, et al. Fungal contamination of medical masks among forensic healthcare workers in the COVID-19 era. New Microbes New Infect. 2023;53:101134. doi: 10.1016/j.nmni.2023.101134. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Marson BA, Craxford S, Valdes AM, Ollivere BJ, Ollivere BJ. Are facemasks a priority for all staff in theatre to prevent surgical site infections during shortages of supply? A systematic review and meta-analysis. Surgeon. 2021;19:e132–9. doi: 10.1016/j.surge.2020.08.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Kangabam N, Nethravathy V. An overview of opportunistic fungal infections associated with COVID-19. 3 Biotech. 2023;13:231. doi: 10.1007/s13205-023-03648-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Mei-Sheng Riley M. Invasive fungal infections among immunocompromised patients in critical care settings: Infection prevention risk mitigation. Crit Care Nurs Clin North Am. 2021;33:395–405. doi: 10.1016/j.cnc.2021.07.002. [DOI] [PubMed] [Google Scholar]
- 12.Baxi SN, Portnoy JM, Larenas-Linnermann D, Phipatanakul W Environmental Allergens Workgroup. Exposure and health effects of fungi on humans. J Allergy Clin Immunol Pract. 2016;4:396–404. doi: 10.1016/j.jaip.2016.01.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Durga CS, Gupta N, Soneja M, Bhatt M, Xess I, Jorwal P, et al. Invasive fungal infections in critically ill patients: A prospective study from a tertiary care hospital in India. Drug Discov Ther. 2018;2:363–7. doi: 10.5582/ddt.2018.01068. [DOI] [PubMed] [Google Scholar]
- 14.World Health Organisation. Mask use in the context of COVID-19. World Health Organisation. December 2020. Available from: https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak .
- 15.Luksamijarulkul P, Aiempradit N, Vatanasomboon P. Microbial contamination on used surgical masks among hospital personnel and microbial air quality in their working wards: A hospital in Bangkok. Oman Med J. 2014;29:346–50. doi: 10.5001/omj.2014.92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Napoli C, Marcotrigiano V, Montagna MT. Air sampling procedures to evaluate microbial contamination: A comparison between active and passive methods in operating theatres. BMC Public Health. 2012;12:1. doi: 10.1186/1471-2458-12-594. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Keri VC, Kumar A, Singh G, Xess I, Khan MA, Rastogi N, et al. Fungal carriage on healthcare workers' hands, clothing, stethoscopes, and electronic devices during routine patient care: A study from a tertiary care centre. J Prev Med Hyg. 2021;62:E170–3. doi: 10.15167/2421-4248/jpmh2021.62.1.1645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Brunetti L, De Caro F, Boccia G, Cavallo P, Capunzo M. Surveillance of nosocomial infections: A preliminary study on yeast carriage on hands of healthcare workers. J Prev Med Hyg. 2008;49:63–8. [PubMed] [Google Scholar]
- 19.Park AM, Khadka S, Sato F, Omura S, Fujita M, Hashiwaki K, et al. Bacterial and fungal isolation from face masks under the COVID-19 pandemic. Sci Rep. 2022;12:1–11. doi: 10.1038/s41598-022-15409-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Toomey EC, Conway Y, Burton C, Smith S, Smalle M, Chan XS, et al. Extended use or reuse of single-use surgical masks and filtering face-piece respirators during the coronavirus disease 2019 (COVID-19) pandemic: A rapid systematic review. Infect Control Hosp Epidemiol. 2021;42:75–83. doi: 10.1017/ice.2020.1243. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Jy Ong J, Cy Chan A, Sharma AK, Sharma S, Sharma VK. The mucormycosis epidemic within the COVID-19 pandemic- lessons from India. Brain Behav Immun. 2021;97:4–5. doi: 10.1016/j.bbi.2021.08.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Obasi C, Agwu A, Akinpelu W, Hammons R, Clark C, Etienne-cummings R, et al. Contamination of equipment in emergency settings: An exploratory study with a targeted automated intervention. Ann Surg Innov Res. 2009;3:1–9. doi: 10.1186/1750-1164-3-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Varghese AD, Mathew G, Kumar SC, Benjamin AI. Awareness regarding Nipah infection among health-care workers in a Medical College Hospital in Kerala. J Curr Res Sci Med. 2019;5:33–8. [Google Scholar]