IOM & face masks: Efficacy vs effectiveness

Yesterday's report from the IOM on respiratory protection for healthcare workers against H1N1 was quite disappointing. Unfortunately, IOM evaluated the question from the standpoint of efficacy (how well an intervention works in an ideal setting) rather than one of effectiveness (how well an intervention works under real world conditions). Effectiveness takes into account compliance, which is likely to be an issue when levels of disease activity rise and healthcare workers spend more of their day wearing a mask. But more importantly, the current supply of N95 masks appears to be insufficient for them to be used when encountering all patients with suspected swine flu. I don't disagree with IOM's conclusion that N95 masks are more protective then standard masks, but to ignore logistics and practicality when making a recommendation is of little help to those of us in the trenches. I received several emails yesterday from hospital epidemiologists at academic medical centers who stated they would not follow the IOM recommendation but continue with SHEA's recommendation (i.e., use of a standard mask except for aerosol generating procedures).