ࡱ>  bjbj ;hh] +++\;4o"o"^"""(((1333333$W++'(++W++""lHh4h4h4++p"+"1h4+1h4h4Y"ly +ݏFH# |-v +4(hH)Jh4)<)6(((WW3v(((++++ ((((((((( : After Action Report on the Face Mask Pilot Exercise (June 2007) Communicable Disease Control and Prevention Section San Francisco Department of Public Health Executive Summary: The San Francisco Department of Public Health (SFDPH) Communicable Disease Control and Prevention (CDCP) Section organized the Face Mask Pilot Exercise on June 7, 8, 12 and 13, 2007. As part of a broad disease containment strategy during certain severe pandemic situations, SFDPH may recommend that all persons in public, including those in work settings, wear masks to cover their nose and mouth (face mask) in order to better contain their own individual respiratory secretions. Currently, no published data exists to guide the quantity of face masks needed for such a measure. We conducted this pilot exercise to study the feasibility and usability of face masks in a work setting under optimal conditions, estimate the number of face masks workers may need to don in an 8-hour shift, and identify factors that may affect the length of mask wear. Prior to the exercise, we estimated that each worker would need approximately 6-10 masks for an 8-hour shift based on two main considerations. First, face mask manufacturers and CDC recommend that masks be changed when they become moist in order to ensure their maximum effectiveness. Second, in addition to aerosol transmission, the influenza virus may also be transmitted via direct or indirect contact with contaminated surfaces, which include the out-facing portion of used masks; therefore, participants were asked to don a new face mask after manual manipulation of the mask for the purpose of eating or drinking. Rules were constructed to guide exercise participants on when to change masks. Exercise participants consisted of 25 CDCP employees who work in an office setting with minimal in-person client interaction. Participation in the exercise was completely voluntary and staff could choose up to 3 days in which to participate. Participants were asked to keep a log of how long each mask was worn, activities performed while wearing each mask, reasons for mask removal, and other observations. They were instructed to try changing masks as few times as possible, though masks had to be changed after eating/drinking or if they became moist. A total of 160 masks were worn for a collective 213 hours of mask time. In our optimal setting (i.e. adequate mask supplies with the ability to replace masks following strict rules outlined above), 5-8 masks per person per 8 hour shift were used. Each mask was worn for a median of 69 minutes (25th, 75th percentile: 38, 111 min). To get a drink was the most common reason for mask removal (39% of all masks), followed by eating lunch/getting a snack, sneezing, and feeling too warm. Only 3 masks were removed due to moistness. While mask-wearing generally did not interfere with office duties, those who wore glasses or had smaller faces noted poor fit that made mask-wearing uncomfortable and others complained of increased thirst while wearing the masks. Despite these difficulties, 23 out of 25 participants noted that they would wear a mask while working during a pandemic, if instructed. We acknowledge that in a pandemic situation, face mask supplies may be inadequate and the estimate of face masks needed per person per day generated by this exercise may be high. We also acknowledge that face mask wearing is part of a set of complementary measures to promote disease containment during a pandemic. This exercise serves as a first step in providing empirical information on which recommendations may be based, rather than using a best guess. Follow-up to this exercise will include the development of specific protocols to increase the length of time a mask is worn, (e.g. how to stay hydrated while wearing masks, how to remove face masks in conjunction with hand sanitizer, and how to reuse face masks). Other next steps include: exercising with a specific pandemic influenza scenario to give participants a greater sense of urgency regarding conserving masks exercising our clinical staff to determine whether the amount of masks needed are different exercising both respirators and face masks under a pandemic scenario to estimate the minimum number of masks that would be needed under shortage conditions. Background In preparation for a pandemic influenza response, the Centers for Disease Control and Prevention (CDC) has developed recommendations on the implementation of various non-pharmacologic interventions including infection control measures and social distancing strategies to limit or mitigate the impact of an influenza pandemic. Cough etiquette and hand hygiene measures are generally recommended, and the use of face masks (surgical or procedure masks) may be appropriate in certain settings. Furthermore, the Occupational Safety and Health Administration (OSHA) recommended that as part of their pandemic influenza preparation, employers should stockpile certain infection control supplies such as soap, hand sanitizer, gloves, masks, tissues and cleaning supplies. Although the role of face masks in preventing the transmission of influenza is unknown, they can act as a physical barrier to limit the spread of infectious respiratory secretions from those infected to others. For the purposes of this document, the term face masks refers to a covering of the nose and mouth and does not include respirators such as N95 masks. During a pandemic, SFDPH may recommend all persons wear masks to cover their mouth and nose while in public to help contain respiratory secretions of potentially infected persons. This policy may be considered an enhancement to currently recommended respiratory etiquette because it asks all persons, rather than just symptomatic persons or healthcare workers, to wear a mask in order to contain respiratory secretions from asymptomatic persons; we also hope that symptomatic persons would comply with the recommendations because they would no longer be singled out for mask wearing measures. This is one non-pharmaceutical measure amongst a menu of public health actions that may be implemented in a targeted, layered and coordinated manner to mitigate the effects of an influenza pandemic. We anticipate using an increased number of and more restrictive non-pharmaceutical measures for those pandemics deemed severe (e.g. a Pandemic Severity Index of 4 or greater). This particular measure may be more effective if we can also minimize the number of ill persons and their contacts in the workplace or in public, and combined with other measures that decrease contact between people such as implementing sneeze barriers, discouraging sharing or handling of common supplies or equipment without disinfecting them between uses, and decreasing the density of people in workplaces and public places by staggering shifts or utilizing work and shop from home strategies. It is not known to what extent having all persons wear face masks would actually decrease transmission, but the wearing of face masks has not been associated with major risks to the wearer, can be well tolerated, can be purchased in advance in bulk, are one-size-fits-all and can be easily stored indefinitely. Face masks have been designed to contain respiratory secretions of the wearer to prevent them from contaminating sterile fields in the medical setting (e.g. surgery, dental care, and other medical procedures) and they are also designed to prevent splashes of blood or body fluids entering the wearers nose or mouth. They have been manufactured for single use and thought to perform their basic functions as long as they are not wet or moist, when they are supposed to be discarded. To the extent that influenza is transmitted by indirect contact from a susceptible person touching surfaces contaminated with influenza containing respiratory secretions and then subconsciously touching their nose or mouth or from droplet transmission of large respiratory droplets that enter a persons nose or mouth, face masks can be expected to decrease transmission to the wearer by these routes. Face masks do not offer the same level of respiratory protection to the wearer as a respirator, so to the extent that influenza is transmitted by inhaling infectious particles, there could still be a risk of transmission to the wearer of the face mask. SFDPH conducted the Face Mask Pilot Exercise because details of how to implement widespread mask-wearing measures for different settings do not currently exist. This exercise was developed to establish some estimates of reasonable rates of mask use under optimal conditions and to determine what types of barriers to mask use might arise. We decided to focus this first exercise on the work setting as a subset of the public setting partly in response to the recent OSHA recommendations for employers to prepare for an influenza pandemic by stockpiling needed PPE in advance. Participants in this exercise consisted of staff of the SFDPH Communicable Disease Control and Prevention (CDCP) Section. All participants were staff who normally work at computer workstations with little client interaction; no staff who worked in a clinic setting or regularly perform strenuous activities were included in this exercise because we expect the amount and pattern of mask use to be different among these staff. In summary, surgical or face masks have traditionally been worn by healthcare providers to prevent accidental contamination of a patients wound, or worn by employees to protect themselves from splashing or splattering of blood and body fluids as part of Standard Precautions or to protect themselves from large droplets entering the mouth or nose as part of Droplet Precautions. All of these situations require the healthcare provider to wear face masks for a relatively short period of time in a controlled setting. However, there are no or limited data on the use of face masks for infection control for a prolonged period in a non-healthcare work setting or a public setting. SFDPH has taken the guidance from the CDC, OSHA, Cal-OSHA and the California Department of Public Health to develop specific interventions as part of the strategy to limit or mitigate the spread of a severe pandemic strain in our local jurisdiction. One possible intervention amongst many that we may recommend is that face masks be used by all persons in public places, including the workplace, in order to contain respiratory secretions of people who may be infected with a pandemic strain, thus protecting other people against infection from the person wearing the facemask,. As there was no available published data, our pre-exercise estimation was that 6-10 masks per 8 hour shift would be required for public health office workers. We then conducted an exercise with members of the SFDPH CDCP Section to evaluate the amount of masks that staff would require as part of this intervention and the variables that could affect the length of mask wear during a pandemic situation. Exercise Description Name of exercise: Face Mask Pilot Exercise Type of exercise: Functional Exercise Date: June 7, 8, 12, and 13, 2007 Location: CDCP Offices (San Francisco, CA) Sponsors: San Francisco Department of Public Health Participants: Volunteers from the San Francisco Department of Public Health Communicable Disease Control and Prevention (CDCP) Section Staff. Exercise Purpose: The purposes of this Exercise were to: Estimate the amount of masks that workers may need to use during an infectious disease emergency Identify the factors that affect whether the masks may be used comfortably Exercise Design: CDCP comprises 39 full-time staff members, all of whom were solicited to participate in the exercise. Staff were asked to participate on a voluntary basis for as few or many hours as they desired up to a maximum of 24 hours within the 4 designated exercise days. Recruitment strategy: Introductory Sessions were offered to all the CDCP staff via an invitation from their respective supervisors, as an opportunity to explain the exercise to the staff and answer questions and to elicit practical suggestions. During the Introductory sessions, staff were also encouraged to sign up to participate. A follow up email was sent to those who did not attend any introductory session that they could still participate by attending one of the Training sessions. Suggestions from the introductory sessions were incorporated into the training sessions and the final design of the Exercise. Orientation to exercise participants: During the training sessions, the purposes of the Exercise were reiterated and exercise materials dispensed. Participants were encouraged to choose up to three (3) of the selected mask days to do the exercise. The ground rules on how to replenish masks and instruction on how to complete the Exercise log were given (see Appendix B). Participants were also shown how to don and doff the face mask, and they demonstrated correct donning and doffing procedure in return. The manner in which confidentiality and/or anonymity of responses was to be maintained was explained during the training. Email reminders were sent before and after the exercise. Exercise protocols and evaluation methods: A folder containing the following supplies was distributed to each participant: 1) Instruction sheet (with the purposes, ground rules and instructions for the Exercise) 2) Instruction on how to sanitize hands 3) 3 I Am Participating in a Face Mask Practice Drill labels to be worn during the exercise 4) 3 days supply of Exercise log sheets 5) Post-exercise evaluation form 6) 20 face masks in a zip lock bag 7) A bottle of hand sanitizer 8) 2 paper bags for mask disposal In this Exercise, participants were asked to wear a face mask during their normal work hours. They were instructed to try to use as few masks as possible during the day, but to change them when the masks became moist. They were also to remove the masks if they needed to get a drink or eat a snack, and to don a new mask afterward. While this measure limited the reuse of masks (thus increasing the overall number of masks used), it also limited the potential for contamination of the mask by hands and other surfaces upon removal. Participants could also take off the mask if they felt it was interfering with their job duties, and they could stop wearing the mask at the end of the day and at any time if they had trouble breathing. Since the participants work in a public building, they were asked to put on a label identifying them as an exercise participant to prevent alarming any visitors, clients, and fellow workers in the building. They were to record each time they donned the mask, the activities they engaged in while wearing the mask, the time they removed the mask, the reason(s) for removing the mask, and whether in a real pandemic emergency situation, they would still remove the mask. Participants were instructed to discard the used mask in a paper bag each time the mask was removed and to sanitize hands. Ordinarily masks that are not contaminated with blood or body fluids can be discarded in regular waste. However, in consideration of the environmental workers who work after office hours and may not have been aware of the exercise, masks were discarded in brown paper bags prior to disposal in regular waste so the environmental staff would not be alarmed. Post-exercise evaluation: Participants were asked to complete the evaluation form included in their folders at the end of their participation. An email was sent to non-participants requesting them to complete a confidential and anonymous online survey consisting of 5 questions asking their reasons for their decision not to participate. Also, a debrief session was scheduled a day after all the Exercise logs had been collected. The session provided an opportunity for participants and non-participants to comment on any of the elements of the exercise. Open-ended questions were prepared to guide the discussion (see Appendix B). Members of the staff were also presented the findings of the exercise approximately 8 weeks after its completion and additional comments and insights gathered at that presentation were incorporated into this report. Exercise artificialities: Even though the impetus for the exercise stemmed from local pandemic influenza preparedness planning, no pandemic influenza scenario was provided to participants during this exercise. Therefore, even though they were instructed to try to use as few masks as possible, participants may have taken their masks off for minor reasons, leading to an overestimation of masks needed per workday. We attempted to assess this effect by asking each participant to note whether they would have removed their masks for the reason stated during a pandemic and performing sensitivity analyses on number of masks used and length of mask use based on their answers. This exercise was held in early June. The weather in San Francisco at that time ranged from comfortable (daytime high of 65oF) to warm (daytime high of 83oF); because the office building does not have internal climate control, participants were exposed to this weather in their offices. Warmth of certain exercise dates may cause participants to wear masks for a shorter period of time, and therefore given a somewhat higher estimate of the number of masks worn per shift compared to a more controlled, comfortable climate. However, a pandemic is an event that can take place at any time during the year, so it is reasonable to base planning and stockpile amounts of masks on these higher warm weather estimates. Summary of Results Detailed analysis results are presented in Appendix A. A) Participation rate: Out of 39 staff recruited to participate in the exercise, 25 participated in the exercise (64%). The participation rate was much higher for those who attended the introductory session (22/24 = 92%) compared to those who were recruited only via email (3/15 = 20%). Out of the 14 non-participants, 10 completed the non-participation survey. Staff who attended the introduction session found it to be useful for learning how to properly don and doff the masks and as a forum for having their questions answered. Out of the 25 exercise participants, 9 participated for 1 day or less, 7 for 2 days and 9 for 3 days. Few participated for an entire 8-hour workday; most wore masks for 4-5 hours and averaged 8.5 hours of participation for the whole exercise period (some as little as less than hour, up to 21 hours). In total, 160 masks were used by 25 participants (213 hours and 20 minutes of total mask-wearing time). Of the 3 participants who quit the exercise within 1 hour of mask wear, reasons cited were: glasses fogging up, had a runny nose due to a cold, and feeling too warm and claustrophobic in the mask. All participants were office workers with computer workstations who did not normally interact with clients or perform any clinical duties during the workday. Some had their own offices and some had shared offices with or without cubicle walls of various heights. Common work tasks included: working on the computer, talking on the telephone (with or without headsets), and other administrative duties; physical exertion is not a normal part of the workday. One participant went to an offsite meeting wearing a mask; otherwise, all participants only wore their masks while in the public health building. Ten out of 14 non-participants filled out a survey to give reasons for their non-participation. The top two reasons were: having a condition that makes the staff person concerned about wearing a mask for a prolonged period (due to a desire for confidentiality, we did not ask them to state their conditions explicitly), and absent during exercise period. Other reasons cited included concerns that mask wearing would interfere with client interaction, and already having had sufficient experience wearing masks in the past. Eight of the ten respondents stated that they would wear a face mask during a pandemic situation. B) Mask wear: number of masks worn and length of mask wear A total of 160 masks were used by 25 exercise participants, who collectively wore the masks for 213.3 hours. On average, each mask was worn for 80 minutes (95% CI: 71.7 88.3, median: 68.5). When normalized for an 8-hour work shift, each participant wore an average of 6.6 masks per shift under ideal conditions (95% CI: 5.2 8.1, median: 5.5). Additional sensitivity analyses were performed to obtain mask-number estimates based on the effect of mask-wearing rules and whether participants would have removed masks for their stated reasons during a real pandemic. While participants anecdotally reported that it was more difficult to wear the masks for a long period of time during hot weather, no correlation between length of mask wear and self-reported room temperature was observed. We also examined whether the number of people in the office affected length of mask wear either positively (e.g., peer encouragement for mask wear) or negatively (e.g., more crowded and uncomfortable working conditions); but did not see any correlation. Lastly, we examined whether those whose duration of participation in the exercise was longer wore each mask for a longer period of time than those who participated for a shorter amount of time; we found a significant positive correlation (corr=0.27, p=0.001) between length of participation and minutes of mask wear. C) General mask-wearing experience: The majority of participants noted some difficulty with mask-wearing, with thirst being the most commonly cited reason; only a few said that it was not as difficult to wear the masks as they had anticipated. Some participants noted that they drank less often than normal because they did not want to waste a mask by having to discard it to take a drink. However, if faced with a pandemic situation, participants indicated that fewer than half of the masks would have been removed for thirst reasons, and most would not have removed the masks even if they experienced slight physical discomfort. Masks were removed due to being moist for only 3 out of 160 masks worn. Those who participated more than 1 day did note acclimation to wearing the mask while working. For some, awareness of the mask moving while breathing and the smell of the masks were constant distractions. Some also cited that mask wearing was fine at the workstation, but did make walking up and down the stairs more difficult. Other observations included the difficulty of interaction among coworkers, especially in meetings, because the mask impeded communication by obstructing the view of coworkers facial expressions. Some participants also noted that, given the discomfort, it was difficult to find motivation to wear a mask when they knew that face masks may not offer respiratory protection for the wearer. During the introduction sessions, some staff noted that mask wearing may interfere with head accessories such as glasses, headsets, etc. Most did not have a problem with making themselves heard over the phone (with or without a headset) although a few people stated that their voices were a little muffled, and most participants with glasses noted that they fogged up while wearing a mask. Some participants with smaller faces found that the mask would not stay put, often hitting their glasses or eyes while they talked. Also, glasses tended to fog up, impeding work, and there was more chafing and mask movement for those with smaller faces. One also noted that after a long period of wear, the masks began to lose their shape due to moisture and became more difficult to wear; one suggestion was to use masks made from a material that would not cling to the face after extended use. However, even given the aforementioned difficulties, 23/25 (92%) of the participants indicated that they would wear a mask during a pandemic if instructed. The reasons for mask removal did not change significantly when stratified by exercise day on which the masks were worn, length of mask wear or self-reported room temperature. In general, participants noted that the rules for donning and doffing were simple and easy to follow. D) Reasons for mask removal: Participants were asked to state as many reasons as they liked regarding why they removed each mask. The top 5 reasons for mask removal were: 1) to get a drink (62/160 = 39%); 2) going to lunch (31/160 = 19%); 3) to eat a snack (20/160 = 13%); 4) to sneeze/blow nose (17/160 = 11%); 5) too warm (11/160 = 7%). Interestingly, in only 3 instances did participants change their masks because they became moist, the recommended threshold at which the surgical/procedure masks stop functioning optimally; these masks were changed at 70, 120 and 140 minutes respectively. General discomfort in mask wearing was cited, but was not a top reason for mask removal. From the post-exercise survey and debriefing session, many participants questioned the necessity of utilizing a new mask after taking a drink, preferring to conserve masks. In general, rankings for the top mask-removal reasons did not change significantly when stratified by the exercise day on which they were worn, the number of minutes of mask wear or office room temperature. Most notably, glasses fogging up ranked higher as a reason for removal among masks worn for 30-60 minutes, and too warm/wet for masks worn for 2 hours or more. Anecdotally, most participants were able to wear the mask comfortably for about an hour before taking it off. Participants noted that for a pandemic situation given the rules for mask use as delineated in this exercise, in only half the instances would masks be removed for a drink or snack, and in fewer than one-fifth of the instances would masks be removed because of general discomfort. Most would still remove their masks if they became wet or because of poor fit during a pandemic. E) Sensitivity analyses: Because we received strong feedback regarding the drink rule, we performed a sensitivity analysis to determine whether our main outcomes would be significantly influenced should we decide to allow participants to keep wearing the same mask after taking a drink. While the average number of masks worn per participant per 8-hour shift slightly decreased from 6.6 to 6.1 masks, and the number of minutes worn per mask increased slightly from 80 to 89.6 minutes, no statistically significant differences were seen. Some participants also noted that because they felt no sense of urgency that may come with a specific pandemic exercise scenario, they may have removed masks for reasons that would be considered minor in a real pandemic situation. To assess this effect, we performed another sensitivity analysis by combining mask-wearing times for instances where participants indicated that they would not have removed their masks for that reason during a pandemic. In this analysis, we saw a significant difference in the number of masks used per participant per 8-hour shift, from 6.6 to 4.5 masks (p=0.01). The average number of minutes per mask worn also increased significantly, from 80 to 117.5 minutes (p<0.001). While this number may be used as a low-end estimate of the number of masks needed per 8-hour shift, this sensitivity analysis did not include fatigue or moisture on mask as an adjustment factor, possibly overestimating the number of minutes for which participants are able to wear their masks. Conclusion In conclusion, we found that that 5-8 masks per person per 8 hour shift would be used under optimal conditions for our office setting. Lessons learned include: Increased participation and buy-in for those who received in-person training and education on the purpose of wearing masks some staff members do not feel comfortable wearing masks that are not providing respiratory protection to the wearer those who have worn N95 respirators in the past found face masks are much more comfortable to wear some staff members have medical conditions that make them disinclined to wear face masks for prolonged periods of time implementing wide-scale use of face masks was not a simple project and had unintended consequences, such as interfering with communication of important information because the mask wearers face could not be seen. Others may consider repeating this exercise with larger numbers of staff, in different types of work settings and/or in a pandemic scenario to find the optimal numbers of masks needed in situations different from that discussed here. We may also consider conducting a similar exercise with respirators to determine the number needed in an office setting per worker per shift, and what the barriers to respirator use would be. During an actual pandemic, we will need to anticipate for shortages of available PPE due to disruptions in our just-in-time supply chain and inadequate stockpile supplies. In a shortage situation, an adequate stockpile of surgical masks may serve as an alternative to respirators for those persons requiring respiratory protection during a pandemic; alternate rules for surgical mask use may be created to conserve supplies. We plan on conducting exercises in the future to determine an estimate a minimum number of face masks needed under shortage conditions. Alternate rules to explore include: using tools to allow for workers to take a drink while keeping masks on, re-using masks after eating meals, and possibly drying out and reusing facemasks for multiple days. In addition to alternate rules, future estimates for the number of masks needed should take into account the following: unauthorized hording or removal of masks from the work place, ratio of defective masks (e.g. loops without elasticity or broken strings) in any given quantity of masks ordered, and whether different types of populations or work activities would require different amounts of masks. This exercise contributed information needed to formulate recommendations for decreasing disease transmission in a workplace setting during a severe influenza pandemic. The use of face masks is only one of many strategies in a realistic and comprehensive disease containment strategy. Other potential components include: ensuring that ill people and their contacts remain at home; allowing workers in a private office to not wear masks while alone, and staggering shifts or reducing work hours at the office to maximize private offices; decreasing the minimum number of people who are required to come into work to perform essential functions. This exercise serves as a first step in providing some information for the mask use portion of the overall strategy, rather than basing a recommendation on a best guess. It shows that office workers are willing and able to perform their job duties while wearing face masks and that mask use may be a viable option for essential workers who must come to work during a severe pandemic. Next Steps: Develop appropriate protocols for the reuse of face masks with an emphasis on hand hygiene and limiting the contamination of masks by the environment and vice versa. Develop appropriate protocols for how to drink/re-hydrate while wearing a face mask. Develop a follow-up exercise where a specific pandemic scenario is given to participants to increase sense of urgency to conserve masks and/or deal with discomfort. Develop a follow-up exercise that specifically includes clinical staff. Develop an exercise or study on the use of respirators in a pandemic scenario. Develop a functional exercise with a mask-wearing component within a pandemic flu scenario in which there are shortages of personal protective equipment supplies to determine the minimum number of masks in this situation. Appendix A CDCP Face Mask Pilot Exercise Data Analysis Summary A) Exercise Population: Exercise ParticipationExercise ParticipantsExercise non-participantsTotalReceived introduction session22224Did not receive introduction session31215Total251439 Exercise Population Description Total number of participants25 personsDays of participation1 day or less9 persons (36%)2 days7 persons (29%)3 days9 persons (36%)Hours of participation (see graph below)Mean (95% CI)8.5 hours (6.0, 11.1)Median (25th, 75th percentile)9.3 hours (2.9, 14.8)Min, Max 0.4 hours, 20.9 hoursTotal number of masks worn 160 masksTotal number of mask-hours for all participants213 hours and 20 minutesStatistics on number of masks worn per participant:Mean (95% CI)6.4 masks (4.5, 8.3)Median (25th, 75th percentile)6 masks (3, 8)Min, Max 1 mask, 21 masksStatistics on number of masks worn per participant, normalized for an 8-hour shift and excluding 3 people who participated in the exercise for less than 1 hour: (N=22)Mean (95% CI)6.6 masks per 8 hours (5.2 masks, 8.1 masks)Median (25th, 75th percentile)5.5 masks per 8 hours (4.4 masks, 7.6 masks)Min, Max 3.3 masks, 18.5 masksStatistics on length of time per mask worn:Mean (95% CI)80 min (71.7, 88.3)Median (25th, 75th percentile)68.5 min (38, 111.3)Min, Max5 min, 240 minStatistics on the number of masks used for an 8-hour shift based on length of time per mask worn, excluding masks that were worn for less than 0.5 hours: (N=132)Mean (95% CI)6.8 masks per 8 hours (6.2 masks, 7.4 masks)Median (25th, 75th percentile)6 masks per 8 hours (4 masks, 8.8 masks)Min, Max 2 masks, 16 masks     B) Mask-wearing experience: Reasons for mask removal Total number of masks worn = 160N*Number who would remove mask during a pandemic for this reason Among masks worn on DAY 1 (83 masks, 25 people)Among masks worn on DAY 2 (47 masks, 16 people)Among masks worn on DAY 3 (30 masks, 9 people)Masks worn for <=30 min (28 masks, 12 people)Masks worn for 30 60 min (36 masks, 16 people)Masks worn for 1-2 hours (42 masks, 16 people)Masks worn for 2+ hours (54 masks, 20 people)NRankNRankNRankNRankNRankNRankNRankTo get a drink6227 (44%)37 11817172201221131Going to lunch3124 (77%)15 2102621563112131**End of day223 (18%)8 7711128To eat a snack2011 (55%)123731533826332To blow nose / sneeze1716 (94%)12353111451714Too warm114 (36%)84172424364423Face was itchy81 (13%)652415363514General discomfort81 (13%)4635154544Glasses fogging up81 (13%)462624156317Needed a break82 (25%)3754155426To go to a meeting81 (13%)55261524273514Hard to breathe63 (50%)462415272614Was leaving the building42 (50%)28171515181714Mask was wet32 (72%)19241723Poor fit32 (72%)371527Wearing the mask the wrong way21 (50%)191527Dry lips202427Face was moist20191727Feeling self-conscious111915Headache101718Mask was moving while breathing in and out111917Mask was distracting my concentration on my work101917Not the culture of the staff around me (offsite) to wear masks101717Removed to see a client101914Smell of mask made it hard to breath111 917Tired101 718No reason given2----------------* these do not add up to 160 because many participants gave more than 1 reason for mask removal ** end of day is not counted in the ranking because it is not a valid reason for taking a mask off during the workday Reasons for mask removal Total number of masks worn = 160N*Among masks worn at cool room temperature (9 masks, 2 people)Among masks worn at just right room temperature (53 masks, 13 people)Among masks worn at hot/warm room temperature (85 masks, 18 people)NRankNRankNRankTo get a drink6222321211Going to lunch3131133132**End of day22389To eat a snack2013373To blow nose / sneeze1715219Too warm114565Face was itchy84546General discomfort8223628Glasses fogging up854Needed a break85428To go to a meeting8134537Hard to breathe62737Was leaving the building41837Mask was wet337Poor fit31828Wearing the mask the wrong way21819Dry lips2Face was moist218Feeling self-conscious118Headache118Mask was moving while breathing in and out119Mask was distracting my concentration on my work118Not the culture of the staff around me (offsite) to wear masks118Removed to see a client119Smell of mask made it hard to breath118Tired118No reason given2------* these do not add up to 160 because many participants gave more than 1 reason for mask removal ** end of day is not counted in the ranking because it is not a valid reason for taking a mask off during the workday Length of time per mask worn NMean (95% CI)Median (25th, 75th percentile)Min, MaxAll masks16080 min (71.7, 88.3)68.5 min (38, 111.3)5 min, 240 minBy self-reported room temperature:Cool9102.9 min (83.2, 122.6)100 min (75, 122)70 min, 150 minJust right8568.4 min (57.3, 79.5)55 min (30, 92)5 min, 225 minHot / warm5398.7 min (84.5, 113.0)93 min (55, 134)15 min, 240 minBy number of people in room:1-37785.4 min (73.6, 97.2)70 min (45, 120)5 min, 240 min4-65569.7 min (58.4, 81)56 min (35, 91.5)10 min, 232 min7+1798.2 min (78.1, 118.3)100 min (65, 120)10 min, 225 min Sensitivity Analyses: Eliminating getting a drink as a reason for removal Consolidating length of mask wear based on participant response to the question: Would you remove your mask for this reason during a pandemic? Original analysisRemoval of drink rule1P-value (vs. original analysis)Removal during a pandemic2P-value (vs. original analysis)Number of masks worn per participant Mean Median Min, Max 6.4 masks (4.5, 8.3) 6 masks (3, 8) 1 mask, 21 masks 5.7 masks (4.1, 7.3) 5 masks (2, 8) 1 mask, 19 masks0.59 4.5 masks (3.4, 5.7) 4 masks (2, 7) 1 mask, 12 masks0.10Length of mask wear Mean Median Min, Max 80 min (71.7, 88.3) 68.5 min (38, 111.3) 5 min, 240 min 89.6 min (79.8, 99.3) 70 min (40.5, 120) 5 min, 262 min0.16 117.5 min (103.6, 131.5) 100 min (55, 169) 7 min, 452 min<0.001Number of masks worn per 8-hour shift3 Mean Median Min, Max 6.6 masks (5.2, 8.1) 5.5 masks (4.4, 7.6) 3.3 masks, 18.5 masks 6.1 masks (4.6, 7.5) 4.8 masks (3.8, 6.9) 3.1 masks, 18.5 masks0.60 4.5 masks (3.8, 5.2) 4.7 masks (3.7, 5.5) 1.1 masks, 7.6 masks0.011 Removal of drink rule = if participants indicated that the only reason why they removed their masks were due to needing a drink, the length of wear for that mask was added to the length of wear for the next mask to simulate the situation in which their masks were not removed at all. 17 masks worn by 6 participants were removed for the sensitivity analysis. 2 Adjusting for mask removal during a pandemic = if participants indicated that they would not remove that mask during a pandemic for the reasons stated, the length of wear for that mask was added to the length of wear for the next mask to simulate the situation in which the masks were not removed at all. 51 masks worn by 15 participants were removed for the sensitivity analysis. 3 Number of masks normalized for 8 hour shift; data from individuals who participated for 1 hour or more (N=22) Comments from end-of-exercise survey General experience: 19/25 participants cited a reason that made mask-wearing difficult. [9] Most commonly cited difficulty in wearing the mask for a prolonged period of time was thirst. Some participants noted that they drank less often than normal because they did not want to waste a mask by having to discard it to take a drink. [3] Those who wore a mask for more than 1 day noted that their experience did improve (i.e., breathing became more normalized, less irritation and feelings of claustrophobia) [4] Some also noted that it was difficult to have meetings while wearing masks because one could not see facial expressions and voices are often muffled. [1] Some noted that it was easy wearing the mask while sitting at the computer and working, but difficult to wear if one had to walk around a lot or up/down stairs. [8] Anecdotally, participants noted that it was more difficult to wear masks on hot days, but this was not reflected in a real difference in mask-wearing time during the data analysis. This seemed to be a complaint mostly from those who participated in the exercise for more than 1 day. [2] Some found the mask-wearing experience distracting because they were constantly aware of the smell or movement of mask while breathing in and out. [2] Some with allergies found it difficult to have same mask on for an appreciable period of time. 23/25 participants would be willing to wear masks during a pandemic Few people wore the masks long enough to experience moisture as the reason for removal. Only 3/160 masks worn during this exercise were removed because the participants cited mask moistness (these masks were worn for 70, 120 and 140 minutes) A couple of participants found it difficult to be motivated to wear a mask when they know that the masks offer no protection for them against influenza, but rather protects their own droplets from infecting others. Training and orientation Staff found this to be helpful in learning the proper way of wearing a mask, and to have opportunities to ask questions. Head accessories [9] Most participants who wore glasses reported that their glasses did fog up when wearing a mask. [3] Most did not have a problem with speaking on the phone, though on occasions others did note that the speaker sounded muffled. [2] Those who used the phone headset did not note any issues with being able to be heard. 4 did not note any interference from head accessories. Fit [4] Some participants with smaller faces found that the mask would not stay put, often hitting their glasses or eyes while they talked. [1] One also noted that after a long period of wear, the mask begins to lose its shape due to moisture and became more difficult to wear. Hand hygiene: Not all participants practiced recommended hand hygiene along with the mask-wearing. Some found the sanitizer drying on the hands, some forgot to use it in conjunction with mask change. Suggestions: [4] Some participants would have liked the option to take a drink without changing masks, or other measures to conserve mask use. [4] Some mentioned that during a pandemic, they would prefer to have the option to work from home. [2] Some would like the option of not wearing a mask unless interacting with others One participant noted that the rules were simple and easy to follow. [2] Participants would have also liked having different sized masks to choose from. [2] Other participants would have liked masks that were odorless or of a different material / design that would not cling to the face after extended use. Some participants would have liked a scenario with higher urgency for future exercises, to see if reasons for mask removal change. Questions: Could not get a tight seal on the top of the mask and that was distracting is it ok for the top of the mask to be loose? Results from non-participation survey Non-participation survey NNumber in CDCP who did not participate in exercise14Number of non-participants who completed survey10Primary reason for non-participation:I have a condition that makes me concerned about wearing a mask for an extended period of time3I wasnt here during exercise period3I didnt want to wear a mask while interacting with clients2I thought wearing a mask would interfere with my work duties0I didnt want to wear a mask in front of my coworkers0Ive tried / worn a mask before0I didnt hear about it0I didnt think the exercise was applicable to me0Other:Too busy and forgot to sign up1I think its a waste of good masks and the exercise may be uncomfortable1Other reasons for non participation:I have a condition that makes me concerned about wearing a mask for an extended period of time1I wasnt here during exercise period1I didnt want to wear a mask while interacting with clients0I thought wearing a mask would interfere with my work duties2I didnt want to wear a mask in front of my coworkers0Ive tried / worn a mask before2I didnt hear about it1I didnt think the exercise was applicable to me0Other:Time constraints1No place to put mask due to office remodel1Would you be willing to wear a face mask during a pandemic situation?Yes8Maybe2No0 Reasons that may prompt a non-participant to wear a mask at work: Concern about infectious disease transmission Protect myself from contagion APPENDIX B FACE MASK PILOT EXERCISE LOG Name: _______________________ CDCP FACE MASK PILOT EXERCISE Thank you for participating in this pilot exercise! Its purpose is to: Estimate the amount of masks that workers may need to use during an infectious disease emergency Identify the factors that affect whether the masks may be used comfortably. We also plan on using these results to help CDCP and SFDPH prepare for responding to a potential infectious disease emergency such as pandemic influenza. We will also be sharing the results with the region and beyond to help them in their planning. The more detailed you are in using this log and noting your experience / suggestions, the better! Individual responses will be kept confidential and will only be shared in an aggregate manner. GROUND RULES AND INSTRUCTIONS Bottom Line: Try to use as few masks as you can during the day, but do change them as often as you need to (see guidance on when to put on a new mask* below) and note reason for changing masks. Its ok to take off your mask if you feel that it is interfering with your job duties, when you need to eat, etc. Just make sure you note the reason in this log. Ground rules: Pick up to 3 days on the following dates to participate in the study: Thurs 6/7, Fri 6/8, Tues 6/12 or Wed 6/13. They dont have to be consecutive days. During these 3 days, keep this log folder with you and note every time you take off a mask and/or put on a new one. Also make any other additional notes that inform us of any other barriers to mask use. Remove mask and sanitize your hands when your mask becomes moist/wet, and/or before eating/drinking Stop wearing a mask: At the end of work day If at any time you have any trouble breathing, take the mask off and do not put a new one on. Please note this in your log and stop participating in this exercise. You should be able to carry on with your daily activities such as talk on the phone, etc. while wearing the masks. If you need more masks, there are more at Room 204 at Carmens Desk, in room 102 former front desk area, and in Room 408 by Josephines desk. For tracking purposes, please sign out the number of masks you took and the date in the Extra Mask Log. Feel free to call Yeva (x2634) or Pancy (x2667) if you have any questions. End-of-exercise experience survey FACE MASK PILOT EXERCISE LOG Please answer these questions about your general experience before turning in your folder at the conclusion of your exercise participation. You may turn in your folders in designated boxes where extra masks were located: Room 204 at Carmens Desk, in room 102 former front desk area and in Room 408 by Josephines desk. 1) General comments about your experience: 2) Was there any reason that made wearing a mask difficult for an extended period of time? Yes / No If Yes, please state reason _______________________________________________ 3) Do you normally wear head accessories during your workday, such as glasses, hearing aid, headset? Yes / No If yes, did the head accessories interfere with the mask-wearing? How so? 4) Did you use the provided hand sanitizer in conjunction with your mask? Yes / No If yes, how much (%) of the bottle is left? __________________ (after 1 / 2/ 3 days) 5) What would make the mask-wearing experience easier? (Think in terms of types of masks, rules for taking masks on/off, etc.) 6) After this exercise, do you think that you would wear a surgical mask if instructed to do so during an infectious disease emergency? Yes / No If No, why not? In addition to this log, we will hold a group debrief on Mon. June 18 in room 220 during CDCP Seminar where you can share your experience with us if youd like. We will share the final summary report with you when it is completed. FACE MASK PILOT EXERCISE LOG Day: 1 / 2 / 3 Date: _______________ Number of people in your office today: ____________ Approximate # of hours at work: __________ Any face-to-face contact with the public today? Yes / No Temperature of work environment: ( hot / warm ( Just right ( Cool ( Other _______ Mask #Main ActivitiesTime on/offReasons for removal & Other observationsOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoPage 1 FACE MASK PILOT EXERCISE LOG Mask #Main ActivitiesTime on/offReasons for removal & Other observationsOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoPage 2 FACE MASK PILOT EXERCISE LOG Mask #Main ActivitiesTime on/offReasons for removal & Other observationsOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoOn the phone (w/headset) On the phone (w/o headset) On computer In a meeting Seeing clients Performing a medical procedure Admin duties Other: ____________ On: Off: If this were a pandemic situation, would you have taken your mask off for this reason? Yes / NoPage 3 Instruction on Using Hand Sanitizer How to Wash with Alcohol-Based Hand Sanitizer Hand sanitizer should have at least 62% alcohol content Apply a dime to quarter size (depending on the size of the hands) of product to the palm of one hand Rub hands together over all surfaces of hands and fingers until hands are dry. If hands are dry before 10 seconds, you probably need to use a bit more product for your hands Tip: If your hands are dirty, wash with soap and water. When You Should Wash Your Hands? Before wearing a face mask After removing a face mask Before preparing or eating food After going to the bathroom After blowing your nose, coughing or sneezing Before or after touching someone who is sick, or the environment of the sick After handling garbage Face Mask Pilot Exercise Debrief Communicable Disease Control & Prevention Section San Francisco Department of Public Health June 18, 2007 Did the informational meeting prior to the orientation sessions help you with deciding whether to participate or not? Was in helpful in any other way? Was the orientation useful? educational? Were the supplies sufficient and/or appropriate? Is there anything else you wanted to have? What went well? What didnt go well? (whether or not your were wearing a mask) While working at your desk While on the phone While interacting with coworkers Did wearing of the mask interfere with your normal routine at all? In what ways? What were some of the most common reasons why you took off the mask or decided not to wear a mask? If this were a pandemic situation, would you do anything differently? How much instruction would you need? Do you know how to wear a face mask? Suggestions for future exercises population, rules, etc.  CDC Interim Pre-Pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States, February 2007, p. 19.  OSHA Guidance on Preparing Workplaces for an Influenza Pandemic, OSHA 3327-02N 2007, p. 14.  OSHA Guidance on Preparing Workplaces for an Influenza Pandemic, OSHA 3327-02N 2007, p. 21.  CDC Interim Pre-Pandemic Planning Guidance for the Use of Facemasks and Respirators in Non-Occupational Community Settings during an Influenza Pandemic, 2007, p.5.     Last revised:  DATE \@ "M/d/yyyy" 9/26/2008 Page  PAGE 1 of  NUMPAGES 27 7/24/07 Page  PAGE 20 of  NUMPAGES 20 Last revised: 5/23/07        Reasons for quitting exercise participation (For those who wore masks for 1 hour or less only, N = 3) Glasses fogging up Was sick and had to constantly remove mask to blow his/her nose Too warm and felt claustrophobic in the mask Correlation between length of participation and length of time each mask was worn: Slope = 0.042 Correlation = 0.27 P-value = 0.001 3?@% 2 K N k     ! " B C L M N O j t ~ շyqyqyqqqiah87CJaJh-jCJaJh,0CJaJh _CJaJhCJaJh#HCJaJhVCJaJh!|hrCJaJh!|h_CJaJh#RCJaJh!|hmCJaJh!|hr3CJaJhmCJaJh!|hm5CJaJh/5CJaJh!|h n5CJaJhD)5CJaJ&@t 9:vwdeC$a$gdr3 & Fgd_)`gdZo`gdr3`gd(@gdm$a$gdm~  3 z   " J X ] a b  / ? 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p֪ytfikd&$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / / p֪ytfikd.$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l " t֪0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd6$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{ " t֪04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd2?$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdVG$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdzO$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdW$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd_$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdg$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd p$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd.x$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdR$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdv$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd*$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdN$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdr$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikd&$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdJ$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfi$$If!vh55h5A5u55u55p5 5 \5 5 \5 5 {55{5#v#vh#vA#vu#v#vu#v#vp#v #v \#v #v \#v #v {#v#v{#v:V l  t֠0455h5A5u55u55p5 5 \5 5 \5 5 {55{5/ / /  / p֪ytfikdn$$Iflz 8Tq "%'z*,t/1n4hAuup\\{{  t֠04DDDD44 lap֪ytfip$$If!vh5g5v52535+#vg#vv#v2#v3#v+:V l4  t20m,++5g5v52535+/ / p2ytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l4  tP0m,++5g5v55A55B55B/ / pPytfikd$$Ifl4ִ qb#', g vABB  tP0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / / pPytfikd $$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tP0m,5g5v55A55B55B/ / pPytfikdZ$$Iflִ qb#',gvABB  tP0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd2$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd"$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikdR'$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd+$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd0$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikdr4$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd8$$Iflִ qb#',gvABB  tF0m,    44 lapPytfi$$If!vh5g5v55A55B55B#vg#vv#v#vA#v#vB#v#vB:V l  tF0m,5g5v55A55B55B/ / pPytfikd2=$$Iflִ qb#',gvABB  tF0m,    44 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