Clinical Microbiology and Infection 26 (2020) 1701e1702
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Clinical Microbiology and Infection
journal homepage: www.clinicalmicrobiologyandinfection.com
Letter to the Editor
Inhale, then exhale: start afresh to diagnose Severe Acute Respiratory
Syndrome Coronavirus 2 (SARS-CoV-2) by non-invasive face-mask
sampling technique
R. Kanaujia, M. Biswal, A. Angrup*, P. Ray
Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
a r t i c l e i n f o
Article history:
Received 14 May 2020
Received in revised form
26 June 2020
Accepted 28 June 2020
Available online 3 July 2020
Editor: L Leibovici
To the Editor,
The severe acute respiratory syndrome coronavirus 2 (SARS-
CoV-2) pandemic is leading to an exponential growth of cases
and the total number of confirmed cases has exceeded 3 million.
Although respiratory droplets are the major route of trans-
mission of the virus, van Doremalen et al. in a recent study
revealed that aerosol and fomites can be plausible routes of
transmission [1].
Nasopharyngeal (NP) swabs are the recommended sample
and RT-PCR is the cardinal modality for SARS-CoV-2 detection.
The method of NP swab collection is invasive and mandates the
availability of trained staff and personal protective equipment.
Also, NP swab specimen collection carries a theoretical risk of
transmitting the virus. The concern of false-negative results due
to faulty technique necessitates an alternative method of sample
collection.
Hence, the current need is for simple, non-invasive methods of
sampling. Few studies have proposed the isolation of virus from
self-collected specimens, like tears, saliva, urine and stools. Another
alternative method is sampling from the mask of the patient. The
size of the respiratory droplet is from >5 to 10 mm in diameter and
* Corresponding author. A. Angrup.
E-mail address: archanaangrup@yahoo.com (A. Angrup).
https://doi.org/10.1016/j.cmi.2020.06.034
1198-743X/© 2020 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
Edwards et al. demonstrated that during normal breathing many
people generate a substantial number of aerosols ~150 nm in
diameter [2]. Hence, N95 masks, which are widely recommended
for prophylaxis against inhaled viral droplets and aerosols, can be
sampled and can offer an easy adjunct for NP samples. This method
will be a solution for the institutions that are suffering because of
rising demand for Viral Transport Medium and swab sticks, and the
requirement of trained medical personnel and personal protective
equipment will also decrease.
The N95 masks use charged electret fibres as the filtering me-
dium, and in vitro experiments have demonstrated that they collect
>95% of the aerosolized virus [3]. Attempts have been made pre-
viously to collect virus aerosols by different methods, including
impaction, impingers and gelatin or nucleopore air filters attached
to air pumps. In 2008, Huynh et al., developed a novel prototype
mask-like sampling device. It was made from impermeable and
stretchable PVC [4]. It contained an electret (25-mm diameter)
opposite the nose and mouth region. This sampling device had low
airflow resistance (15 mmH2O) at normal respiratory flows and was
able to collect 80% of 0.52-mm latex particles (virus droplet repre-
sentative). Hence, after sampling, electret can be easily removed,
placed in RNA lysis buffer and PCR can be performed [4]. In a recent
study from the University of Leicester by Williams et al., face-mask
sampling offered an efficient and non-invasive method for detec-
tion of exhaled Mycobacterium tuberculosis, with a high sensitivity
of 86$5% [5]. This group is also working on the isolation of SARS-
CoV-2 from the mask. In this simple technique, the person wears
a face mask containing strips made of a gelatin sampling matrix for
a duration of 30 minutes. These moist strips will trap the virus in
the matrix [5] and can then be preserved after drying out and used
for virus isolation. The preserved strips can be directly transported
to the laboratory, precluding the need for special storage before
analysis. This method obviates the need for health-care workers,
and no expertise is required to collect the samples (Fig. 1a,b).
However, although these innovative approaches are promising
tools, their efficiency needs to be confirmed by further studies.
Standardization of the duration for which the patient needs to wear
the mask is required as the proportion of virus droplets produced
per hour in asymptomatic carriers or patients with a smaller viral
1702 Letter to the Editor / Clinical Microbiology and Infection 26 (2020) 1701e1702
Fig. 1. COVID-19 diagnostic test by face-mask sampling.
load is not similar. It will also be relevant to think whether or not
the sampling from the mask will provide us with a true represen-
tation of the ongoing pathogenies in the respiratory tract. The
major limitation of this method is that it is patient-dependent.
Non-compliance in a claustrophobic patient can limit the sensi-
tivity of detection. Another concern is the storage of samples. An NP
swab in Viral Transport Medium can be refrigerated at 2 Ce8 C for
48 hours and at e70 C for a longer duration and has a shelf life of
5 years. Storage and shelf life of the mask with gelatin strips war-
rants more studies.
Since the outbreak of SARS-CoV-2, researchers have been
trying to develop an alternative method of sample collection. This
approach will be advantageous, simple, safe, easy to use and non-
invasive. A larger population can be sampled in less time and the
method can be used for a wide range of age groups, especially
children and asymptomatic and non-cooperative patients. Trans-
portation of the masks would be easier than that of NP swabs as
there is no risk of sample contamination or leakage. The cost of
both the mask and Viral Transport Medium with swab are com-
parable ($2.50). The method of collection will be easier and less
bio-hazardous waste will be generated. Also, other respiratory
viruses can be detected from one sample using multiplex PCR,
providing diagnosis for infections other than SARS-CoV-2. The
sensitivity and specificity can be derived from further studies,
which can compare the face-mask sampling to nasopharyngeal
PCR. Even though studies are in the preliminary stages, this
innovative approach is a breath of fresh air and provides a new
insight for the future.
Transparency declaration
The authors have stated that there are no conflicts of interest.
Funding
None.
Authors' contributions
RK and AA were responsible for writing the original draft and for
conceptualization. MB and PR responsible for reviewing and editing
the article.
Acknowledgements
Figure was made using the BioRender online tool and was
adapted from the methodology of Huynh et al. [4] and Williams
et al. [5].
References
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