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Face Masks and COVID-19 Advice

What Lies Behind the Mask: There is a Message for Us All
by Mika Hiroi | BMedSc, GradDipBiotech | Programme Care Ltd & Dr Bob Kass | Public Health Physician - March 25, 2020

Mixed Messaging around the use of Face Masks and COVID-19 from different countriesDuring the SARS outbreak of 2003, images of people wearing face masks on planes were splashed across our televisions and in the print media. Yet, after the outbreak, we were told that no-one contracted the disease while flying. It was NOT a disease of travellers, but one of healthcare workers and close family contacts. Thousands of cases, many deaths yet not one acquired case during air travel.  It wasn’t until after the disease had peaked that we understood the reason.  SARS behaved differently to influenza.  Individuals were infectious a few days into the illness and not in the early stages of the disease.  You could not contract the disease from asymptomatic individuals. You had to be unwell to pass it on. 

Unfortunately, COVID-19 behaves more like influenza. It is far more infectious than SARS. It has definitely become a disease of travelers.

Eighteen years later and the use of face masks has again become the norm in China and most of SE Asia. In some domains it has been compulsory to wear a face mask.

Why are some authorities in Asia strongly recommending the use of masks while in America and most other Western countries we are being told they are of limited benefit and predominant use should be reserved for use by health personnel only?

The messaging according to experts is very much: “face masks provide no effective protection against Coronavirus”!  Does this message have substance or are we trying to manage stocks depleted by panic buying and market opportunism.

We believe the answer lies somewhere in between.

There is currently very little evidence to support widespread community use of face masks to protect against respiratory illnesses such as COVID-19. In fact, face masks made of cloth have been shown to promote the spread of viral infection and this is disturbing.  On the other hand, the use of appropriate face masks has been proven to be substantially protective in settings where health workers are in close contact with respiratory infections.

People can reasonably state; “If this were the case, would it then be beneficial for those at risk of serious disease to wear a mask in public if this particular disease, COVID-19, can be spread by asymptomatic individuals or by those in the early stages of their illness”.  I believe this is a legitimate question but would only apply if there was good evidence of widespread community transmission.

Despite the visual messaging in the media, country advice is remarkably consistent (see below). It is interesting to note that most authorities do endorse the use of masks in specific situations, many of which probably don’t apply in places like Australia where the population density is much lower.

MIXED MESSAGING AND THE PUBLIC

As we move into a period of increasing case notifications and deaths, how will people respond to conflicting visual messaging on masks out of South East Asia and those from the experts here in Australia and in Europe and North America??

In Asian cultures, particularly Japan, wearing a face mask is reflective of a collectivist culture. This is an embedded social practice that represents an obligation to protect the wider community.  In China and Hong Kong, perhaps more recently, this is an effective way of remaining relatively incognito or protection against rising air pollution.  

However, in Western cultures, a facemask is seen as an alien symbol of contamination – someone to be avoided.  This is where we have to be careful.  It is very important we don’t discriminate against normal cultural practices!

In a low transmission environment as we currently have in Australia, misinformation surrounding the protective efficacy of face-masks against respiratory viruses has contributed to unnecessary panic at an individual level. This has resulted in a global shortage of personal protection equipment. Personal protection equipment is vitally important for healthcare workers who are at high risk of contracting COVID-19 and those who might have symptoms and risk of the disease.

While an N95 respirator mask may provide a modest amount of protection against airborne viral particles, and certainly helps in the prevention of spread when worn properly, however, the reality is that surgical masks offer very little personal protection. Surgical masks, disposable masks, woven cloth and fabric masks, provide negligible protection from respiratory viruses, especially if ill-fitted, and likely contribute to a false sense of security.  

However, they might help reduce transmission from a sick person to others!

The World Health Organization states that healthy people should only wear a face-mask if they are taking care of someone with suspected or confirmed COVID-19. They advise to wear a mask if coughing or sneezing, and to be mindful that masks are only effective when used in combination with frequent hand-washing with soap and water or alcohol-based hand sanitizer. 

More liberal use of masks might be considered in higher density areas where disease prevalence is high. Thankfully this is unlikely in Australia at this time, but it may be different in 6 to 8 weeks.

COVID-19’s main mode of spread is via close contact with an infected individual (less than 2m) and droplet transmission from the nose or mouth of an infectious person – this happens when the person coughs, sneezes or exhales. Droplets from the virus land on objects and surfaces. Others can then catch the virus by touching these infected objects or surfaces, then touching their eyes, nose or mouth.

A person touches their face at an average of 23 times per hour. If you have the virus on your hands, and touch your eyes, or lift your face-mask to eat a snack – you have potentially infected yourself. It is far more important to maintain good hand-hygiene as opposed to feeling a false sense of security from a face-mask.

So, if masks can’t protect me, what precautions can I take?

Face masks are not very effective in preventing someone from catching a respiratory illness, but they are beneficial in reducing the spread if you are actively coughing or sneezing.  It is far more important to practice good hand-hygiene, and refrain from touching your eyes, nose and mouth. The importance of hand hygiene in a viral pandemic cannot be overstated.

Keep in mind that over 80% of COVID-19 cases are considered to be mild. Those who are considered to be at ‘high risk’ of developing severe complications are those over the age of 60 (increasing with age) and/or those who have pre-existing medical conditions, such as heart disease, diabetes, high blood pressure and existing respiratory illness.

Even if you are not in an ‘at risk’ group, you still have a responsibility to mitigate the risk of transmission to those around you.

Why hand-washing?

It may sound banal, but hand-washing really does help. The COVID-19 virus is comprised of a fatty outer layer (the lipid bilayer). The outer membrane is the most vulnerable part of the nanoparticle. Soap dissolves this membrane and essentially the virus collapses like a house of cards.

What else should I be aware of?

It is important to be aware of the latest COVID-19 information in your current location and/or in the region you are intending to travel to. Updates should be sourced from the WHO website and through your national and local public health authority. Simple precautions can be taken to reduce the risk of being infected with COVID-19:

  • Follow good hand hygiene. Regular and thorough washing of hands is the most important precaution. This should be done either with an alcohol-based hand sanitizer or washing with soap and warm water. This will kill viruses on your hands.
    • Remember to wash your hands: after coughing or sneezing; when caring for the sick; before, during and after preparing food; before eating; after toilet use; when hands are visibly dirty and after handling animals.
  • If you are in the vicinity of someone coughing or sneezing, maintain a 1 to 2-metre distance between each other. (Perhaps it would be nice to note that the person who is coughing or sneezing is wearing a mask!)
  • Avoid touching your eyes, nose and mouth.
  • If you feel unwell – self-isolate by staying at home. Seek medical attention (call in advance) if you have a fever, cough and difficulty breathing.
  • Stay informed on the latest developments. Follow advice given by your healthcare provider and your national/local public health authority.
  • Avoid travelling to areas where there is uncontrolled, localized transmission of COVID-19 (i.e. hotspots), especially if you are deemed to be ‘at risk’.

COUNTRY ADVICE ON MASKS

WHO

  • If you are healthy, you only need to wear a mask if you are taking care of a person with suspected SARS-CoV-2 infection

[WHO is more talking about the healthcare situation but ignores high density living where transmission is/was high (Wuhan)].

CHINA

  • People at moderate risk of infection: surgical or disposable mask for medical use.  
  • People at low risk of infection: disposable mask for medical use.
  • People at very low risk of infection: do not have to wear a mask or can wear non-medical mask (such as cloth mask).

People at moderate risk of infection include those working in areas of high population density (eg, hospitals, train stations), those have been or live with somebody who is quarantined, and administrative staff, police, security, and couriers whose work is related to COVID-19. †

People at low risk of infection include those staying in areas of high population density (eg, supermarket, shopping mall), who work indoors, who seek health care in medical institutions (other than fever clinics), and gatherings of children aged 3–6 years and school students. ‡

People at very low risk of infection include those who mostly stay at home, who do outdoor activities, and who work or study in well-ventilated areas.

[China had high rates of infection in Wuhan. They understood early that the disease behaved differently to SARS. Infections were not confined to household contacts and healthcare workers, but widespread in the community. They went into lockdown quickly and saw every individual as a potential source. The use of masks was recommended]

HONG KONG

  • Surgical masks can prevent transmission of respiratory viruses from people who are ill. It is essential for people who are symptomatic (even if they have mild symptoms) to wear a surgical mask.
  • Wear a surgical mask when taking public transport or staying in crowded places. It is important to wear a mask properly and practice good hand hygiene before wearing and after removing a mask.

[Health authorities are in control of the spread and the people were disciplined through their experience with SARS. They were culturally comfortable with the use of masks, particularly when unwell]

SINGAPORE

  • Wear a mask if you have respiratory symptoms, such as a cough or runny nose.

[Health authorities are in control of the spread and the people were disciplined through their experience with SARS. They were culturally comfortable with the use of masks, particularly when unwell]

JAPAN

  • The effectiveness of wearing a face mask to protect yourself from contracting viruses is thought to be limited. If you wear a face mask in confined, badly ventilated spaces, it might help avoid catching droplets emitted from others but if you are in an open-air environment, the use of face mask is not very efficient

[Health authorities are in control of the spread and the people were disciplined through their experience with SARS. They were culturally comfortable with the use of masks, particularly when unwell]

USA

US Surgeon General says that wearing face masks could increase the risk of contracting Coronavirus

[The message is very confusing. What if you were at home with a COVID-19 positive patient. Surely the unwell person would wear a mask if there is any contact with well people. Are the health authorities trying to get you to focus on hand hygiene and social distancing as more important messages? Are they so convinced they can encourage people to keep away from high density activities? This didn’t work for Australians on Bondi Beach!]

UK

  • Face masks play a very important role in places such as hospitals, but there is very little evidence of widespread benefit for members of the public.

[London is a densely populated area. Should we be considering a mask once the virus is widespread in the community as well as promoting the more important message of hand hygiene and social distancing. Where there is widespread disease in a densely populated community we may be protecting others by an undiagnosed person wearing a mask. This is where Singapore, Hong Kong and South Korea may have it right!]

GERMANY

  • There is not enough evidence to prove that wearing a surgical mask significantly reduces a healthy person’s risk of becoming infected while wearing it. According to WHO, wearing a mask in situations where it is not recommended to do so can create a false sense of security because it might lead to neglecting fundamental hygiene measures, such as proper hand hygiene

[The Germans are the most honest but go back to WHO’s statement. At least they talk about the mask creating a false sense of security. Unfortunately, they don’t note the protection afforded when a sick person wears a mask]

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