COVID19 is still in the air and we need to ex­pand our knowl­edge as much as we can. Global in­for­ma­tion and an­a­lyt­ics com­pany which en­ables in­sti­tu­tions and pro­fes­sion­als to ad­vance health care and pro­vide an open plat­form for the ben­e­fit of hu­man­ity has been pro­vid­ing rel­e­vant and per­ti­nent in­for­ma­tion since Jan­u­ary 2020 on its on­line re­source cen­tre on El­se­vier Con­nect, re­lat­ing to novel coro­n­avirus COVID19. As the ma­te­r­ial is in the pub­lic do­main, The World Sikh News pre­sents the re­port of a study on the “in­no­v­a­tive so­lu­tion us­ing an un­der-mask beard cover called Singh Thattha Tech­nique for over­com­ing the beard fac­tor to en­able bearded in­di­vid­u­als to wear a res­pi­ra­tor mask.”

THE UN­DER-MASK BEARD COVER (SINGH THATTHA TECH­NIQUE) for don­ning res­pi­ra­tor masks in COVID-19 pa­tient care study has been car­ried out by R. Singh, H.S. Safri, S. Singh, B.S. Ubhi, G. Singh, G.S. Alag , G. Rand­hawa, S. Gill, in as­so­ci­a­tion with Sikh Doc­tors & Den­tists As­so­ci­a­tion, UK, Sikh Doc­tors As­so­ci­a­tion, UK, British Sikh Den­tal As­so­ci­a­tion, UK, British Sikh Doc­tors Or­gan­i­sa­tion, UK, Uni­ver­sity of Bed­ford­shire, Bed­ford, UK.

In­tro­duc­tion

Tight-fit­ting res­pi­ra­tor face masks such as N95 or fil­ter­ing face­piece (FFP3) masks are con­sid­ered to be the ref­er­ence stan­dard res­pi­ra­tory pro­tec­tive equip­ment (RPE) for health­care work­ers (HCWs) work­ing in aerosol-gen­er­at­ing pro­ce­dure (AGP) en­vi­ron­ments in­volv­ing coro­n­avirus dis­ease 2019 (COVID-19) [1].

Op­ti­mal use of face masks de­pends on their tight seal with the wear­er’s skin, as­sessed via RPE fit test­ing. Prior to work­ing in AGP en­vi­ron­ments, HCWs must un­dergo and pass the manda­tory RPE fit test, which is con­ducted ei­ther as a qual­i­ta­tive fit test (QFT) or as a quan­ti­ta­tive fit test (QNFT). QFT is based on sub­jec­tive as­sess­ment of face mask seal com­pe­tency by de­tec­tion of a test agent, usu­ally sensed as a bit­ter or sweet taste, or smell by the wearer. QNFT gives an ob­jec­tive mea­sure of face fit, by pro­vid­ing a nu­mer­i­cal mea­sure of the seal com­pe­tency.

Fit test is con­ducted by a cer­ti­fied fit tester, and pass­ing it de­pends on type of res­pi­ra­tor mask tested. In the event of short­age of suc­cess­fully fit-tested face masks, HCWs must un­dergo re­peat fit test­ing with other types of avail­able face masks.

Ev­i­dence sug­gests that fa­cial hair re­duces tight-fit­ting res­pi­ra­tor face mask ef­fi­cacy with wors­en­ing pro­tec­tion with longer fa­cial hair [2]. Con­ven­tional fit test­ing in the pres­ence of fa­cial hair has been shown to have a high test-fail­ure rate [3,4]. Hence, in line with the avail­able ev­i­dence, face mask man­u­fac­tur­ers’ guid­ance for fit test­ing rec­om­mends that wear­ers are clean-shaven to en­able a good seal of FFP3 mask over their face cov­er­ing the nose and the mouth.

This pi­lot study opens up pos­si­bil­i­ties for bearded HCWs look­ing to safely wear a tight-fit­ting res­pi­ra­tor mask for whom shav­ing may not be a vi­able op­tion.

In­di­vid­u­als un­able to shave due to per­sonal or re­li­gious rea­sons are rec­om­mended to use al­ter­na­tives such as pow­ered air-pu­ri­fy­ing res­pi­ra­tors (PA­PRs) [2]. How­ever, these al­ter­na­tives are ex­pen­sive, lim­ited in sup­ply, and cum­ber­some to use [5]. They do not al­low for fit­ting of sur­gi­cal loupes. Den­tists are un­able to per­form all the pro­ce­dures in their reper­toire. Re­de­ploy­ment to non-AGP ar­eas in­curs a loss of their skill-sets and need for re­train­ing. Ju­nior doc­tors have their train­ing im­pacted with con­cerns for in­ad­e­quate and pro­longed train­ing.

There­fore, this op­tion of an al­ter­na­tive PPE may not be ideal for some in­di­vid­u­als af­fected by the above-men­tioned fac­tors. There is no ev­i­dence in the lit­er­a­ture to sug­gest why, in­stead of shav­ing, the fa­cial hair fac­tor can­not be over­come with an un­der-mask beard cover. The pur­pose of this study is to in­ves­ti­gate an in­no­v­a­tive po­ten­tial so­lu­tion called Singh Thattha tech­nique, where an un­der-mask beard cover is used to over­come the fa­cial hair fac­tor for wear­ing a res­pi­ra­tor mask by bearded in­di­vid­u­als.

Meth­ods

The tech­nique of ap­ply­ing the un­der-mask beard cover to cover the beard over the chin and cheeks and tie the knot at the top of the head is called ‘Singh Thattha’ tech­nique, and pi­o­neered by a trans­plant sur­geon in Man­ches­ter. Thattha is the col­lo­quial term used for the beard cover, and the ma­te­r­ial used for the first case was fab­ric made of poly­ester-cot­ton blend.

Us­ing this method the can­di­date ‘passed’ the Bi­trex QFT Qual­i­ta­tive Fit Test (Mac­far­lan Smith, Ed­in­burgh, UK) in one at­tempt wear­ing a 3M 8833 FFP3 mask. It was men­tioned that the ‘pass’ was with a beard us­ing a beard cover. The ma­te­r­ial was sub­se­quently switched to a flat elas­tic rub­ber sheet (Pi­lates & Yoga Elas­tic band) for a bet­ter seal by the au­thor (Fig­ure 1a). The knot on top of the head could be ei­ther over the tur­ban (Fig­ure 1b) or over the in­ner head cloth (Fig­ure 1c), de­pend­ing on which gave the best fit with the FFP3 mask. We are re­port­ing the out­comes of the Singh Thattha tech­nique tested by QFT and QNFT.

Qual­i­ta­tive fit test
Singh Thattha tech­nique was adopted by 27 male, bearded, Sikh den­tists in the UK who sub­jected them­selves to Bi­trex QFT con­ducted by cer­ti­fied fit testers to ex­ist­ing in­dus­try stan­dards set by the British Safety In­dus­try Fed­er­a­tion. Data was col­lected by the British Sikh Den­tists As­so­ci­a­tion and sub­mit­ted to us for analy­sis.

Quan­ti­ta­tive fit test
The tech­nique was fur­ther sub­jected to ro­bust re­view with a re­puted fit tester through a QNFT ses­sion in Shrews­bury, UK. The QNFT method used was ‘Am­bi­ent Par­ti­cle Count­ing’ us­ing Ac­cu­FIT9000 S/​N; Pro­to­col: INDG 479; Pass Level: 100. In­formed con­sent was ob­tained, and no par­tic­i­pant was al­ler­gic to ma­te­ri­als used. Par­tic­i­pants in­cluded five male can­di­dates from the bearded Sikh com­mu­nity.

Re­sults
The re­sults are sum­ma­rized in Table I.

Out­comes of qual­i­ta­tive fit test
The Singh Thattha tech­nique was used by 27 male bearded den­tists, and the QFT pass rate was 25/​27 (92.6%). Sta­tis­ti­cal analy­sis com­par­ing the masks showed that the test pass was sig­nif­i­cantly greater us­ing the stealth half-mask (14/​14), JSP Force 8 P3 (8/​8), GSV half mask P3 (2/​2) as com­pared to the 3M Half Mask P3 (1/​3) (P < 0.01, Fish­er’s ex­act test).

Out­comes of the quan­ti­ta­tive fit test
All five male can­di­dates passed QNFT us­ing the Singh Thattha tech­nique. The first three can­di­dates passed us­ing 3M 8833 masks, with the knot of the un­der-mask Thattha tied on the top of the head cov­ered by a cloth (Fig­ures 1c, 2c). One of these can­di­dates also passed us­ing a 3M 1863 mask with an ad­he­sive dual mural tape (DMT) in its up­per in­ner lin­ing, with the knot of the un­der-mask Thattha tied di­rectly over the tur­ban. The other two male can­di­dates used FFP3 Stealth Half Masks and passed the QNFT with the un­der-mask Thattha tied di­rectly over their tur­ban (Fig­ure 2b). Small num­bers pre­cluded a sta­tis­ti­cal analy­sis. 

Dis­cus­sion

The COVID-19 pan­demic caused by the novel coro­n­avirus known as se­vere acute res­pi­ra­tory syn­drome coro­n­avirus 2 (SARS-CoV-2) has re­sulted in a sig­nif­i­cant loss of lives and im­pacted re­source uti­liza­tion [1]. In their front­line du­ties, HCWs have suf­fered sig­nif­i­cant mor­tal­ity. Health­care providers have come un­der in­tense scrutiny to en­sure that ad­e­quate and ap­pro­pri­ate per­sonal pro­tec­tive equip­ment (PPE) is pro­vided for front­line work­ers.

The Singh Thattha tech­nique to wear an FFP3 mask was pi­o­neered in Man­ches­ter and was adopted and tested by a large num­ber of bearded British Sikh den­tists (25/​27) who passed the QFT us­ing cer­ti­fied fit testers. The tech­nique was fur­ther tested us­ing ro­bust QNFT in a pi­lot study and all (5/​5) fully bearded men passed the fit test.

Tight-fit­ting res­pi­ra­tor masks, which de­pend on a seal of the mask with the wear­er’s face, are con­sid­ered the best pro­tec­tive RPE for HCWs work­ing in AGP en­vi­ron­ments in­volv­ing COVID-19. How­ever, these are not suit­able for bearded in­di­vid­u­als as ev­i­dence has shown that beards will not al­low for an op­ti­mal maske­face seal. There­fore, bearded in­di­vid­u­als who are un­able to shave due to per­sonal rea­sons have to rely on al­ter­na­tive RPE such as ex­pen­sive and cum­ber­some PA­PRs, which may not be ide­ally suited for the work or train­ing of some of these in­di­vid­u­als e no­tably den­tists and sur­geons.

We are of­fer­ing an in­no­v­a­tive so­lu­tion us­ing an un­der-mask beard cover called Singh Thattha tech­nique for over­com­ing the beard fac­tor to en­able bearded in­di­vid­u­als to wear a res­pi­ra­tor mask.

The Singh Thattha tech­nique to wear an FFP3 mask was pi­o­neered in Man­ches­ter and was adopted and tested by a large num­ber of bearded British Sikh den­tists (25/​27) who passed the QFT us­ing cer­ti­fied fit testers. The tech­nique was fur­ther tested us­ing ro­bust QNFT in a pi­lot study and all (5/​5) fully bearded men passed the fit test.

The rel­a­tively stur­dier masks such as 3M 8833, Stealth Half Mask P3, JSP Force 8 P3, and GSV El­lipse Half Mask P3 were best-suited to achieve a com­pe­tent seal us­ing the Singh Thattha tech­nique.

The beard-cover used (Pi­lates & Yoga Elas­tic band) is rub­ber ma­te­r­ial. Dur­ing the fit test the dif­fer­ent ex­er­cises used test that the sil­i­cone mask does not slip over the skin. In fact, the re­sis­tance of the rub­ber and sil­i­cone ac­tu­ally im­proved the fit in these ex­er­cises with the beard cover.

Whilst a lim­i­ta­tion of this study re­mains small num­bers of in­di­vid­u­als tested us­ing the un­der-beard cover tech­nique, it pro­vides en­cour­ag­ing re­sults to pave the way for larger scale stud­ies. The au­thors plan to con­duct a fol­low-up study with the Singh Thattha tech­nique in­volv­ing larger num­bers of bearded in­di­vid­u­als given that the pre­lim­i­nary re­ports are quite en­cour­ag­ing.

Fa­cial skin may sweat, but the Thattha ma­te­r­ial does not and is of an added ad­van­tage. Whereas other de­ter­mi­nants of face-fit, such as face ar­chi­tec­ture and mask shapes, may be ir­re­versible fac­tors gov­ern­ing the out­come of the fit test, the beard fac­tor could be over­come by an un­der-mask beard cover.

This pi­lot study opens up pos­si­bil­i­ties for bearded HCWs look­ing to safely wear a tight-fit­ting res­pi­ra­tor mask for whom shav­ing may not be a vi­able op­tion. In ad­di­tional to cost-sav­ing im­pli­ca­tions for health­care providers, this so­lu­tion min­i­mizes po­ten­tial risk of re­de­ploy­ment of some af­fected in­di­vid­u­als who ei­ther have no ac­cess to al­ter­na­tive PPE, or if the avail­able PPE are not con­ducive to per­form­ing for their spe­cific job roles. Whilst a lim­i­ta­tion of this study re­mains small num­bers of in­di­vid­u­als tested us­ing the un­der-beard cover tech­nique, it pro­vides en­cour­ag­ing re­sults to pave the way for larger scale stud­ies. The au­thors plan to con­duct a fol­low-up study with the Singh Thattha tech­nique in­volv­ing larger num­bers of bearded in­di­vid­u­als given that the pre­lim­i­nary re­ports are quite en­cour­ag­ing.

To sum­ma­rize, the fi­nal ar­biter of face-mask fit is a fit test-not the dif­fer­ence in the nu­ances of the chem­istry be­tween the ‘mask with face’ ver­sus the ‘mask with beard cov­er’. Fa­cial hair, al­beit an ac­cepted risk fac­tor for face-mask leak­age, can be over­come by us­ing an un­der-mask beard cover.

Ac­knowl­edge­ments
British Sikh Den­tists As­so­ci­a­tion.

Con­flict of in­ter­est state­ment Three of the au­thors were par­tic­i­pants in the study. One of the au­thors is Pres­i­dent of the Sikh Doc­tors and Den­tists As­so­ci­a­tion which funded the study, but he has no fi­nan­cial in­ter­est to de­clare.

Fund­ing sources
Sikh Doc­tors & Den­tists As­so­ci­a­tion (UK).

Ref­er­ences
[1] Pub­lic Health Eng­land. Guid­ance. Covid-19 per­sonal pro­tec­tive equip­ment (PPE). Avail­able at:
https://​www.gov.uk/​gov­ern­ment/​pub­li­ca­tions/​wuhan-novel-coro­n­avirus-in­fec­tion-pre­ven­tion-and­con­trol/​covid-19-per­sonal-pro­tec­tive-equip­ment-ppe [last ac­cessed Sep­tem­ber 2020].

[2] Health and Safety Ex­ec­u­tive. The ef­fect of wearer stub­ble on the pro­tec­tion given by Fil­ter­ing Face­pieces Class 3 (FFO3) and Half Masks. HSE; 2015. https://​www.hse.gov.uk/​re­search/​rrpdf/​rr1052.pdf [last ac­cessed Sep­tem­ber 2020].

[3] San­daradura I, Goe­man E, Pon­ti­vivo G, Fine E, Gray H, Kerr S, et al. A close shave? Per­for­mance of P2/​N95 res­pi­ra­tors in health­care work­ers with fa­cial hair: re­sults of the BEARDS (BEnch­mark­ing Ad­e­quate Res­pi­ra­tory De­fenceS) study. J Hosp In­fect 2020;104:529e33. https://​doi.org/​10.1016/​j.jhin.2020.01.006.

[4] 3M Pol­icy Doc­u­ment. Fa­cial hair & res­pi­ra­tor fit test­ing pol­icy. Avail­able at: https://​mul­ti­me­dia.3m.com/​mws/​me­dia/​1682579O/​fa­cial-hair-and-res­pi­ra­tor-fit-test­ing-pol­icy-tech­ni­cal-bul­letin.pdf [last ac­cessed Sep­tem­ber 2020].

[5] Trivedy C, Mills I, Dhanoya O. The im­pact of the risk of COVID-19 on Black, Asian and Mi­nor­ity Eth­nic (BAME) mem­bers of the UK den­tal pro­fes­sion. Br Dent J 2020;228:919e22.