What alternatives to face coverings or masks (e.g., face shields) are being considered or used for non-healthcare workers returning to work sites, who cannot tolerate wearing facial coverings? CDC guidance only states that facial coverings should NOT be worn by children under 2 yo and anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

There is general acceptance that use of face covering (non-medical masks) can limit the spread of COVID-19, not as personal protective equipment but protecting the spread from an individual who is pre-symptomatic, has minimal symptoms or may be asymptomatic. There are multiple types of masks.9  Now that the CDC is recommending and many localities or employers are requiring them for non-healthcare workers, the issue of those who “cannot tolerate” a face covering has become an issue.  Some do not wear the mask properly10,11. The goal of the face covering is to minimize the spread of respiratory droplets from one individual to another, especially in those situations where physical distancing cannot be assured.

The first consideration is whether the individual who reports that they cannot tolerate the face covering has tried the various styles available. There are differences in material, how they are secured (around the ears or behind the head) and whether they cover just the nose and mouth or extend to the neck as well. The important factor is that they do cover the nose and mouth (wearing a face covering below the nose is not effective).10,11  Some may find a bandana or “gator” type of face covering more comfortable and easier to keep in place. 

Transparent physical barriers, such as plexiglass help provide protection from respiratory particles and can provide an alternative for individuals who cannot tolerate face coverings. They are often used for additional protection along with face coverings in jobs  such as retail cashiers, meat packers, or office workers when it is difficult to maintain proper physical distances.  Some states with face covering requirements permit these barriers for certain jobs  in lieu of face coverings.  Although they can mitigate the spray of droplets, they are unlikely to capture fine particles (aerosols)1.  If a workplace chooses  to utilize these as physical barriers, factors for selection should include; scratch and impact resistance, cleaning and ventilation requirements and dimensions of the barrier. These should also be considered potentially contaminated and should be cleaned as any high touch area but being careful to not use products which might damage the surface.  Ventilation requirements must be considered to avoid interference with HVAC systems.  The dimensions of the barrier should be sufficient to block the breathing zone of those on all sides, both sitting and standing (should extend above the head of the tallest user).   It should be as wide as possible, ideally at least 6 feet to provide sufficient work space.  Any necessary openings should be as small as possible and not directly in front of any user and out of all breathing zones.   
Another option would be to have that individual work in an area where there is no, or limited exposure to others where duration of face covering use could be minimized.  

While the CDC suggested the use of face shields as PPE in health care settings when face masks are not available2, some have considered their use as a replacement for face coverings in non-healthcare settings. In the health care setting, a face shield, may be used as PPE as an adjunct to a face mask.  The face shield is used to protect the eyes and in conjunction with the mask, the nose and mouth from splashes and other droplets.3  They also add protection of  the face skin from contamination by aerosol droplets and block touching a face mask or N 95 worn under a face shield.  Given that they do not reliably fit close to nose and mouth, they will not provide as much protection to others from droplets emitted from the nose or mouth as would a face covering.  Some are designed to protect only the face, while others may extend to the neck or sides of the head.  Some are designed to protect against splashes and others may provide both splash and act protection. A face shield should fit snugly, without gaps between forehead and shield, many will not achieve this and if tight, may lead to headache which would limit their prolonged use.  Many of the face shields are designed for single use and prolonged use or use of cleaning products may affect fit or surface integrity. The type of material use could affect sturdiness leading to crimping, bending or tearing and affect air flow. Individuals who do not tolerate face coverings may also be unable to tolerate face shields due to claustrophobia or other concerns.  They will be difficult to wear with corrective lenses, may interfere with vision and may fog. 

Other challenges which may affect the effectiveness of a face shield
Distance of the shield from the nose and the angle of the shield,  and how far they should extend from top to bottom or side to side.   Airflow and flow of respiratory droplets around the face shield is unknown and may vary depending on design. There are currently no universal standards for face and eye protection from biological hazards4. The various models that have been used during the pandemic have not been evaluated by NIOSH or FDA. When used, face shields would need to be considered as potentially contaminated and should be handled, cared for and cleaned appropriately.  Given the above concerns, face shields as an adjunct to face coverings may still have value in non-health care settings, especially in those positions where physical distance cannot be maintained where there is high community spread as they would cover the eyes and could provide some additional personal protection to the individual5

And while not part of the question, I did want to address the situation where the person is truly unable to wear a face covering due to an actual disability and alternative solutions are not readily available.  It is considered that requiring an individual to wear PPE or a face covering during the pandemic, is a legitimate business requirement6 and may be mandated by some local or state governments.  In this situation, if the individual makes a request for an accommodation due to disability, (not wanting to wear a mask would not be a disability, chronic respiratory problems might be) the employer would need to engage in an interactive process under the American’s with Disabilities Act and evaluate whether a reasonable means to accommodate exists.

Possible accommodations might include:


1. Use of alternate types of face covering
2. Physical barriers or working in more isolated area
3. Remote working
4. If all else fails, providing the employee and leave of absence until face covering are no longer required.  

Citations

1. ACOEM COVID-19 Forum - Guidance on the use of plexiglass barriers. https://acoem.org/COVID-19-Resource-Center/COVID-19-Q-A-Forum/Could-you-provide-guidance-on-the-use-of-plexiglass-barriers-for-workplaces-for-sneeze-guard”-dropl 
2. CDC - When No Facemasks Are Available, Options Include - https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html
3. Lindsley  WG, Noti  JD, Blachere  FM, et. al. Efficacy of face shields against cough aerosol droplets from a cough simulator. J Occup Environ Hyg. 2014;11(8):509-518. 
4. Roberge RJ. Face shields for infection control: A review. J Occup Environ Hyg. 2016;13(4):235‐242. 
5. Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis [published online ahead of print, 2020 Jun 1]. Lancet. 2020;S0140-6736(20)31142-9. doi:10.1016/S0140-6736(20)31142-9.

6. EEOC. What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws. Updated May 7, 2020. https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws
7. Who Updates Mask Recommendations, Says General Public Should Wear Facemasks. June 5, 2020. https://pandemic.internationalsos.com/reports/who-updates-mask-recommendations-says-general-public-should-wear-facemasks-jun-05-2020
8. CDC Use of Cloth Face Coverings to Help Slow the Spread of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html 
9. https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html
10. https://www.nytimes.com/2020/04/08/well/live/coronavirus-face-mask-mistakes.html
11. https://gothamist.com/news/coronavirus-updates-june-13-2020

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Disclaimer:
The Forum does not necessarily represent an official ACOEM position. The Forum is intended for health professionals and is not intended to provide medical or legal advice, including illness prevention, diagnosis or treatment, or regulatory compliance. Such advice should be obtained directly from a physician and/or attorney. Questions are answered with the best available data or recommendations at the time.