← Product Code [JOJ](/productcode/JOJ) · K202565

# WAVICIDE-OPA MEC Indicator (K202565)

_Serim Research Corporation · JOJ · Dec 2, 2020 · General Hospital · SESE_

**Canonical URL:** https://fda-staging.innolitics.com/device/K202565

## Device Facts

- **Applicant:** Serim Research Corporation
- **Product Code:** [JOJ](/productcode/JOJ.md)
- **Decision Date:** Dec 2, 2020
- **Decision:** SESE
- **Submission Type:** Traditional
- **Regulation:** 21 CFR 880.2800
- **Device Class:** Class 2
- **Review Panel:** General Hospital

## Indications for Use

When properly worn, the surgical face masks are intended to protect both patient and healthcare workers from transfer of microorganisms, body fluids and airborne particles. This device is non-sterile and for single use only.

## Device Story

BASE4 Disposable Medical Mask is a non-sterile, single-use, three-layer, flat, pleated surgical mask. It features spunbond polypropylene outer and inner layers with a melt-blown polypropylene middle filter layer. The mask is secured via ear loops and includes a PVC-coated galvanized wire nosepiece for facial contouring. Used in clinical settings by healthcare workers and patients to provide a physical barrier against microorganisms, body fluids, and airborne particles. The device functions as a passive protective barrier; it does not involve electronic processing, software, or active sensing. Clinical benefit is derived from its ability to meet ASTM F2100 Level 2 performance standards for fluid resistance, particulate filtration, and bacterial filtration, thereby reducing the risk of cross-contamination.

## Clinical Evidence

Bench testing only. The device was evaluated against ASTM F2100, ASTM F1862 (fluid resistance), ASTM F2299 (particulate filtration efficiency: 98.8%), ASTM F2101 (bacterial filtration efficiency: >99.9%), MIL-M-36954C (differential pressure: 4.4 mmH2O/cm²), 16 CFR 1610 (flammability: Class 1), and ISO 10993-5/10 (biocompatibility: non-cytotoxic, non-sensitizing, non-irritating).

## Technological Characteristics

Three-layer construction: spunbond polypropylene (outer/inner), melt-blown polypropylene (filter). Nosepiece: PVC-coated galvanized wire. Ear loops: 70% polyester, 30% spandex. Dimensions: 17.5 cm x 9.5 cm. Performance: ASTM F2100 Level 2. Non-sterile, single-use.

## Regulatory Identification

Biological sterilization process indicator: A device intended for use by a health care provider to accompany products being sterilized through a sterilization procedure and to monitor adequacy of sterilization. The device consists of a known number of microorganisms, of known resistance to the mode of sterilization, in or on a carrier and enclosed in a protective package. Subsequent growth or failure of the microorganisms to grow under suitable conditions indicates the adequacy of sterilization. Physical/chemical sterilization process indicator: A device intended for use by a health care provider to accompany products being sterilized through a sterilization procedure and to monitor one or more parameters of the sterilization process. The adequacy of the sterilization conditions as measured by these parameters is indicated by a visible change in the device.

## Predicate Devices

- Mask, Surgical Apparel ([K200847](/device/K200847.md))

## Submission Summary (Full Text)

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Image /page/0/Picture/0 description: The image shows the logo of the U.S. Food and Drug Administration (FDA). On the left is the Department of Health & Human Services logo. To the right of that is the FDA logo, with the letters "FDA" in a blue square. To the right of the blue square is the text "U.S. FOOD & DRUG ADMINISTRATION" in blue.

December 1, 2020

Base4 Group, Inc. % Thomas Knott Senior Regulatory Advisor Benjamin L. England and Associates, LLC 810 Landmark Dr, Suite 126 Glen Burnie, Maryland 21061

Re: K202069

Trade/Device Name: BASE4 Disposable Medical Mask Regulation Number: 21 CFR 878.4040 Regulation Name: Surgical Apparel Regulatory Class: Class II Product Code: FXX Dated: November 2, 2020 Received: November 2, 2020

Dear Thomas Knott:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. Although this letter refers to your product as a device, please be aware that some cleared products may instead be combination products. The 510(k) Premarket Notification Database located at https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm identifies combination product submissions. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal

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statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); medical device reporting of medical device-related adverse events) (21 CFR 803) for devices or postmarketing safety reporting (21 CFR 4, Subpart B) for combination products (see https://www.fda.gov/combination-products/guidance-regulatory-information/postmarketing-safety-reportingcombination-products); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820) for devices or current good manufacturing practices (21 CFR 4, Subpart A) for combination products; and, if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21 CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to https://www.fda.gov/medical-device-safety/medical-device-reportingmdr-how-report-medical-device-problems.

For comprehensive regulatory information about medical devices and radiation-emitting products, including information about labeling regulations, please see Device Advice (https://www.fda.gov/medicaldevices/device-advice-comprehensive-regulatory-assistance) and CDRH Learn (https://www.fda.gov/training-and-continuing-education/cdrh-learn). Additionally, you may contact the Division of Industry and Consumer Education (DICE) to ask a question about a specific regulatory topic. See the DICE website (https://www.fda.gov/medical-device-advice-comprehensive-regulatoryassistance/contact-us-division-industry-and-consumer-education-dice) for more information or contact DICE by email (DICE@fda.hhs.gov) or phone (1-800-638-2041 or 301-796-7100).

Sincerely,

For CAPT Elizabeth Claverie, M.S. Assistant Director DHT4B: Division of Infection Control and Plastic Surgery Devices OHT4: Office of Surgical and Infection Control Devices Office of Product Evaluation and Quality Center for Devices and Radiological Health

Enclosure

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# Indications for Use

510(k) Number (if known) K202069

Device Name Surgical Face Mask

Indications for Use (Describe)

When properly worn, the surgical face masks are intended to patient and healthcare workers from transfer of microorganisms, body fluids and airborne particles. This device is non-sterile and for single use only.

| Type of Use (Select one or both, as applicable) |  |
|-------------------------------------------------|--|
|-------------------------------------------------|--|

Prescription Use (Part 21 CFR 801 Subpart D)

|X Over-The-Counter Use (21 CFR 801 Subpart C)

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## 510(k) SUMMARY

# Date of Summary Prepared: November 25, 2020 510(k) Number: K202069

| Submitted By: | Benjamin L. England And Associates, LLC                  |
|---------------|----------------------------------------------------------|
| Address:      | 810 Landmark Drive<br>Suite 126<br>Glen Burnie, MD 21061 |
| Phone:        | (410) 220-2800                                           |
| Fax:          | (443) 583-1464                                           |
| E-mail:       | tcknott@englandlawgroup.com                              |
| Contact:      | Thomas C. Knott, Senior Regulatory Consultant            |
| On Behalf of: | BASE4 Group, Inc.                                        |
| Address       | 4393 Sunbelt Drive<br>Addison, TX 75001                  |
| Phone:        | (972) 331-6619                                           |
| Fax:          |                                                          |
| E-Mail:       | Jon@ebase4.com                                           |
| Contact:      | Jon Filipski                                             |

## 1. Regulatory Information

| Proprietary Name:    | BASE4 Disposable Medical Mask (NB Green2020-12; Model<br>Number is 07787) |
|----------------------|---------------------------------------------------------------------------|
| Classification Name: | Surgical Face Mask, Apparel                                               |
| Common Name:         | Surgical face mask                                                        |
| Classification:      | Class II                                                                  |
| Product Code:        | FXX                                                                       |
| Panel                | General Surgery Devices                                                   |
| Regulation:          | 21 CFR 878.4040                                                           |

## 2. Predicate Device

| 510(k) Number: | K200847                |
|----------------|------------------------|
| Device Name:   | Mask, Surgical Apparel |

## 3. Indications for Use

When properly worn, the surgical face masks are intended to protect both patient and healthcare workers from transfer of microorganisms, body fluids and airborne particles. This device is non-sterile and for single use only.

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The surgical face mask is a non-sterile, single use, three-layer, flat, pleated style with ear loops and a nose piece. The outer and inner layers are spunbond polypropylene, and the middle layer consists of melt-blown polypropylene filter. Each mask is secured to the face with ear loops with a nosepiece to conform the mask to the shape of the nose.

## 5. Summary of Comparison and Technological Characteristics

#### Table 1 - General Comparison

4. Device Description

| CLASSIFICATION INFORMATION |                                                                                                                                                                                                                                                       |                                                                                                                                                                                                                                                      |      |
|----------------------------|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------|
| 510(k) Number              | K202069                                                                                                                                                                                                                                               | K200847                                                                                                                                                                                                                                              | N/A  |
| Manufacturer               | Ningbo Green Textile Co., Ltd                                                                                                                                                                                                                         | Mexpo International, Inc.                                                                                                                                                                                                                            | N/A  |
| Common<br>Name             | Surgical Face Mask                                                                                                                                                                                                                                    | Surgical Face Mask                                                                                                                                                                                                                                   | Same |
| Product Code               | FXX                                                                                                                                                                                                                                                   | FXX                                                                                                                                                                                                                                                  | Same |
| Classification             | Class II                                                                                                                                                                                                                                              | Class II                                                                                                                                                                                                                                             | Same |
| Regulation                 | 21 CFR 878.4040                                                                                                                                                                                                                                       | 21 CFR 878.4040                                                                                                                                                                                                                                      | Same |
| Intended use               | When properly worn, the<br>surgical face masks are<br>intended to protect both patient<br>and healthcare workers from<br>transfer of microorganisms,<br>body fluids and airborne<br>particles. This device is non-<br>sterile and for single use only | When properly worn, the surgical<br>face masks are intended to<br>protect both patient and<br>healthcare workers from transfer<br>of microorganisms, body fluids<br>and airborne particles. This<br>device is non-sterile and for<br>single use only | Same |
| Model                      | Three ply, flat pleated, ear<br>loops                                                                                                                                                                                                                 | 3 Ply, Ear Loops, Flat-Pleated<br>Style                                                                                                                                                                                                              | Same |
| Tensile<br>Strength        | 10 – 15 N                                                                                                                                                                                                                                             | N/A                                                                                                                                                                                                                                                  | N/A  |

| MATERIALS |              |                                    |                                        |         |
|-----------|--------------|------------------------------------|----------------------------------------|---------|
|           | Outer Layer  | Spunbond Polypropylene             | Spunbond Polypropylene                 | Same    |
|           | Middle Layer | Melt Blown Polypropylene<br>Filter | Melt Blown Polypropylene<br>Filter     | Same    |
|           | Inner Layer  | Spunbond Polypropylene             | Spunbond Polypropylene                 | Same    |
|           | Nose Piece   | Galvanized wire coated by PVC      | Single Galvanize Wire, Coated<br>By PE | Similar |
|           | Ear Loops    | 70% polyester; 30% spandex         | not made with natural rubber<br>latex  | Unknown |
|           | Color        | Blue outer layer                   | White                                  | Differs |
|           | Width        | $95 mm = 9.5 cm$                   | $9.0cm \pm 0.5cm$                      | Same    |
|           | Length       | $175 mm = 17.5 cm$                 | $17.5cm \pm 0.5cm$                     | Same    |
|           | OTC Use?     | Yes                                | Yes                                    | Same    |
|           | Sterility    | Non-Sterile                        | Non-Sterile                            | Same    |
|           | Single Use?  | Yes                                | Yes                                    | Same    |
|           | ASTM F2100   | Level 2                            | Level 2                                | Same    |

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| ASTM F1862<br>Fluid<br>Resistance<br>Performance        | 31 out of 32 pass at 80 mm Hg<br>30 out of 32 pass at 120 mm Hg | 30 Out of 32 pass at 120 mm Hg                     | Same                 |
|---------------------------------------------------------|-----------------------------------------------------------------|----------------------------------------------------|----------------------|
| ASTM F2299<br>Particulate<br>Filtration<br>Efficiency   | 98.8%                                                           | 99.9%                                              | Both Pass<br>Similar |
| ASTM F2101<br>Bacterial<br>Filtration<br>Efficiency     | > 99.9%                                                         | > 99.9%                                            | Same                 |
| Differential<br>Pressure (Delta<br>P) MIL- M-<br>36954C | 4.4 mmH20/cm²                                                   | 3.0 mmH20/cm²                                      | Both Pass<br>Similar |
| Flammability<br>16 CFR 1610                             | Class 1                                                         | Class 1                                            | Same                 |
| Biocompatibility<br>Testing                             | Non-Cytotoxic, Non-<br>Sensitizing, Non-Irritating              | Non-Cytotoxic, Non-<br>Sensitizing, Non-Irritating | Same                 |

The outer layer of the subject mask is colored blue, and the predicate device is white. Otherwise, they are the same material, polypropylene. The outer layer does not contact the patient's skin and therefore presents minimal risk to the health of the user.

The nose piece for both devices is galvanized wire. The subject device is covered by PVC and the predicate device is covered by PE. However, neither material will contact the user's skin so there is no difference in risk to the health of the user.

The 510(k) Summary for the predicate device does not show the material for the ear loops. Therefore, no comparison can be made.

The Particulate Filtration Efficiency and Differential Pressures are similar for both masks and pass the specification required by ASTM F2100 for a level 2 mask.

## 6. Non-clinical Tests Performed on the Proposed Device

The proposed device was tested and conformed to the following standards and the requirements stated in the Guidance for Industry and FDA Staff: Surgical Masks -Premarket Notification [510(k)] Submission issued on March 5, 2004.

- . ASTM F2100: Standard Specification for Performance of Materials Used in Medical Face Masks
- . ASTM F1862/F1862M-17: Standard Test Method for Resistance of Medical Face Masks to Penetration by Synthetic Blood (Horizontal Projection of Fixed Volume at a Known Velocity)
- . ASTM F2299/F2299M-03: Determining the Initial Efficiency of Materials Used in Medical Face Masks to the Penetration of Particulates Using Latex Spheres
- . ASTM F2101: Standard Test Method for Evaluating the Bacterial Filtration Efficiency (BFE) of Medical Face Mask Materials, Using a Biological Aerosol of Staphylococcus aureus
- . MIL - M-36954C: Medical face masks - Requirements and test methods, Annex C

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- 16 CFR 1610 CPSC CS-191-53 Flammability Test Method (16 CFR 1610) Standard for ● Flammability of Clothing Textiles.
- ISO 10993-5: Biological evaluation of medical devices-Part 5: Tests for In Vitro ● Cytotoxicity
- ISO 10993-10: Biological evaluation of medical devices Part 10:Tests for irritation and skin sensitization

|  |  | Table 2 - Performance Testing |  |
|--|--|-------------------------------|--|

| Test                                                    | Proposed Device                                                 | Acceptance Criteria               | Result          |
|---------------------------------------------------------|-----------------------------------------------------------------|-----------------------------------|-----------------|
| Fluid<br>Resistance<br>Performance<br>ASTM F1862        | 31 out of 32 pass at 80 mm Hg<br>30 out of 32 pass at 120 mm Hg | 29 out of 32 pass at 120 mm<br>Hg | Pass<br>Level 2 |
| Particulate<br>Filtration<br>Efficiency<br>ASTM F2299   | 98.8%                                                           | ≥ 98%                             | Pass            |
| Bacterial<br>Filtration<br>Efficiency<br>ASTM F2101     | > 99.9%                                                         | ≥ 98%                             | Pass            |
| Differential<br>Pressure (Delta<br>P) MIL- M-<br>36954C | 4.4 mmH20/cm²                                                   | < 5.0 mm H20/cm²                  | Pass            |
| Flammability<br>16 CFR 1610                             | Class 1                                                         | Class 1                           | Pass            |

#### Table 3 - Biocompatibility Testing

| Item    | Proposed Device                                    | Acceptance Criteria                                | Result |
|---------|----------------------------------------------------|----------------------------------------------------|--------|
| Results | Non-Cytotoxic, Non-<br>Sensitizing, Non-Irritating | Non-Cytotoxic, Non-<br>Sensitizing, Non-Irritating | Pass   |

## 7. Conclusion

The conclusion drawn from the non-clinical tests demonstrates that the subject device is as safe, as effective, and performs as well as the legally marketed predicate device.

***END OF 510(k) SUMMARY****

---

**Source:** [https://fda-staging.innolitics.com/device/K202565](https://fda-staging.innolitics.com/device/K202565)

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