Journal of Academia and Industrial Research (JAIR)

Volume 2, Issue 6 November 2013 320

ISSN: 2278-5213

REVIEW ARTICLE

Surgical Face Masks: Manufacturing Methods and Classification

K.P. Chellamani*, D. Veerasubramanian and R.S. Vignesh Balaji

The South India Textile Research Association, Coimbatore, TN, India
spg@sitra.org.in, kpc@sitra.org.in*; 0422-4215347
______________________________________________________________________________________________
Abstract
A surgical face mask is also known as a procedure mask and purposely to be worn by health care
professionals during operation procedures. It helps to catch the bacteria shed in liquid droplets and aerosols
from the wearer's mouth and nose. Normal activities such as sneezing, coughing, breathing and speaking
may release oral, dermal and nasopharyngeal bacteria that may cause post-operative infections.
Microorganisms have varying characteristics that can influence their potential ability to penetrate the
facemask material including shape, size and their surface characteristics. Some studies reported that variety
of pathogens are encountered in the hospital environment, a relatively limited number of hospital infections
including Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis, Candida albicans and
Staphylococcus aureus. Some studies reported that the rod shaped bacteria penetrate less than spherically
shaped bacteria of similar size. This review focuses on surgical face masks and their classification based on
the performance like filtration efficiency, pressure difference, splash resistance etc. Further, the quality
evaluation of surgical face masks and standards for manufacturing surgical face masks has also been
reviewed.
Keywords: Surgical face mask, operation procedures, hospital infections, pathogens, filtration efficiency.

Introduction Hamilton also found that mouth is a source of

Healthcare workers involved in treating and caring for streptococcal bacteria which causes the communicable
individuals injured or sick as well as the patient can be diseases and recommended that physicians should wear
exposed to biological aerosols capable of transmitting a specially constructed mouth guard. In 1918, weaver
diseases. These diseases, which may be caused by a published the results of his study on the surgical face
variety of microorganisms, can pose significant risks to masks which play a main role to spread of diphtheria,
life and health (Chellamani and Thiruppathi, 2009). meningitis, pneumonia and so on. He introduced the
Surgical face masks are used to cover the mouth and practice to cover the nose and mouth when caring the
nose by doctors and other healthcare workers. It reduces patients (Hamilton, 1915).
the risk of contaminations from secretion of the mouth
and nose in operation room or clinics. It is purposely to Doust and lyon (1918) observed the role of surgical face
be worn by health care professionals during surgery and masks is to prevent the respiratory tract based infections.
at same time to catch the bacteria shed in liquid droplets They also found that the surgical face masks with two
and aerosols from the wearer’s mouth and nose layers provide the better protection to the wearer as
(Hayavadana and Vanitha, 2009). Surgical face masks compared to the single layer face masks. They also
were originally developed to contain and filter droplets found that speaking with a surgical face masks in an
containing microorganisms that are liberation from the ordinary conversation for 5 min release relatively few
mouth and nasopharynx of healthcare workers during bacteria from the mouth to a distance of only 1 to
surgery, thereby providing protection for the patient. 2 ft. In case of without surgical face masks, for 5 min, the
However, there are several ways in which surgical face liberation of bacteria from the mouth is quite high. And
masks contaminate the surgical wound. For example, the liberated bacteria are found even to as distance more
due to poor tying of surgical face masks and incorrectly than 3 ft (Belkin, 2009). Surgical face masks not only
worn surgical face masks causes leaking of air from the provide a barrier for airborne organisms, it also protects
side of the surgical face mask (Hofmeyr et al., 2008). In the wearer against splashing of blood and other body
1897, Mikulicz, a German physician, published the first fluids (Woodhead et al., 2002).
study which supports the need for wearing a surgical
face masks. In 1906, Hamilton found that the Manufacturing methods
transmission of Infectious diseases and the importance The surgical face mask is produced using fabric forming
of droplets of sputum in the dissemination of tuberculosis technology as shown in Fig. 1. They are a. Woven,
infection. b. Non-woven and c. Knitted.

©Youth Education and Research Trust (YERT) jairjp.com Chellamani et al., 2013
Journal of Academia and Industrial Research (JAIR)
Volume 2, Issue 6 November 2013 321

Fig. 1. Different fabric forming technology. The typical material used to manufacture surgical face
masks are polypropylene with 20 gsm made using
spunbond technology and 25 gsm polypropylene
non-woven sheet made using meltblown technology.
The surgical face masks are made in different sizes like
17.5 X 9.5 cm for adult, 14.5 X 9.5 cm for child use and
12 X 7 cm for infants. They are available in different color
like white, blue, green, yellow and pink (Hayavadana and
vanitha, 2009). Over the past decade, there has been a
tremendous increase in the demand for polymeric
nanofibres which are used in various applications
including tissue engineering, protective clothing, filtration
and sensors (Nayak et al., 2012). The nanofibers have a
very large surface area to volume ratio, which makes
a. Plain weave (Anon, 2010).
them suitable to manufacture filtration products and
particularly for medical textile products such as surgical
facemasks, wound dressings, drug delivery systems etc.
(Jayaraman et al., 2004).

Fibres used to manufacture surgical face masks

More effective surgical face masks which provides 85%
or even 99% protection is required to prevent the spread
of transmission diseases. The high degree of filtration
efficiency is attained with a very fine filter layer of textile
fibres covered on both sides with conventional
non-woven bonded fabrics. The thickness of fibre is from
<1 to 10 µm. Polypropylene, polystryrene, polycarbonate,
polyethylene, polyester etc. are suitable for
manufacturing surgical face masks. Apart from fibre
selection, the filtration efficiency of surgical face masks
depends on the method of manufacture, the structure of
b. Non-woven (diytrade, 2013). web, the cross-sectional shape of the fibre and its
change (McCarthy, 2011). The suitable polymers are
converted as a non-woven sheet using spunbond
technology or electrostatically produced web from
solvents. The methods of electrostatically produced web
have uniform web density giving a high degree of
filtration efficiency and less web weight (Luneneschloss
and Albrecht, 1985).

Benefits of non-woven based surgical face masks

Non-woven based surgical face masks are disposable.
It is generally made up of three or four layers, often with
two filters that filter the material, 1 µ in size. Hence, it
traps bacteria of that size or larger. Face masks of this
type can provide protection against bacteria for a
minimum of 4 h (Lipp and Edwards, 2002). Advantages
c. Knitted (stellas, 2013). of non-woven fabrics over woven fabric in filtration are
higher air permeability, higher bacterial filtration
efficiency, no yarn slippage and low manufacturing cost
Even though, there are three fabrics forming technology, (Kothari, 2008). The non-woven technology guarantees
nowadays, most of the surgical face masks are made up better barrier properties than cotton, polyester or even
of non-woven with a view of disposing after use. more advanced woven products. Besides, disposable
Non-woven fabric forming technology is cheaper than non-wovens (surgical face masks, gowns, drape etc.) are
other fabric forming technology like woven or knitted. sterilized, packaged, opened, used and then disposed.
Most of the surgical face mask manufacturers produce Hence, there is a less risk of contamination after using of
the surgical face mask using SMS (Spunbond Meltblown disposable non-wovens than reusable products either
Spunbond) technology. woven or knitted.

©Youth Education and Research Trust (YERT) jairjp.com Chellamani et al., 2013
Journal of Academia and Industrial Research (JAIR)
Volume 2, Issue 6 November 2013 322

Table 1. Comparison between disposable and reusable textiles used in healthcare applications.
Reusable
Properties Disposable non-woven
Traditional textiles Micro-porous textiles
Mechanical resistance • •• •••
Linting (reduction of particle emission) ••• • ••
Resistance to bacterial penetration ••• • ••
Resistance to liquid penetration ••• • ••
Flexibility ••• • ••
Drapeability •• ••• •••
Comfort •• ••• •••
• Minimum to •••Best adopted.

Table 2. Classification of medical face masks based on its barrier properties.

Surgical face masks
Quality evaluation characteristics
Low barrier Moderate barrier High barrier
Bacterial filtration efficiency (%) ≥95 ≥98 ≥98
2
Differential pressure (mm H2O/cm ) ˂4.0 ˂5.0 ˂5.0
Sub-micron particulate filtration efficiency (%) Not required ≥98 ≥98
Resistance to penetration by synthetic blood
80 120 160
(minimum pressure in mm Hg for pass result)
Flame spread Class 1 Class 1 Class 1

In case of reusable non-woven, that should be Bacterial filtration efficiency in vitro (BFE): This test
decontaminated, washed, sterilized for every reuse. method is designed for measuring bacterial filtration
Table 1 shows that the superiority of disposable efficiency of surgical face masks using Staphylococcus
non-woven over other reusable products in terms of aureus as the challenge organism. Staphylococcus
barrier properties (Najjar et al., 2009). Disposable aureus is based on its clinical relevance as a leading
surgical face masks are often perceived to have cause of nosocomial infections. A bacterial challenge
protective advantages over reusable surgical face aerosol is passed through the test specimen either face
masks; they must be immediately discarded as side or inner side at a flow rate of 28.3 L/min, allowing
bio-hazardous materials. In contrast, reusable surgical evaluation of filtration efficiencies related to both patient
face masks can be sterilized and laundered for reuse, generated aerosols and wearer generated aerosols.
with a lifetime more than 50 cycles. However, reusable The mean particle size of the bacterial aerosol used in
surgical face masks may be prescribed as less protective this test is maintained at 3.0±0.3 µm as per relevant
and more time-consuming for production as well as ASTM specifications. A higher bacterial filtration
washing and sterilization for reuse. The repeated efficiency percentage indicates the better protection level
laundering of reusable surgical face masks may for the patient and healthcare professionals against
consume more energy and generate more waste water transmission diseases from the source of patient as well
to the environment (McCarthy, 2011). as healthcare professionals. Classifications of surgical
face masks as per BFE in European standard EN 14683
Classification of surgical face masks is as follows:
As per international standard ASTM F 2100–07, surgical  BFE ≥ 95% indicates the Type-I surgical face masks
face masks are generally classified in to 3 types. They  BFE ≥ 98% indicates the Type-II surgical face masks.
are i) Low barrier, ii) Moderate barrier and iii) High
barrier. The basic characteristics to distinguish the Breathing resistance (ΔP): Breathing resistance is used
surgical face masks based on its barrier properties are to determine the resistance of airflow through the
listed in Table 2 (ASTM F 2100, 2007). facemask. The surgical face mask is subjected to
controlled flow of air. The difference in airflow pressure of
Quality evaluation: European standards and ASTM inlet and outlet of the sample is measured.
standards provides the standardize quality evaluation The difference in pressure is divided by the surface area
procedure for surgical face masks to prevent (in cm2) of the sample. A lower in breathing resistance
transmission diseases from health care professionals to indicates a better comfort level to the end user (patient
patients and in certain situations vice-versa. Also provide and healthcare professionals). It means that breathing is
the critical requirements before marketing the surgical easier through the surgical face mask by wearer.
face masks (EN 14683, 2005). There are five test During breathing, the surgical face mask will maintain its
methods used to evaluate the performance of the shape in a better way.
surgical face masks.

©Youth Education and Research Trust (YERT) jairjp.com Chellamani et al., 2013
Journal of Academia and Industrial Research (JAIR)
Volume 2, Issue 6 November 2013 323

Classifications of surgical face masks based on  Consumer Product Safety Commission (CPSC) 16
breathing resistance are as follows: CFR 1610: Standard for flammability of clothing
 For Type-I and II surgical face masks, the breathing textiles.
resistance would be (non-splash resistant surgical  National Fire Production Agency (NFPA) Standard
face masks) ≤3.0 mm H2O/cm2. 702-1980: Standard for classification of flammability
 For Type-IR and IIR surgical face masks, the of wearing apparel.
breathing resistance would be (splash resistant  Underwriters Laboratory (UL) 2154: Fire test for
surgical face masks) ≤ 5.0 mm H2O/cm2. surgical fabric.
The increase in comfort of surgical face masks needs to The flame spread characteristics are classified in terms
have a low breathing resistance value per cm2. For that, of class 1 to class 4 for the above tests. For NFPA,
the available surface area of the facemask is increased class 1 indicates relatively slow burning where as CPSC
and thereby the total area available for ventilation is standards, class 1 indicates that minimum of 3.5 sec or
increased. more required to ignite and spreading of flame on the
specimen against the standard flame. In case of UL
Splash resistance (ASTM F1862-07): Splash resistance standards, test to measure the quantity of atmospheric
is used to determine the penetration resistance of oxygen required to propagate the flame while ignition is
surgical face masks under high velocity stream of caused by an electro surgery unit or laser unit. Higher
potentially contaminated fixed volume of fluid (splash of levels of oxygen required for flame propagation indicate
fluid) over a relatively short period of time. A specimen is that the materials are more flame resistant.
supported on an apparatus that allows viewing the back FDA recommends that class 1 and class 2 flammability
side of the specimen from behind. A fixed volume of materials are to be used to manufacture the surgical face
synthetic blood (stimulant fluid have equivalent liquid masks.
characteristics like surface tension of actual blood and
other body fluids), is aimed at the specimen and Conclusion
dispersed at a known velocity. It simulates the impact of Disposable surgical face masks are worn by both patient
blood or other body fluid onto the specimen. and healthcare professionals to reduce the frequency of
Any evidence of synthetic blood penetration on the back post-operative surgical wound infections. These
side of the medical face mask constitutes failure. infections result to increase the medical expenses.
Specimen medical face masks are evaluated at a total of Hence, the quality of the surgical face masks is essential
three different velocities corresponding to human blood and the same is determined by standard testing
pressures of 10.6, 16.0, and 21.3 kPa (80, 120 and procedure provide by internal standards like ASTM and
160 mm Hg). Test results are reported at each velocity European standards. Reusable surgical face masks can
and the medical face mask is rated at the highest be sterilized and laundered for reuse, with a lifetime
corresponding blood pressure. A higher splash more than 50 cycles. However, reusable surgical face
resistance means that the surgical face mask will protect masks have less filtration and protection efficiency as
the user in a better way against splashes of potentially compared to disposable one. As number of washing
contaminated fluid during a surgical procedure. cycle is increased the protection efficiency is decreased
Classifications of surgical face masks based on splash for reusable one. Also the repeated laundering of
resistance in European standard EN 14683 are as reusable surgical face masks may consume more energy
follows: and generate more waste water to the environment
 For Type-I and Type-II surgical face masks, this test
is not applicable. Acknowledgements
 For Type-IR and Type-IIR surgical face masks, the Authors are thankful to Dr. Prakash Vasudevan, Director,
specimen should be tested under the constant SITRA for his keen interest in this study.
velocity of 120 mm Hg.
References
Flammability (16 CFR 1610): There are many potential
1. Anon. 2010. The American heritage dictionary of the
ignition sources in the operating room, including surgical
English language, 4th edn. Published by Houghton Mifflin
lasers, electrosurgical units, endoscopic fiber optics and Harcourt publishing company. Retrieved October 15,
high-energy electro-medical devices. The materials used 2013, from http//images.yourdictionary.com/plain weave.
in operation theatre will burn if high intensity heat energy 2. ASTM F 2100. 2007. Standard specification for
is applied to them, especially in the presence of elevated performance of materials used in medical face masks,
oxygen levels. Hence, the flammability test for surgical USA. pp.390-392.
face masks is essential. The standards given below are 3. Belkin, N.L. 2009. The surgical mask has its first
used to determine the flammability by class for medical performance standarda century after it was introduced.
device like surgical face masks (Guidance for Industry Bull. Amer. College Surgeons. 94(12): 22-25.
and FDA staff, 2004).

©Youth Education and Research Trust (YERT) jairjp.com Chellamani et al., 2013
Journal of Academia and Industrial Research (JAIR)
Volume 2, Issue 6 November 2013 324

4. Chellamani, K.P. and Thiruppathi, S. 2009. Design and 13. Kothari, V.K. 2008. Progress in textiles: Science and
fabrication of a bacterial filtration efficiency tester. SITRA Technology Technical textiles: Technology,
Res. Report. 54(1):1-11. developments and applications. Vol. 3. IAFL
5. Diytrade. 2013. Diytrade fabric for sanitary products. Publications, India. pp.197-230.
Retrieved on October 17, 2013 from 14. Lipp, A. and Edwards, P. 2002. Disposable surgical face
http://diytrade.com/nonwovenfabricsanitaryprod.html. masks for preventing surgical wound infection in clean
6. Doust, B.C. and Lyon, A.B. 1918. Face masks in surgery. Cochrane Database of Systematic Reviews.
infections of the respiratory tract. J. Amer. Med. Assoc. Issue 1. Retrieved on October 17, 2013, from
Chicago. 911(15): 1216. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD0
7. EN 14683. 2005. Retrieved October 22, 2013 from 02929/pdf.
http://www.irema.com/site/wpcontent/themes/firebug/ima 15. Lunenschloss, J. and Albrecht, W. 1985. Non-woven
ges/EN_14683-2005.pdf. bonded fabric. Ellis horwood limited, UK. pp.396-397.
8. Guidance for Industry and FDA staff. 2004. Draft 16. McCarthy, B.J. 2011. Textiles for hygiene and infection
Guidance for Industry and FDA Reviewers on the control. Woodhead Publishing Ltd., UK. pp.125-135.
content and format of premarket notification [510(k)] 17. Najjar, M., Rjiba, A., Ameur, S.B. and Kammoun, O.
submissions for surgical mask. Retrieved October 23, 2009. Nonwoven disposable apparel for surgical use.
2013 from http://www.fda.gov and Guidance/ MBA thesis. Retrieved October 15, 2013, from
GuidanceDocuments/ucm072561.pdf. http://webmail.msb-online.org disposable_apparel.pdf.
9. Hamilton, C.D. 1915. The effect of typhoid vaccination 18. Nayak, R., Padhye, R., Kyratzis, I.L., Truong, Y.B. and
on the Widal reaction. J. Amer. Med. Assoc. Chicago. Arnold, L. 2012. Recent advances in nanofibre
95(22): 1873. fabrication techniques. Text. Res. J. 82(2): 129-147.
10. Hayavadana, J. and Vanitha, M. 2009. The world of 19. Stellas Knits handmade hand knit surgical style masks.
surgical textiles surgical mask. Asian Text. J. 18(12): 2013. Retrieved October 16, 2013, from http://www.etsy.
33-35. com/listing/67236750/handmade-handnit-surgical-style-
11. Hofmeyr, J., James, G., Neilson, P., Alfirevic, Z., mask.
Crowther, C.A., Duley, L., Gulmezoglu, M., Gyte, G.M.L. 20. Woodhead, K., Taylor, E.W., Bannister, G.C., Hoffman,
and Hodnett, E.D. 2008. A Cochrane pocketbook: P. and Humphreys, H. 2002. Behaviours and rituals in
Pregnancy and child birth. Wiley Cochrane series. John the operating theatre–A report from the hospital infection
Wiley and sons Ltd., England. pp.327-350. society working party on infection control in operating
12. Jayaraman, K., Kotaki, M., Zhang, M. and Ramakrishna, theatres. J. Hosp. Infect. 51(4): 241-255.
S. 2004. Recent advances in polymer nanofibers.
J. Nanosci. Nanotechnol. 4(1-2): 52-65.

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