The Use of Cloth Face Mask During the Pandemic Period in Indonesian People

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Yudhastuti. Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Kesmas: Jurnal Kesehatan Masyarakat Nasional Journal). 2020; Special Issue 1: 32-36 DOI: 10.21109/kesmas.v15i2.3945 (National Public Health Journal) The Use of Cloth Face Mask during the Pandemic Period in Indonesian People

Ririh Yudhastuti

Department of Environmental Health, Faculty of Public Health, Universitas Airlangga, Indonesia

Abstract The use of masks protects individuals from the spread of COVID-19 and control the source of transmission through droplets, but with limited medical masks, a cloth face mask can be used as an alternative personal protection from COVID-19. This study aimed to describe the use of cloth face mask as an alternative personal protection during the pandemic. WHO recommends the use of non-medical masks both at home and in public places. The use of face masks is a WHO’s recommendation on April 6, 2020. Medical masks are categorized as medical waste, then the disposal must be appropriate to prevent COVID-19 transmission in community. Cloth face mask can be used repeatedly and washed, its use can be adjusted to face. However, using a face mask alone is not enough to provide an adequate protection level. Other steps must be taken, such as washing hands with hand soap in running water, keeping a physical distance of minimum one meter from people, especially from those showing respiratory tract symptoms (coughing, sneezing), cleaning items touched by hands of people such as door handles and handles stairs. Therefore, the use of cloth face mask must be carried out together with clean and healthy living behaviors.

Keywords: cloth face mask, COVID-19, Indonesia, mask crisis, pandemic

Introduction 4,628,903 confirmed cases were reported with a total of Coronavirus is a large family of viruses that cause dis- 312,009 deaths where cases were reported in 216 coun- eases, ranging from mild to severe symptoms. tries or regions.2 The total number of confirmed cases in Coronavirus disease 2019 (COVID-19) is a new type of Indonesia up to May 19, 2020, was 18,010 cases with a disease that has never been identified before in humans. mortality rate of 6.6%.3 In December 31, 2019, the World Health Organization Several behaviors have been recommended to limit (WHO) China Country Office reported a case of pneu- the spread of COVID-19 to be carried out, which is the monia of unknown etiology in Wuhan City, Hubei same as in the influenza pandemic, such as washing Province, China. On January 7, 2020, China identified hands, limiting social distance and coughing, and sneez- pneumonia of unknown etiology as a new type of corona - ing.4 In addition, WHO has recommended the commu- virus (coronavirus disease, COVID-19). In January 30, nity to use face masks.5,6 Several studies also suggest the 2020, WHO has designated the Public Health Emergency use of face masks in public places.7,8 of International Concern (PHEIC). The increase in the Medical masks must be provided for health workers.9 number of COVID-19 cases took place quite quickly and The use of medical masks in the community will cause a there has been a spread between countries.1 shortage of masks for health workers.6 The impact of the Common signs and symptoms of COVID-19 infection COVID-19 pandemic, such as people's fear of the dis- include symptoms of acute respiratory disorders such as ease, causes people flock to buy face masks and some fever, coughing, and shortness of breath. The average in- even hoard them. This results in a mask vacuum and sky- cubation period is 5 - 6 days with the longest incubation rocketing mask prices.10 period of 14 days. In severe cases, COVID-19 can cause The Centers for Disease Control and Prevention pneumonia, acute respiratory syndrome, kidney failure, (CDC) recommends the use of cloth face mask in public and even death.1 As of May 18, 2020, a total of settings, especially in significant community-based trans-

Correspondence*: Ririh Yudhastuti, Department of Environmental Health Received : May 30, 2020 Faculty of Public Health, Universitas Airlangga, Airlangga Street, Surabaya City, Accepted : May 31, 2020 East Java, Indonesia, E-mail: [email protected], Phone: +62-878-5486-2677 Published: July 31, 2020

Copyright @ 2020, Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal), p-ISSN: 1907-7505, e-ISSN: 2460-0601, SINTA-S1 accredited, http://journal.fkm.ui.ac.id/kesmas, Licensed under Creative Commons Attribution-ShareAlike 4.0 International Yudhastuti, The Use of Cloth Face Mask during the Pandemic Period in Indonesian People mission areas. The CDC also recommends the use of a community should be considered.15,16 Concern about the simple face-covering mask to slow the spread of the virus insufficient supply of masks in the community is because and help people who might have the virus, but not know a medical mask must be provided for health workers. it from spreading it to others.11 The recommended cloth While, to control the source of COVID-19 and protect face mask is not a surgical mask or an N-95 respirator. yourself, the use of a cloth face mask (non-medical) is Surgical masks or N-95 respirators are critical supplies sufficient for protection, especially if everyone uses it. that must be continuously reserved for health workers Fabric masks are easily made at home and reused after and other first medical respondents.11 washing.16 In Indonesia, the need for face masks in the The use of face masks protects individuals from the community is increasing, especially after the Indonesian spread of COVID-19 and control the source of transmis- Government recommends to always use masks while do- sion through droplets of others, but with limited medical ing activities outside home.17 It is recommended to at masks, a cloth face mask can be used as an alternative least use a cloth face mask to prevent the coronavirus personal protection from COVID-19. This study aims to transmission which is increasing and spreading across describe the use of cloth face mask as an alternative per- provinces and districts in Indonesia. sonal protection during the pandemic. A research on influenza, influenza-like illness, and coronavirus in humans provides evidence that the use of Method medical masks can prevent the spread of sparks that can In a commentary, the authors sought to present new cause transmission from the infected people to other peo- views to researchers about certain topics. Commentary ple and the air contamination due to the sparks. There is can also draw attention to current progress and speculate an evidence that the use of medical masks by healthy peo- on the direction of certain topics in the future. Therefore, ple at home or by people who come in contact with peo- the authors review scientific texts and messages pub- ple infected with COVID-19, as well as in a crowd, face lished in the mass media and scientific articles as well as masks can serve as limited prevention, although there is social life about the use of face masks during the COVID- currently no evidence that using face masks (either med- 19 pandemic. Also, the authors use prior knowledge and ical masks or other types) by healthy people in the com- experience, particularly regarding information on the use munity at large, including the use of face masks together of cloth face masks during the COVID-19 pandemic in in the wider community, can prevent people from respi- Indonesia. In this commentary, the author attempts to ratory tract infections, including COVID-19.18 The account for any information published during the Indonesian Government’s policies recommend that medi- corona virus crisis. cal masks should be provided for health workers. The use of medical masks by the public can create a false Results and Discussion sense of security, so that other health measures such as Since the outbreak of the coronavirus (COVID-19), maintaining hand hygiene and physical distance are ig- there have been battles related to the use of face masks nored, and there is still a practice of touching the face be- in the community. Sometime before, WHO is still incon- hind the mask and under the eyes. Some suggestions such sistent in the use of masks in the community. On January as maintaining a physical distance of approximately one 2020, WHO did not recommend the use of face masks in meter, avoiding crowds of people (more than five people) healthy individuals in the community (mass making) as a and washing hands in running water with hand soap for way to prevent the transmission of COVID-19 in the in- 30 seconds is a very helpful role in preventing the trans- terim guidelines dated on April 6, 2020.12,13 The United mission of COVID-19.19,20 Kingdom Public Health has made similar recommenda- WHO and decision-makers can continue to advocate tions, however, the United States Centers for Disease the use of non-medical masks both outdoors and Control and Prevention has recommended the use of indoors.19 In such places, the following points related to cloth face masks outside home or public places and the non-medical masks must be considered, such as 1) the action is followed by other countries, such as Canada number of layers of cloth / tissue, 2) the ease of breathing and South Korea. Initially, the purpose of using face given to the user of the mask material 3) the waterproof masks was to protect oneself, then for reasons of public or hydrophobic nature 4) the shape of the mask 5) con- health, the use of face masks is to protect each other be- formity to face shape and 6) mask size. tween people from asymptomatic COVID-19 transmis- Several types of masks that are available in the com- sion sources.14,15 From a workshop organized by WHO munity: in 2019, the workshop concluded that although there 1. Cloth face mask,20,21 was no evidence of trials of effectiveness in reducing Cloth face masks can be used to prevent transmission, corona virus transmission, WHO recommended that the while anticipating the scarcity of masks that occur in use of a severe influenza pandemic mask wear in the markets such as pharmacies and health stores. Fabric

33 Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal). 2020; Special Issue 1: 32-36 masks made need to have three layers, namely a water- Medical personnel use particulate respirators with pro- proof non-woven layer (front), microfiber melt-blown tection at least equivalent to N95 certified by the US non-woven fabric (middle), and ordinary non-woven fab- National Institute for Occupational Safety and Health, ric (rear). Cloth masks need to be washed and can be European Union standard FFP2, or equivalent, when car- worn many times. The material used for fabric masks is rying out or working in the place of carrying out proce- cotton, scarf, and so on. This type of mask can be used dures that produce aerosols, such as tracheal intubation, in public places and other facilities while maintaining a ventilation noninvasive, tracheotomy, cardiac pulmonary safe distance of 1 - 2 meters. A three-layer fabric mask resuscitation, manual ventilation before intubation, and can filter the air and ward off viruses by up to 70%. bronchoscopy.25,26 Ways and models of fabric masks can be adjusted to the face and not loose. Masks can be sewn manually or using 3. Surgical masks,21,22,26 machines, the use of these masks is important, consider- This type is a mask easily found in the nearest store or ing the spread of the virus through the nose, mouth, and pharmacy. Usually, surgical masks are green or blue. eyes carried by human fingers. The use of cloth face Surgical masks have a function for protecting the users masks can be indoors or outdoors.22,23 from drops of large particles or splashes of water from a Fabric mask treatments can be washed using deter- person's mouth. However, it has not been able to protect gents with less rubbing, so that the fabric pores do not against airborne particles. Surgical masks have a filtra- widen and should be used for four hours to prevent con- tion effectiveness of 0.1 microns 10 to 95%. tamination by other microorganisms like bacteria such as Escherichia coli, Enterobacter aeruginosa, Shigella 4. Facepiece respirator,26 sp., Staphylococcus aureus, and fungus / fungi A facepiece respirator or gas mask serves to protect Aspergillus sp., Penicillium sp., and Candida sp. because themselves from harmful gases and vapors. This mask the cloth face mask becomes moist. The average temper- does not filter out airborne particles unless it is designed ature of 27oC and 75% relative humidity are preferred to have a filter to block it. Among others, masks that cov- by microorganisms including bacteria, viruses, or fungi / er almost the entire surface of the face are usually de- fungus.9 It is important to note that cotton cloth face signed to protect users from big and small splashes, with- masks are not considered suitable for health workers. out leakage and effectiveness of up to 99%. This mask Regarding fabric masks as Personal Protective can be used repeatedly after disinfection according to rec- Equipment (PPE), the production of cloth face masks for ommendations from WHO. Facepiece respirators are use in health service facilities is proposed to be carried rarely encountered every day because they are usually on- out locally if the supplies are inadequate or run out. ly used by workers in the gas field or jobs with high levels WHO stresses that medical masks and respirators must of contamination. In addition to the masks above, there be prioritized for medical workers or health workers. are still N99, N100, and P95 masks. 24,25 Management of the use of mask,27,28 2. N95 mask,26 The use and disposal of masks regardless of the type N95 mask is one of the protective or filter particles are important to be done properly to ensure they are ef- that are harmful to the users. However, the N95 mask fective and to avoid increased transmission. The follow- can only function for dirt and dust, not for gas and steam. ing information on the proper use of masks is taken from Even so, N95 mask can protect its users from droplets, practices in health care facilities,28: particles which are 0.1 micron in size and have an effec- 1. Place the mask carefully, and ensure the mask covers tiveness of up to 95%. Medical personnel use particulate the mouth and nose and attaches it firmly to minimize respirators with at least equivalent protection to N95 cer- the distance between the face and the mask tified by the US National Institute of Occupational Safety 2. Avoid touching the mask while it is used and Health, code 95 means that it can filter out airborne 3. Take the mask off with the correct technique: do not particles as much as 95%. In the N95 mask, there are touch the front of the mask, but remove the mask three levels of mask filtering which are divided into three from the back levels of filtering, namely FFP1, FFP2, and FFP3. FFP1 4. After removing or whenever you accidentally touch means filtering out at least 80% of particles in the air, the mask used, clean your hands with alcohol-based FFP2 means filtering out at least 94% of particles in the antiseptic liquid or soap/detergent with running water air, and FFP3 means filtering out at least 99% of particles if hands look dirty in the air. From this explanation, it can be interpreted 5. If the mask becomes moist, it must be replaced imme- that FFP2 has almost the same standard with an N95 diately with a new mask that is clean and dry mask, whereas FFP3 is the same as an N99 mask.26 6. Disposable masks are not used anymore

34 Yudhastuti, The Use of Cloth Face Mask during the Pandemic Period in Indonesian People

7. Take off and discard the disposable mask after use nuscripts Education on proper disposal of the masks must be actively delivered to the community, and people must Acknowledgment learn how to properly handle the masks. For this reason, The author thank the Ministry of Health of the Republic of Indonesia the government urges the public to dispose the used for providing COVID-19’s data that being used in this manuscript. masks to spray disinfectants first. Then you should re- member that, before removing the mask, please cut it References first. The waste masks used by the people have been cate- 1. Kementerian Kesehatan Republik Indonesia. Pedoman Pencegahan gorized as potential medical waste in toxic and hazardous dan Pengendalian Coronavirus Disease (Covid-19); 2020. waste. After that, wrap it in clear plastic as a marker of 2. World Health Organization. Coronavirus disease (COVID-19) pan- mask waste. 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Advice on the use of masks in the community, during home care and in healthcare settings in the context of Ethics Approval and Consent to Participate the coronavirus (2019-nCoV) outbreak: interim guidance; 2020. Permission to use this data has been approved by the Ministry of Health 14. Yu P, Zhu J, Zhang Z, Han Y. A familial cluster of infection associat- of the Republic of Indonesia through the COVID-19 Task Force. ed with the 2019 Coronavirus novel indicates possible person-person transmission during the incubation period. The Journal of Infectious Competing Interest Diseases. 2020; 221 (11): 1757-61. The author states that there are no competing interests to disclose. 15. Wycliffe E W, Zongbin L, Calvin J C, Sarah E Y, Toh P, Vernon J L . Presymptomatic transmission of SARS-CoV2 - Singapore, January 23 Availability of Data and Materials – March 16, 2020. CDC: MMWR. 2020; 69(14): 411-5. Data is available in the COVID-19 Task Force text of the Ministry of 16. 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