Table of Contents
Recommendations by various countries and organisations
Introduction
The COVID-19 pandemic has certainly brought much confusion in terms of what the guidelines should be for use of protective equipment - particularly wearing face masks in a community setting. Thus, it is important to discuss the pros and cons of wearing face masks in the community.
Types of masks available
There are different types of masks available- medical masks and non-medical masks. Medical masks include surgical masks and N95. Non-medical masks can be made of household items such as clothes fabrics, bedsheets, and bandanas. In order for either type of mask to work, it needs to cover the nose and mouth firmly, secured with ear loops, and not affect the user’s breathing (Desai & Aronoff, 2020).
Pros of wearing masks
Firstly, the virus can be transmitted even if people are asymptomatic. By wearing masks regardless, the overall rate of community transmission can be reduced. Additionally, there are situations where physical distancing might be difficult, such as at a supermarket or while taking public transport. In these instances, wearing masks can mitigate the risk of transmission (Desai & Aronoff, 2020). Furthermore, physical distancing alone may not be sufficient. The virus droplet are viable in the air for several hours, meaning that even if everyone maintained social distancing, that may not be enough to completely stop transmission (Greenhalgh, Schmid, Czypionka, Bassler, & Gruer, 2020).
Interestingly, wearing masks can also have a psychological impact- reminding others to continue practicing physical distancing (Feng et al., 2020). It makes people more aware of their surroundings and who they come into contact with.
Precautionary Principle
There is not enough knowledge regarding the treatment for the virus. We do not yet have a vaccine nor definitive treatment. Globally, the number of cases continue to rise, increasing the strain on the health care system. Thus, it can be argued that adopting a precautionary principle might be better (Greenhalgh et al., 2020). The virus is proving to be such a serious threat that it might be better for everybody to wear a mask regardless. There can only be population benefits with harms unlikely (Javid, Weekes, & Matheson, 2020).
Non-medical masks might be a great alternative. While its efficacy may not be very well understood, mass manufacturing is easy and cheap, and it could generate some economic activity (Javid et al., 2020).
Cons of wearing masks
There are four main arguments as to why not everybody needs to wear masks.
Firstly, masks may not be as effective against reducing transmission as we think they might be. Two systematic reviews testing the efficacy of wearing masks to reduce influenza transmission revealed no substantial effect on decreasing influenza transmission. Another systematic review comprising 31 studies demonstrated a reduction in influenza transmission but was not statistically significant (Greenhalgh et al., 2020).
Secondly, people in the community, particularly non-health care workers may not know how to put on a mask properly and how to use it. Masks are only effective if users prevent touching their masks repeatedly and wear them for most of the time (Desai & Aronoff, 2020; Greenhalgh et al,. 2020). Improper use could not only reduce the protective effect but also increase risk of infection (Feng et al., 2020).
Thirdly, it creates a false sense of security and may cause neglect of basic hygiene measures. Wearing masks only protect the user from virus transmission through their nose and mouth. However, the virus can also be transmitted through contact with the eyes. Thus, relying on masks can provide false security. Additionally, less importance could be given to fundamental measures such as hand hygiene and social distancing as a result of relying on masks to provide protection (Javid et al., 2020).
Lastly, if everybody in the community is recommended to wear masks, it creates a huge shortage of protective gear for medical workers, especially for frontline medical workers. This is already happening and as a result, certain countries such as South Korea and Germany have already banned exportation of protective gear to secure supply for local demand. The World Health Organisation (WHO) has requested a 40% increase in the supply of protective gear including face masks (Feng et al., 2020).
Discussion
While there are many pros and cons to everybody wearing masks, a few factors need to be considered before deciding- the location, the vulnerability of the population, cultural context, supply and efficacy.
Location
Firstly, in open, well-ventilated areas, there is no need for everybody to wear a face mask. However, in poorly ventilated areas, wearing a mask helps to prevent inhaling respiratory droplets (Desai & Aronoff, 2020). A case study in China demonstrated that persons wearing masks while using public transport had a reduced risk of acquiring the infection (Liu & Zhang, 2020).
Vulnerable population
Secondly, vulnerable populations such as health care workers, the elderly, and the immunocompromised should be recommended to wear masks (Feng et al., 2020). Healthy individuals may not need to wear masks in the community whereas those in quarantine or with confirmed COVID-19 infection should.
Cultural context
Thirdly, the cultural context must be taken into account. In many countries, most Asians wear a mask whereas non-Asians do not. This has led to racial aggravation and discrimination (Feng et al., 2020). This highlights the importance of public education and recognising the underlying attitudes towards public health problems.
Limited resources
With scarce resources, it might not be possible for everybody in the community to wear masks without overstaying the lifespan of masks. This might be possible if there was a greater supply of masks. Additionally, research on prolonging the lifespan of each mask and making reusable masks might allow everyone in the community to wear masks (Feng et al., 2020).
Efficacy
As mentioned above, studies have shown that the efficacy of masks in reducing community transmission rates is not significant. However, one argument is that even if the decrease in community transmission may not be statistically significant, it could still mean a major difference to the demand elsewhere in the health care system (Greenhalgh et al., 2020). For example, even a small decrease could mean more beds and ventilators available in the hospitals. The low risk of harm should outweigh the absence of evidence (Javid et al., 2020).
Recommendations by various countries and organisations
The recommendations for face mask use in the community are varied across countries and organisations as shown in the following table (Feng et al., 2020).
Country/Organisation
Recommendations
WHO
· If healthy, wear a mask only if taking care of person with suspected infection
China
· If at high risk, wear a surgical or disposable mask
· If at low risk, wear a disposable mask
· If at very low risk, do not wear a mask or wear a non-medical mask such as cloth mask
Hong Kong
· If symptomatic, wear a surgical mask
· Wear a surgical mask if taking public transport or in a crowded area
Singapore
· Wear a mask if you have respiratory symptoms such as cough, runny nose
Japan
· If you are at an open-air environment, no need for mask. Wear one only if in poorly ventilated, confined areas.
USA
· Centres for Disease Control and Prevention recommends not to wear medical face mask to prevent respiratory infections. Non-medical face masks are encouraged in community settings.
UK
· If working in hospital or health care environment, wear a mask. Otherwise, little evidence for efficacy of masks
Germany
· Not enough evidence to prove that wearing a surgical mask significantly reduces healthy person’s risk of contracting infection.
Australia
· Wear a mask if sick with COVID-19 symptoms or taking care of someone with these symptoms
Conclusion
Rather than deciding on a blanket rule, multiple approaches need to be considered given the lack of information. Firstly, there needs to be an increase in supply of protective equipment. Secondly, education needs to be given to not only health care workers but also to the public about how to use face masks effectively and their indications. Thirdly, more research needs to be conducted on the efficacy of face masks to aid informed decision-making. Lastly, efforts need to be put into creating a more definitive treatment, starting with a vaccine. The varied recommendations by different countries and organisations have certainly been a source of much confusion amongst the public, and further worsened by social media. While there may not be a clear right or wrong answer, a more united approach is certainly needed so that the public can trust and adhere to the guidelines, instead of panicking and mass purchasing of masks.
References
Desai, A. N., & Aronoff, D. M. (2020). Masks and Coronavirus Disease 2019 (COVID-19). JAMA. doi:10.1001/jama.2020.6437
Feng, S., Shen, C., Xia, N., Song, W., Fan, M., & Cowling, B. J. (2020). Rational use of face masks in the COVID-19 pandemic. The Lancet Respiratory Medicine. doi:https://doi.org/10.1016/S2213-2600(20)30134-X
Greenhalgh, T., Schmid, M. B., Czypionka, T., Bassler, D., & Gruer, L. (2020). Face masks for the public during the covid-19 crisis. BMJ, 369, m1435. doi:10.1136/bmj.m1435
Javid, B., Weekes, M. P., & Matheson, N. J. (2020). Covid-19: should the public wear face masks? BMJ, 369, m1442. doi:10.1136/bmj.m1442
Liu, X. and Zhang, S. (2020), COVID‐19: Face masks and human‐to‐human transmission. Influenza Other Respi Viruses. doi:10.1111/irv.12740