Infectious Diseases

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/infd20

Effectiveness of surgical, KF94, and N95 respirator

masks in blocking SARS-CoV-2: a controlled
comparison in 7 patients

Min-Chul Kim, Seongman Bae, Ji Yeun Kim, Se Yoon Park, Joon Seo Lim, Minki
Sung & Sung-Han Kim

To cite this article: Min-Chul Kim, Seongman Bae, Ji Yeun Kim, Se Yoon Park, Joon Seo Lim,
Minki Sung & Sung-Han Kim (2020) Effectiveness of surgical, KF94, and N95 respirator masks in
blocking SARS-CoV-2: a controlled comparison in 7 patients, Infectious Diseases, 52:12, 908-912,
DOI: 10.1080/23744235.2020.1810858

To link to this article: https://doi.org/10.1080/23744235.2020.1810858

View supplementary material Published online: 26 Aug 2020.

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INFECTIOUS DISEASES, https://doi.org/10.1080/23744235.2020.1810858
2020; VOL. 52,
NO. 12, 908–912

BRIEF REPORT

Effectiveness of surgical, KF94, and N95 respirator

masks in blocking SARS-CoV-2: a controlled
comparison in 7 patients

Min-Chul Kima , Seongman Baeb , Ji Yeun Kimb, Se Yoon Parkc , Joon Seo Limd,
Minki Sunge and Sung-Han Kimb
a
Division of Infectious Diseases, Department of Internal Medicine, Chung-Ang University Hospital, Seoul, South Korea;
b
Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; cDivision
of Infectious Diseases, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University
College of Medicine, Seoul, South Korea; dClinical Research Center, Asan Institute for Life Sciences, Asan Medical Center,
University of Ulsan College of Medicine, Seoul, South Korea; eDepartment of Architectural Engineering, Sejong University, Seoul,
South Korea

ABSTRACT
Background: Data on the filtration efficacies of various masks against severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) are limited. We thus evaluate the effectiveness of the surgical mask, the N95 respirator mask, and its equiva-
lent (KF94 mask) in filtering SARS-CoV-2.

Methods: Patients hospitalised with SARS-CoV-2 infection were instructed to cough five times each while wearing (1) no
mask, (2) surgical mask, (3) KF94 mask, and (4) N95 mask. The coughs were separated by 20-second intervals, and the
patients were rested for at least 5 min between each setting. SARS-CoV-2 viral loads in patient samples (i.e. nasopharyngeal
swabs and saliva), petri dishes placed in front of the patients during coughing, and swabs from the outer and inner surfa-
ces of the masks were analysed with PCR.

Results: A total of 7 patients with SARS-CoV-2 infection participated in the mask test. SARS-CoV-2 was detected on the
petri dishes after coughing in 3 out of 7 cases with the surgical mask or no mask. Viral particles were not found in the
petri dishes after coughing while wearing the N95 mask or the KF94 mask. While viral particles were detected in both the
inner and outer surfaces of the surgical masks, those were detected only in the inner surfaces of the N95 and K94 masks.

Conclusion: Surgical masks were less effective in filtering viral particles from coughing patients with SARS-CoV-2 infection.
N95 masks and its equivalents efficiently blocked SARS-CoV-2 particles from coughing patients.

KEYWORDS ARTICLE HISTORY CONTACT

Surgical mask Received 17 July 2020 Sung-Han Kim
N95 respirator Revised 9 August 2020 kimsunghanmd@hotmail.com
coronavirus disease 2019 Accepted 11 August 2020 Department of Infectious Diseases, Asan
severe acute respiratory syndrome coronavirus 2 Medical Center, University of Ulsan College of
Medicine, 88, Olympic-ro 43-gil, Songpa-gu,
Seoul, 05505, South Korea

These authors equally contributed to the work.

Supplemental data for this article can be accessed here.
ß 2020 Society for Scandinavian Journal of Infectious Diseases

Introduction
Face masks serve dual roles in respiratory viral diseases
by preventing both the transmission and acquisition of
diseases [1], which is especially important in this current
pandemic spread of coronavirus disease 2019 (COVID-
19) [2]. Proper use of face masks among patients with
COVID-19 would be critically helpful in preventing con-
tamination of the surrounding air and environments
with particles of severe acute respiratory syndrome cor-
onavirus 2 (SARS-CoV-2). A previous study reported that
surgical masks and N95 masks were equally effective in
preventing the dissemination of influenza from patients
with acute influenza infection [1]. However, the filtration
efficacies of various masks against SARS-CoV-2 are
unknown. We thus evaluated the effectiveness of the
surgical mask, the N95 respirator mask, and its equiva-
lent (KF94 mask) in filtering SARS-CoV-2.
Methods
Study participants and design
Seven patients with varying degrees of COVID-19 in
three hospitals in Seoul, South Korea were invited to
participate in this study. All patients were admitted in
specially designed isolation rooms with negative pres-
sure, where all experiments were conducted. The
detailed clinical information are presented in the
Supplemental Material. Informed consent was obtained
from each patient, and the study protocol was approved
by the institutional review boards of each hospital.
We compared the (1) disposable surgical masks
(180 mm  90 mm, 3 layers [inner surface mixed with
polypropylene and polyethylene, polypropylene filter,
and polypropylene outer surface], pleated, bulk pack-
aged in cardboard; KM Dental Mask, KM Healthcare
Corp) with (2) K94 masks (Dr. PuriV KF [Korea Filter] 94-
R
fine dust, yellow dust mask, 165 mm  110 mm, 4 layers
of non-woven fabric, individually packaged in plastic;
KM Healthcare Corp) and (3) N95 respirators (3 MTM
Health Care Particulate Respirator 1860, bulk-packaged
in a paper box; 3 M Health CareTM).
Sample collection
The experiment was performed in negative pressure
rooms where the average air change rate was approxi-
mately 12 changes per hour. All masks were placed on
the face of the patients by infectious disease physicians
(M-C. K., S.Y.P., and S.B.) with expertise in environmental
INFECTIOUS DISEASES 909
sampling. A petri dish (90 mm  15 mm) containing
1 mL of viral transport media (sterile phosphate-buffered
saline [PBS] with 0.1% bovine serum albumin, 10,000 U/
mL penicillin, 10 mg streptomycin, 25 mg amphotericin-B)
were placed at approximately 20 cm from the patients’
mouths. The patients were instructed to cough a total
of 20 times in the following sequence (five times each):
(1) coughing without a mask, (2) coughing with surgical
mask, (3) coughing with KF94 mask, and (4) coughing
with N95 mask. There were 20-second intervals between
each cough, and patients were rested for at least
2–3 min before the next sequence. Dacron swabs pre-
moistened with viral transport media (3 mL) were used
to swab the outer and inner surfaces of the mask asep-
tically and sequentially.
Laboratory procedures
SARS-CoV-2 viral loads were quantified by real-time RT-
PCR assay targeting the S and the N gene. The detailed
methods are presented in Supplemental Materials. The
detection limits of which were 5 copies/reaction and 3
copies/reaction, respectively. The limit of detection
(LOD) for SARS-CoV-2 was 5 copies per reaction, which
was equivalent to 434.7 copies (2.63 log copies) per 1 ml
of the collected sample. When both the S and N genes
showed amplification peaks and Ct values, the viral copy
numbers were determined by plotting the Ct values
against the log copies/reaction. When only one of the
two genes showed amplification peaks or only one of
the duplicated samples showed amplification peaks, it
was considered as Not Detected. All experiments were
run in duplicates, and positive and negative controls
were included in each assay. The negative controls
showed flat amplification curves (no peak). All calculated
copy numbers – including those below the LOD – are
presented in Table 1. Details of laboratory procedures
are presented in Supplemental Materials.
Results
The results of the coughing test in four conditions – no
mask, surgical mask, KF94, N95 – are shown in Table 1.
Both KF94 and N95 effectively blocked the transmission of
SARS-CoV-2, as SARS-CoV-2 was detected on their inner
surfaces but not on the outer surfaces and the petri dishes
in front of the patients wearing those masks. Surgical
masks were notably less effective, as SARS-CoV-2 was often
detected in their inner and outer surfaces as well as the
petri dishes in front of the patients.
 910
M.-C. KIM ET AL.

Table 1. SARS-CoV-2 viral load in patient samples, petri dishes, and mask surfaces.
Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7
Patient (Hospital A) (Hospital A) (Hospital A) (Hospital B) (Hospital B) (Hospital C) (Hospital C)
Age, years 62 16 40 49 21 63 69
Sex Female Female Female Male Female Female Female
Clinical diagnosis Pneumonia Upper respiratory Upper respiratory Pneumonia Pneumonia Pneumonia Pneumonia
infection infection
Symptom onset before admission, days 2 2 0 10 5 6 7
Timing of the mask test, hospital days 13 8 5 6 4 6 2
Viral load, log copies/mL
Nasopharyngeal swab 3.67 3.18 6.95 3.38 5.79 3.66 3.07
Saliva 3.02 3.61 3.80 3.69 6.03 4.18 3.48
Petri dishb
Coughing without a maskc ND ND 3.00 <LOD (1.41)a 2.65 3.41 <LOD (2.25)a
Coughing with surgical maskc ND ND 2.68 ND <LOD (2.49)a 3.75 2.66
Coughing with KF94d maskc ND ND ND ND ND ND ND
Coughing with N95 respiratorc ND ND ND ND ND ND ND
Mask surfacee
Inner surface of surgical mask ND 3.05 2.70 2.63 ND <LOD (2.49)a ND
Outer surface of surgical mask ND 3.20 2.69 <LOD (2.53)a ND 2.69 2.86
Inner surface of KF94d mask 3.18 3.16 <LOD (2.44)a <LOD (1.92)a 2.71 <LOD (2.55)a ND
Outer surface of KF94d mask ND ND ND ND ND ND ND
Inner surface of N95 respirator ND 3.11 2.79 <LOD (2.48)a 2.73 ND ND
Outer surface of N95 respirator ND ND ND ND ND ND ND
ND: not detected; KF: Korea Filter; LOD: limit of detection.
a
These values were below the limit of detection (LOD) of SARS-CoV-2 PCR (2.63 log copies/ml). The LOD is a statistical measure of the lower limit of reliably reporting data (a 95% statistical certainty factor
for ‘detected’).
b
A petri dish (90 mm  15 mm) containing 1 mL of viral transport media were placed at approximately 20 cm from the patients’ mouths.
c
There were about 20-second intervals between each cough, and patients were rested for at least 2-3 min before the next sequence.
d
KF is the mark of approval for reliable prevention efficacy given by the Ministry of Food and Drug Safety in South Korea. KF94 can filter  94% of particles with an average size of 0.4 mm.
e
Dacron swabs premoistened with viral transport media (3 mL) were used to swab the outer and inner surfaces of the mask aseptically.

Discussion
Compared with surgical masks that seem to allow the
penetration of aerosols containing SARS-CoV-2, N95 res-
pirators and KF94 masks were able to filter out viral par-
ticles likely due to their denser fibre structure, larger
number of layers, different materials, and the band and
mask structure that allow tighter fits. Furthermore, the
reduced leakage of turbulent airflow due to the tighter
fit of N95-equivalent masks may also be responsible for
their effectiveness. Therefore, applying more efficient
masks in coughing patients with COVID-19 may further
reduce the surrounding environmental contamination in
situations in which the supply of such masks
is sufficient.
It is worthwhile to note that the numerical data pre-
sented here obtained from a small number of patients
do not entail statistical significance, and we do not
intend to suggest that surgical masks do not have any
role in quantitatively reducing the spread of SARS-CoV-2
from coughing patients. Although targeted studies on
SARS-CoV-2 are yet unavailable, previous empirical evi-
dence suggests that wearing any type of face masks
improve outward protection by shortening the distance
of aerosol contamination [3] and modifying the turbu-
lent jets in less harmful directions [4]. Furthermore, face
masks may also confer benefits in inward protection to
the wearer due to the aerodynamics of inhalation in
which the velocity of particles is reduced and the masks
adhere to the face by depressurisation (Supplemental
Figure 2). Thus, the relative ineffectiveness of surgical
masks compared with KF94 masks or N95 respirators in
preventing outward contamination in coughing patients
with COVID-19 does not argue against their potential
role in protecting healthy individuals from SARS-CoV-2.
Furthermore, a recent meta-analysis of four randomised
controlled trials showed that surgical masks were not
significantly different from N95 respirators in protecting
healthcare workers from laboratory-confirmed viral
respiratory infections, influenza-like illness, and clinical
respiratory illness [5]. Therefore, along with maintaining
sufficient hand hygiene, wearing any kind of face masks
in public settings is highly recommended [6]. In add-
ition, due to the concerns about the possibility of viral
transmission from asymptomatic or minimally symptom-
atic carriers, universal masking should be emphasised,
especially in hospital settings, in which may confer
health care workers’ safety as well as psychological well-
being by decreasing anxiety of acquiring the illness [7].
On the other hand, a false sense of protection due to
INFECTIOUS DISEASES 911
universal masking might result in increased face-touch-
ing behaviours [7]. So, appropriate education with bal-
anced policy-making is needed.
Various factors may have affected the viral load of
swab samples from the outer and inner surfaces of the
masks. Environmental sampling from hard surfaces such
as plastic or metal has been widely studied in respira-
tory viruses including MERS-CoV [8,9]. For sampling from
fabric materials, we assume that the surface wetness or
swab pressure may affect the PCR results. Elution of
punched layers of face masks may provide more valu-
able information about the surface contamination of the
masks. Further studies are needed on the viral contamin-
ation of mask surfaces. In addition, we could not provide
meaningful quantitative data for the masks to reduce
outspreading SARS-CoV-2 because most of the viral
loads were near the LOD due to the inclusion of COVID-
19 patients with relatively late stage of the disease. So,
further studies are needed by more sensitive test meth-
ods such as digital PCR with an earlier state of COVID-19
patients. Some may question the discrepancy of the
recent study showing the efficacy of surgical masks in
reducing human coronavirus detection and viral load
from 17 patients [10]. The difference between Leung’s
study and ours is the method of collecting coronavirus
particles from the patients. Leung’s study collected virus
particles by a closed system such as G-II bioaerosol-col-
lecting device which consists of a large cone connected
with a close duct. In contrast, we collected virus particles
of SARS-CoV-2 directly from coughing COVID-19 patients
with an open-air system in a negative pressure room.
Furthermore, the results of the efficacy of surgical masks
on the influenza virus from Leung’s study [10] are differ-
ent from those by the previous study [1]. The different
methodology of sample collection may explain this
discrepancy.
In conclusion, N95-equivalent masks were more
effective in preventing the dissemination of SARS-CoV-2
from the coughs of patients with COVID-19 than surgical
masks. Strict hand hygiene is important after touching
the outer surfaces of masks. Other independent groups
should evaluate the outward and inward protective
effectiveness of various masks against SARS-CoV-2 with
more well-designed protocols.
Acknowledgments
We are deeply grateful for the patients who participated in
this study.
912 M.-C. KIM ET AL.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This study was supported by a grant from the Korea Health
Technology R&D Project through the Korea Health Industry
Development Institute (KHIDI), funded by the Ministry of Health &
Welfare, Republic of Korea [grant no. HI20C0073].
ORCID
Min-Chul Kim http://orcid.org/0000-0003-4410-5608
Seongman Bae http://orcid.org/0000-0001-6375-3657
Se Yoon Park http://orcid.org/0000-0002-4538-7371
Minki Sung http://orcid.org/0000-0001-8915-2710
Sung-Han Kim http://orcid.org/0000-0002-6596-8253
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