REVIEW ARTICLE

Unmasking the Need for during the COVID 19 Pandemic: A Review Article

Suman S. Varghese, Naveen Ramesh, Pooja R. Sridhar

Department of Community Health, St. John’s Medical College, Bengaluru, Karnataka, India

ABSTRACT

Panic seized the world as the coronavirus (CoV) disease 19 pandemic ushered in the New Year. Non-pharmaceutical interventions are strategies that are adopted by communities and individuals who are both well (to reduce exposure and avoid infection) and unwell (to avoid affecting others). The directives pertaining to the use of masks in the community by major health organizations contradicted each other. The articles that were reviewed included studies done post-recent pandemics vis-a-vis influenza pandemic 2009 and severe acute respiratory syndrome-CoV 2002–2003. The literature showed that there is sufficient reason to use “mass masking” as a strategy to cope with severe pandemics. There is evidence that cloth masks are comparable to other types of masks. In conclusion, cloth masks may be used by the public, and other masks and should be reserved for frontline workers. This non-pharmaceutical intervention, when used in conjuncture with hand hygiene and physical distancing, could potentially flatten the curve.

Key words: Cloth-masks, Coronavirus disease 19 pandemic, Mass masking

INTRODUCTION According to the Centers for Disease Control and Prevention (CDC) the N95 respirators, although disposable, can be he end of 2019 took the world by storm; a novel reused up to 5 times.[10] Triple-layer surgical masks, normally disease had begun to spread like wildfire. Little was used in healthcare, can filter up to 80% of the particles.[11] Tknown about the disease, let alone details such as route of transmission, incubatory period, or reproduction number. It is widely agreed on that the respirators have to be Eventually, many of these questions were finding answers. reserved for health-care professionals.[12,13] There are Yet, numbers were soaring, and each day bore another dismal clear directives regarding the use of masks by health-care tiding. Before China could seal down the affected areas, professionals and symptomatic individuals; however, till similar cases were cropping up in other countries. recently, regulations regarding the use of masks among the general public during the current pandemic was somewhat Non-pharmaceutical interventions are strategies that are ambiguous.[13] adopted by communities and individuals who are both well (to reduce exposure and avoid infection) and unwell (to Newspaper articles[14,15] have speculated that, in addition avoid affecting others).[1] Mobility restrictions,[2] physical to the cluster-based approach in Japan and mass screening distancing,[3-5] reducing public transport,[6,7] and limiting social in South Korea, much of the success in managing the gatherings[2] are few of the non-pharmaceutical measures coronavirus (CoV) disease (COVID) 19 pandemic may undertaken by the governing bodies across the globe. be attributed to the customary usage of facemasks. Furthermore, they usually maintain distance even while In a bid to out-run the virus, the frenzied public bought masks greeting each other, unintentionally practicing physical and sanitizers by the dozen thus forcing stores to run out of distancing.[16] stock. This sky-rocketed prices of masks even before official guidelines from major health organizations could be released. In this article, we attempt to answer the elephant in the room, It created a crisis among healthcare personnel, who needed it “Is it practical to use masks in the community to mitigate the the most.[8,9] COVID 19 pandemic?”

Correspondence: Dr. Pooja R. Sridhar, Department of Community Health, St. John’s Medical College, Bengaluru, Karnataka, India. Phone: +91-8105813770. E-mail: [email protected]

Annals of Community Health • Jul-Sep 2020 • Vol 8 • Issue 3 98 Varghese, et al.: Mass-masking, the need of the hour

USE OF MASKS DURING AN OUTBREAK donning and doffing. It needs to be reinforced that the use of face masks is not a substitute for physical distancing and “Mass masking” is the usage of masks by seemingly healthy hand hygiene.[22] individuals of the community. Although skeptical of the move, the interim guidelines issued on April 6, 2020, the Some studies show that the adherence to facemasks is low. World Health Organization (WHO) agreed that this strategy However, using the theories of “Planned Behavior” and would play a role in: “Protection Motivation” the perceptions regarding the use of • Source control (preventing the transmission of the virus masks can be steered to increase one’s protective behavior by asymptomatic/pre-symptomatic individuals) and and improve adherence.[1,23,24] • Destigmatization of symptomatic patients who wore masks. It is not recommended that children under the age of two use masks as adequate filtration cannot be achieved.[25,26] In 2019, the WHO conducted a workshop in which they reviewed the use of masks to deter the impact of the influenza If cloth masks deter breathing while performing high-intensity pandemic. It was concluded that in spite of the lack of exercises, CDC, Atlanta recommends that these activities be evidence regarding the effectiveness of masks in reducing conducted in open ventilated areas with physical distancing.[27] the progression of the pandemic “there is mechanistic plausibility for the potential effectiveness of this measure.” It EFFECTIVENESS OF HOMEMADE MASKS also recommended the use of masks in public during a severe pandemic.[17] To be better prepared for outbreaks of respiratory infections, With regard to using face masks in the community a comment Brienen et al. created a population transmission model to was published in The Lancet, which stated that, “the absence explore the impact of population-wide use. It estimated of evidence of effectiveness should not be equated to evidence the effects of mask efficacy and coverage (i.e., number of of ineffectiveness.”[18] individuals who use masks) on the basic reproduction number and the infection attack rate of the influenza virus. They concluded that population-wide use of face masks could play MASKS AMONG OTHER STRATEGIES a key role in delaying a pandemic. Mask use also reduces the reproduction number, possibly even to levels sufficient for [19,20] Two randomized trials, one by Cowling et al. and the containing an influenza outbreak.[28] other by Larson et al., comprising three interventional arms were carried out with regard to influenza pandemic of 2009. Opportunistic data collected during the severe acute The first arm was health education, the second arm was hand respiratory syndrome (SARS) (2002–2003) in hygiene, and the third was the use of masks and hand sanitizer. Asia suggested that population-wide use of face masks may Both studies showed that the third arm was more effective significantly decrease its transmission.[29-33] In fact, there than the first two. This goes to show that usage of face masks was a dose-response effect with regard to the consistency of contributes to interrupting the transmission of respiratory wearing masks in the 2 weeks before the onset of symptoms. droplet infections when used in association with hand hygiene. Those who consistently used the mask had a 70% lower chance of being diagnosed with SARS, while those who used CHALLENGES OF MASS MASKING masks intermittently had a 60% lower risk.[29]

Mass masking is a double-edged sword, and just like any The size of the CoV is 0.05–0.2 µ in diameter.[34] Single other strategy, it has its cons. The June 5, 2020, interim issue layered homemade cloth masks (made of 100% ) can by the WHO listed a few disadvantages, some of which are filter about 50% of particles between 0.02 and 1 µ in size, detailed as follows:[21] while a double layered mask filters about 70%.[35] However, • Especially in diseases that have more than one route of cloth masks made of tea towels captured about 60% of transmission, a false sense of security could creep in with particles between the same size range.[25] the use of facemasks, leading to decreased adherence to other preventive measures such as physical distancing CDC guidelines recommend a “Do It Yourself” double- and hand hygiene layered cotton mask[26] while the WHO recommends triple • Improper donning and doffing practices could lead layered cloth mask[12] to be used by the public. The cloth to self-contamination that can occur by touching and masks have to meet the following criteria[26] reusing contaminated mask. • It should be snugly fit • Easily secured with ties or ear loops These issues can be addressed by imparting health education • Two layers of fabric should be used to the public. They need to be taught the correct methods of • The mask should allow for easy breathing

99 Annals of Community Health • Jul-Sep 2020 • Vol 8 • Issue 3 Varghese, et al.: Mass-masking, the need of the hour

• Laundered effortlessly without compromising the fitness CONCLUSION of the mask. While using masks may reduce the likelihood of the infection A group of scientists and doctors used particulate filtration to with SARS nCoV-2, there is always a possibility of contracting determine the protection rendered by cloth masks for particles the disease, particularly when there is more than one route of between 0.3 and 1 µ size range. Four hundred masks made transmission.[12] Thus, it is of utmost importance that usage by community volunteers were tested, and varying results of masks be supplemented with the other non-pharmaceutical were obtained. They concluded that the material chosen to interventions such as – avoiding unnecessary touching of the make the mask was vital to its ability to filter.[36] The ideal eyes, nose, and mouth, hand hygiene, cough etiquette,[40] material would be (spunbond, and nonwoven) physical distancing, refrain from social gatherings,[41] and with a filter quality factor of 16.9/kPa.[12] The quality of cloth isolation and quarantine.[42] Mass making is a typical example masks can be tested using the candle test. In this test, a flame of the “prevention paradox,” where it offers some benefit is held six inches from the mouth, and the wearer attempts to the individual and heaps of benefit to the community, to extinguish the flame. If the flame is not blown out, it is particularly in settings where physical distancing poses as a considered a “good sign”.[22] challenge.[26]

The benefits of mass masking a community out-weigh the MASK MANAGEMENT risks. If triple-layered cloth masks are adopted for public use, there will be an adequate supply of triple ply surgical Any type of mask, which is not appropriately used and masks and N95 respirators for frontline workers who are in disposed, does more harm than good. dire need. Before discarding disposable masks along with other domestic waste, it is recommended that the masks are cut, so REFERENCES as to prevent reuse, and stored in a separate paper bag for at least 72 h.[37] 1. Teasdale E, Santer M, Geraghty AW, Little P, Yardley L. Public perceptions of non-pharmaceutical interventions for The guidelines while handling cloth masks are as follows:[35,38] reducing transmission of respiratory infection: Systematic review and synthesis of qualitative studies. BMC Public Health • The mask has to be thoroughly washed and cleaned with 2014;14:589. soap and warm water. The mask should be sun-dried for 2. Report of the WHO-China Joint Mission on Coronavirus at least 5 h Disease; 2019. Available from: https://www.who.int/docs/ • If sun-drying is not an option, the mask may be boiled default-source/coronaviruse/who-china-joint-mission-on- in hot water for 15 min with salt. Alternately, a pressure covid-19-final-report.pdf. [Last accessed on 2020 Apr 26]. cooker may be used to pressure boil the mask for 10 min 3. WHO/Europe|WHO Expert Mission to Belarus Recommends • If none of the above methods is an option, wash with Physical Distancing Measures as COVID-19 Virus Transmits water and soap and apply heat on the surface for about in the Community. Available from: http://www.euro.who.int/ 5 min with the help of an iron en/countries/belarus/news/news/2020/4/who-expert-mission- • Hands have to be washed before wearing the mask to-belarus-recommends-physical-distancing-measures-as- • The mask has to be changed as soon as it becomes damp/ covid-19-virus-transmits-in-the-community. [Last accessed on 2020 Apr 26]. humid 4. Ministry of Health and Family Welfare, Government of India. • The mask has to be washed after every use Advisory on Measure in View of Spread • At no point should the outer surface of the mask be of COVID-19 Disease. Available from: https://www.mohfw. touched. In case of string ties, the lower strings have to gov.in/pdf/SocialDistancingAdvisorybyMOHFW.pdf. [Last be undone first accessed on 2020 Apr 26]. • Hand hygiene has to be practiced after removal of the 5. Coronavirus (COVID-19): Physical Distancing|NHS Inform. mask Available from: https://www.nhsinform.scot/illnesses-and- • Clean masks have to be stored in clean and airtight plastic conditions/infections-and-poisoning/coronavirus-covid-19/ covers coronavirus-covid-19-physical-distancing. [Last accessed on • Each individual needs two facemasks, as one can be 2020 Apr 26]. washed while the other is being used 6. International Association of Public Transport. Management of COVID-19 Guidelines for Public Transport Operators; 2020. • Facemasks should not be shared between individuals Available from: https://www.uitp.org/sites/default/files/cck- • Used facemasks have to be stored in paper cover after focus-papers-files/Corona Virus_EN.pdf. [Last accessed on [39] use 2020 Apr 26]. • The final disposal of cloth masks is by burning or deep 7. Coronavirus and Your Commute: How COVID-19 is burial after treatment with 5% bleach or 1% sodium Affecting Public Transportation Around the World : Moovit. hypochlorite solution. Available from: http://www.company.moovit.com/blog/

Annals of Community Health • Jul-Sep 2020 • Vol 8 • Issue 3 100 Varghese, et al.: Mass-masking, the need of the hour

coronavirus-effect-public-transportation-worldwide. [Last 25. Can DIY Masks Protect Us from Coronavirus? Smart Air accessed on 2020 Apr 26]. Filters. Available from: https://www.smartairfilters.com/en/ 8. Amazon Hand Sanitizer: Report Finds COVID-19 Price blog/diy-homemade-mask-protect-virus-coronavirus. [Last Spikes, Gouging; 2020. accessed on 2020 Apr 25]. 9. Mukherjee RB. Coronavirus Mask Shortage Coronavirus 26. Centers for Disease Control and Prevention. Use Cloth Face Terror in India: Sanitisers, Masks Sold Out, Prices Peak; 2020. Coverings to Help Slow Spread. Atlanta, Georgia, United 10. Centers for Disease Control and Prevention. Recommended States: Centers for Disease Control and Prevention. Available Guidance for Extended Use and Limited Reuse of N95 Filtering from: https://www.cdc.gov/coronavirus/2019-ncov/prevent- Facepiece Respirators in Healthcare Settings NIOSH Workplace getting-sick/diy-cloth-face-coverings.html. [Last accessed on Safety and Health Topic. Available from: https://www.cdc.gov/ 2020 Apr 25]. niosh/topics/hcwcontrols/recommendedguidanceextuse.html. 27. COVID-19: Considerations for Wearing Cloth Face Coverings. [Last accessed on 2020 Apr 26]. Atlanta, Georgia, United States: Centers for Disease Control 11. Davies A, Thompson KA, Giri K, Kafatos G, Walker J, and Prevention. Avaialble from: https://www.cdc.gov/ Bennett A. Testing the efficacy of homemade masks: Would coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover- they protect in an influenza pandemic? Disaster Med Public guidance.html. [Last accessed on 2020 Jul 07]. Health Prep 2013;7:413-18. 28. Brienen NC, Timen A, Wallinga J, Van Steenbergen JE, 12. Organización Mundial de la Salud. Advice on the Use of Teunis PF. The effect of mask use on the spread of influenza Masks in the Context of COVID-19: Interim Guidance-2. Guía during a pandemic. Risk Anal 2010;30:1210-8. Interna la OMS. Geneva, Switzerland: Organización Mundial 29. Wu J, Xu F, Zhou W, Feikin DR, Lin CY, He X. Risk factors de la Salud; 2020. p. 1-5. for SARS among persons without known contact with SARS 13. Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. Rational patients, Beijing, China. Emerg Infect Dis 2004;10:210-6. use of face masks in the COVID-19 pandemic. Lancet Respir 30. Lau JT Tsui H, Lau M, Yang X. SARS transmission, risk Med 2020;8:434-6. factors, and prevention in Hong Kong. Emerg Infect Dis 14. Suzuki K. COVID-19 Strategy: The Japan Model the diplomat. 2004;10:587-92. The Diplomat; 2020. 31. Lo JY, Tsang TH, Leung YH, Yeung EY, Wu T, Lim WW. 15. Combating COVID-19: Lessons from South Korea. Available Respiratory infections during SARS outbreak, Hong Kong, from: https://www.brookings.edu/blog/techtank/2020/04/13/ 2003. Emerg Infect Dis 2005;11:1738-41. combating-covid-19-lessons-from-south-korea. [Last accessed 32. Wilder-Smith A, Low JG. Risk of respiratory infections in on 2020 Apr 26]. health care workers: Lessons on infection control emerge from 16. Social Distancing is the Norm in Japan. That’s why COVID- the SARS outbreak. Southeast Asian J Trop Med Public Health 19 Spread is Slow There. Available from: https://www.theprint. 2005;36:481-8. in/health/social-distancing-is-the-norm-in-japan-thats-why- 33. Tang CS, Wong CY. Factors influencing the wearing of covid-19-spread-is-slow-there/384498. [Last accessed on 2020 facemasks to prevent the severe acute respiratory syndrome Apr 26]. among adult Chinese in Hong Kong. Prev Med (Baltim) 17. Non-Pharmaceutical Public Health Measures for Mitigating 2004;39:1187-93. the Risk and Impact of Epidemic and Pandemic Influenza 34. Can Masks Capture Coronavirus Particles? Smart Air Filters. Globalinfluenza Programme Non-pharmaceutical Public Avaialble from: https://www.smartairfilters.com/en/blog/ Health Measures for Mitigating the Risk and Impact of coronavirus-pollution-masks-n95-surgical-mask. [Last Epidemic and Pa; 2019. accessed on 2020 Apr 25]. 18. Leung CC, Lam TH, Cheng KK. Mass masking in the COVID- 35. Advisory on use of Homemade Protective Cover for Face and 19 epidemic: People need guidance. Lancet 2020;395:945. Mouth; 2020. Avaialble from: https://www.mohfw.gov.in/ 19. Cowling BJ, Chan KH, Fang VJ, Cheng CK, Fung RO, Wai W, pdf/Advisory&ManualonuseofHomemadeProtectiveCoverfor et al. Facemasks and hand hygiene to prevent influenza Face&Mouth.pdf. [Last accessed on 2020 Apr 26]. transmission in households: A cluster randomized trial. Ann 36. Testing Shows Type of Cloth Used in Homemade Masks Intern Med 2009;151:437-46. Makes a Difference, Doctors Say Wake Forest Baptist Medical 20. Larson EL, Ferng YH, Wong-McLoughlin J, Wang S, Haber M, Center. News Release; 2020. Available from: https://www. Morse SS, et al. Impact of non-pharmaceutical interventions newsroom.wakehealth.edu/News-Releases/2020/04/Testing- on URIs and influenza in crowded, urban households. Public Shows-Type-of-Cloth-Used-in-Homemade-Masks-Makes-a- Health Rep 2010;125:178-91. Difference. [Last accessed on 2020 Apr 26]. 21. Advice on the Use of Masks in the Context of COVID-19. 37. Central Pollution Control Board. Guidelines for Handling, Available from: https://www.who.int/publications. [Last Treatment and Disposal of Waste Generated during Treatment/ accessed on 2020 Apr 25]. Diagnosis/Quarantine of COVID-19 Patients; 2020. 22. Madeleine Cummings. Edmontonians Embracing Non-medical Available from: https://www.tnpcb.gov.in/pdf_2020/BMW- Masks, CBC News. CBC News; 2020. GUIDELINES-COVID_Revisied_April2020.pdf. [Last 23. The Theory of Planned Behavior. Available from: http:// accessed on 2020 Apr 27]. www.sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/ 38. Use of Cloth Face Mask to Help Slow the Spread of COVID- BehavioralChangeTheories/BehavioralChangeTheories3. 19 Advisory on Use of Face Mask. Available from: https:// html. [Last accessed on 2020 Apr 25]. www.health.odisha.gov.in/pdf/Use-of-Cloth-Face-Mask-to- 24. Rogers RW. A protection motivation theory of fear appeals and Help-Slow-the-Spread-of-COVID-19.pdf. [Last accessed on attitude change. J Psychol 1975;91:93-114. 2020 Apr 26].

101 Annals of Community Health • Jul-Sep 2020 • Vol 8 • Issue 3 Varghese, et al.: Mass-masking, the need of the hour

39. Hospital Infection Control Committee AIIMS New Delhi. 41. Ministry of Health and Family Welfare (MoHFW). Advisory Standard Operating Procedure (SOP) for Extended Use of N95 on Social Distancing Measure in View of Spread of COVID- Mask for Personal Safety of Health Care Workers (HCW) at 19 Disease; 2020. Available from: https://www.mohfw.gov.in/ AIIMS; 2020. Available from: https://www.aiims.edu/images/ pdf/SocialDistancingAdvisorybyMOHFW.pdf. [Last accessed pdf/notice/SOP_N95_09_04_20.pdf. [Last accessed on 2020 on 2020 Apr 26]. Apr 26]. 42. Directorate General of Health Services Ministry of Health 40. Cleaning and Hygiene Tips to Help Keep the COVID-19 Virus and Family Welfare Government of India Guidelines for out of Your Home|UNICEF. Available from: https://www. Setting up Isolation Facility/Ward COVID-19 Outbreak. unicef.org/coronavirus/cleaning-and-hygiene-tips-help-keep- Available from: https://www.ncdc.gov.in/WriteReadData/ coronavirus-covid-19-out-your-home#personal-hygiene. [Last l892s/42417646181584529159.pdf. [Last accessed on 2020 accessed on 2020 Apr 26]. Apr 26].

Annals of Community Health • Jul-Sep 2020 • Vol 8 • Issue 3 102