Time to face up to the truth on face masks

It is not an understatement to say that the coronavirus has turned our lives upside down, and impacted on us financially, mentally and physically. Those who fall under the category of vulnerability due to their physical or mental health are particularly more anxious at this time.

Extensive research concerning physical disasters on an individual's mental health has established that emotional distress is prevalent in affected populations — a finding sure to be echoed in individuals affected by this Covid-19 (coronavirus disease) pandemic.

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Sandro Galea, dean at Boston University School of Public Health, says the isolation, as well as the uncertainty about how long it will last and how the pandemic will play out, can all contribute to increased anxiety.

Facing this uncertainty when you already have an unlaying anxiety disorder, may become all-consuming for some individuals — leading to frequent panic attacks or psychosis.

Galea, who studied the impacts of quarantine during the SARS epidemic in Toronto, says isolation can contribute to a range of mental disorders like anxiety and depression, but can also trigger more substantial consumption of drugs and alcohol, and even a post-traumatic stress disorder (PTSD).

Even the official media platforms can be confusing at times and the advice changes daily. Unfortunately, this is a new strain of the virus, and the assumptions we made about it today may prove to be right or wrong tomorrow.

Most of the current strategies to combat this virus are universal in either social isolation or distancing, and this was an effective strategy over a hundred years ago during the Spanish flu pandemic.  

The virus is extremely contagious, and this was underestimated at the start.  However, it does have its Achilles heel within its genetic design and doesn’t need any mind-boggling tech equipment or viral antidote which may not be available for another year. Still, something as simple as soap and water can dissolve this beast and make it inert.

Nevertheless, there is a divergence in the use of protective equipment between the East and West when it comes to surgical masks. At the start of the outbreak, Asian countries mostly went full-mask right out of the gate during the current pandemic crises. Whereas, many Western countries have been reluctant to follow suit.

The World Health Organization (WHO) discouraged the use of masks within the general population at the start of the pandemic for reasons:

  • They thought the mask would be ineffective and many individuals would incorrectly wear the mask and therefore, lead them into a false state of security while ignoring other recommended safety protocols—for example, less attention to other essential behaviours such as social distancing and handwashing.
  • The demand for masks would deplete the currently available stock World Wide and deprive the critical services in vital equipment at the front line. 
  • Profiteering would take place with individuals hoarding, and then price-extorting for individual profit, and this would then create shortages on the healthcare front lines. Sadly, that nightmare had indeed happened and The New York Times called N95 masks the most sought-after product on the planet. This has become a problem for everyone on the front line with shortages of PPE and responsible for medical staff deaths, sickness and increased anxiety World-Wide. 
  • Inefficient use of the face mask could cause more transmission by ill-fitting, soiled or wet material not being replaced promptly. The virus can remain on surfaces from a few hours to days. This also includes the surgical mask.

Also, the America Centres for Disease Control and Prevention (CDC) initially discouraged face masks as a waste of time, but by the beginning of April 2020, it had reversed course. Wearing a cloth face coverings in public settings where other social distancing measures are difficult to maintain is actively encouraged by them on their website. (https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html)

Perhaps the most disrupting comment this week was from Dr David Nabarro (WHO) has now suggested that more widespread use of masks will become “the norm” as the world adjusts to living with COVID-19 in the future.

Incidentally, parts of Asia, including China, the wearing of face masks in public has become the norm for a considerable amount of years within the general community, and this behaviour is vigorously encouraged by health agencies, even when there is no ongoing public-health crisis.

Has the West been too slow in recommending face masks for the general public?

There is disagreement within the scientific community over whether wearing low-quality masks prevents people from inhaling the virus, even if it does reduce the chances of them spreading it by sneezing or coughing.

Czechoslovakia, for example. On 18 March, without complaint, the entire nation transformed itself almost overnight into a giant factory churning out homemade masks, wrote a USA Today reporter living in Prague.

Within three days, there were enough masks for every man, woman, and child in this country of 10 million. The extraordinary mass-buy-in compressed the usually long life cycle of a trend into something almost instantaneous.

In two days, the country went from ‘Look at that idiot wearing a mask!’ to “Look at that idiot not wearing a mask!’" as one Czech man put it in a news video.

Having your nose and mouth covered was no longer just a health intervention but become a badge of honour and a form of social bonding.

If you mock the mask code, you then risk inflaming the wrath of bystanders, who enlisted themselves as deputy enforcers.

Meanwhile, by all accounts in Prague, it is as uncool to pull your mask down near someone, and it is equivalent to blowing cigarette smoke in their face. Aus­tria now requires masks in places such as supermarkets and pharmacies.

At this point, when World Health Organization officials will mask up to deliver their news briefings, and it is pretty clear that a homemade mask is an inexpensive weapon in the viral fight.

The scientific community, for once agree without incongruity, that this measure was not intended to replace other means like social distancing but to enhance them.

Columbia University  Medical Center wrote to the editor of the New York Times on 2 April, stating:

New York Times 

Nowhere does this seem more evident than in our current reluctance to embrace universal mask-wearing.

Columbia University  Medical Center

If you have heard of mimetic theory, chances are it just sprang to mind.

Mimesis says in a nutshell: Statistical data does not change peoples views; people change peoples views. We decide who we trust, and then we adopt their opinions and copy their behaviours.

He was referring to the René Girard fundamental concept in ‘mimetic desire’ in which a person influences the desires and preferences of another person.  This is undoubtedly a common marketing technique to promote a product; some celebrity is recruited to ‘mediate’ a consumer desire. In a sense, the personality is inviting people to imitate them in their passion for that product they may not, in reality, use.

The product is not promoted on the basis of its inherent qualities, but simply because of the fact that some celebrity desires it.

There are many examples of this principle, perhaps the most current and noticeable is President Donald Trump (celebrity status) desire to push for a controversial malaria drug that Dr Anthony Fauci, and the remainder of his medical team (Statistical data - evidence) have warned is not clinically proven to combat the virus safely.

The same was true a century ago as the Spanish flu ravaged the world. Snake oil salespeople profiteered off fake cures, and the general public turned to questionable and sometimes unsafe treatments to rid themselves of the illness.

Meanwhile, during that period a cloth face masks became mandatory for doctors and nurses, and public health officials in some regions required civilians to don the face coverings as well. But it was only after enough people had developed an immunity to the Spanish flu that the pandemic subsided.

Even though the American health officials changed its tune on 4 April 2020 and called for universal mask-wearing, their President immediately undermined that message by saying: "You can do it," he told Americans.

You do not have to do it. I am choosing not to do.  The first lady on the following Thursday posted a picture of herself wearing a mask on Twitter, emphasising the Centers for Disease Control and Prevention recommendation that Americans wear face masks in public to help slow the spread of coronavirus across the U.S.

Surgical mask V's DIY mask

An experiment carried out in 2013 by Public Health England, found that a commercially made surgical mask filtered 90% of virus particles from the air coughed out by participants.

  • A vacuum cleaner bag filtered out 86%
  • tea towel blocked 72%
  • cotton t-shirt 51%
  • —though fitting any DIY mask properly and ensuring a good seal around the mouth and nose is crucial.

The who recommends standard surgical masks as part of the personal pro­tective equipment to be worn by doctors and nurses who are caring for covid-19 pa­tients in clinics and hospitals. The same goes for anyone caring for a patient at home.

This does not, of course, show that masks for the public are of no use. A better way to think about them in this context might be that, rather than helping healthy people shield themselves from infection, they could be used to stop those who are already infected broadcasting the virus into the air around them.

The coronavirus can live on a surgical mask for 7 days, cloth for 2 days, and paper for 3 hours

The silent transmission

Asymptomatic carriers or the silent transmission, as epidemiologists, calls this phenomenon. You may also find that other articles mention this as the silent spreaders or stealth transmission. Accruing evidence suggests a substantial amount of the covid-19 infections it caused by people whose symptoms have not yet appeared (pre-symptomatic) at that time but still test positive. Thereby actively spreading the virus unknowingly.  However, the majority of them will go on to develop symptoms later — are not truly asymptomatic.

Asymptomatic carriers have been observed in many diseases, perhaps the most notorious being Typhoid Mary, who has become a synonym for disease carriers.  Mary Mallon, a cook to wealthy families, and also to a maternity hospital, in New York in the early 1900s.  As she went from one employer to another, typhoid fever, then deadly for one case in ten, followed in her wake. She eventually became demonised in the eyes of the public. Her nickname remains an all-purpose pejorative term for individuals - real or imaginary - who wilfully spread disease.

A small but useful cohort was several planeloads of Japanese evacuated from Wuhan, the Chinese city where the epidemic began. Among the 12 people in this group found to be infected, five of them like Typhoid Mary have never developed symptoms. Some recent data shows the asymptomatic ratio to be higher among children than in older adults. The consequence of this could be that they are potentially spreading the virus to others, including their vulnerable grandparents.

Given that much transmission of covid-19 is suspected to occur before someone who has the virus may or may not show any symptoms, encouraging everyone to wear masks in public regardless of whether they are symptomatic could be a useful way to break the chain of transmission. 

Pandemics end when the pathogen causing them runs out of individuals to infect. Some of those susceptible will have unfortunately died. The remaining individuals would then be immune for the population to have developed "herd immunity".   It's become clear that transmission by people who are asymptomatic or mildly affected (symptomatic syndrome) is responsible for more transmission than previously thought. In the case of the current pan­demic, the more silent infec­tions there have been, the faster this herd immunity will arrive.

The British government announced that the current lockdown could continue until mid-may and the country will have to practise social distancing until a vaccine is found.  The U.S approach is to reopen by May 2020, to stabilise the economy and prevent a recession. This approach has been criticised for placing the dollar before lives.

What is the best type of mask?

A surgical mask is a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. Surgical masks are regulated under 21 CFR 878.4040.

Surgical masks are not to be shared and may be labeled as surgical, isolation, dental, or medical procedure masks. They may come with or without a face shield. These are often referred to as face masks, although not all face masks are regulated as surgical masks.

Surgical masks are made in different thicknesses and with different ability to protect you from contact with liquids. These properties may also affect how easily you can breathe through the face mask and how well the surgical mask protects you.

If worn properly, a surgical mask is meant to help block large-particle droplets, splashes, sprays, or splatter that may contain germs (viruses and bacteria), keeping it from reaching your mouth and nose. Surgical masks may also help reduce exposure of your saliva and respiratory secretions to others.

While a surgical mask may be effective in blocking splashes and large-particle droplets, a face mask, by design, does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures.

Surgical masks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and your face.

Surgical masks are not intended to be used more than once.

If your mask is damaged or soiled, or if breathing through the mask becomes difficult, you should remove the face mask, discard it safely, and replace it with a new one. 

To safely discard your mask, place it in a plastic bag and put it in the trash. Wash your hands after handling the used mask.

The Centers for Disease Control and Prevention (CDC) does not recommend that the general public wear N95 respirators to protect themselves from respiratory diseases, including coronavirus (COVID-19).

Those are critical supplies that must continue to be reserved for health care workers and other medical first responders, as recommended by current CDC guidance.

General N95 Respirator Precautions

People with chronic respiratory, cardiac, or other medical conditions that make breathing difficult should check with their health care provider before using an N95 respirator because the N95 respirator can make it more difficult for the wearer to breathe.

Some models have exhalation valves that can make breathing out easier and help reduce heat build-up. Note that N95 respirators with exhalation valves should not be used when sterile conditions are needed.

All FDA-cleared N95 respirators are labeled as "single-use," disposable devices. If your respirator is damaged or soiled, or if breathing becomes difficult, you should remove the respirator, discard it properly, and replace it with a new one.

To safely discard your N95 respirator, place it in a plastic bag and put it in the trash. Wash your hands after handling the used respirator.

N95 respirators are not designed for children or people with facial hair. Because a proper fit cannot be achieved on children and people with facial hair, the N95 respirator may not provide full protection.

In conclusion

The article initially discussed the stress and anxiety this pandemic has caused for the general population, and in particular, those who anxiety is normally elevated. Mental health support may be required for both patients and medical staff.  

The shortage of protective equipment is of concern to those on the front line within hospitals, care homes and those on self-isolation due to medical reasons. Medical staff need to feel safe and protected in their place of work and environment, and the government have an overall duty of care for those workers.

The face mask is only a small portion of the personal protective equipment (PPE) needed to carry out their business/duty.  If the face mask is extended out to the general population, then the available stock will be depleted and not available for those who need it the most.

However, if we can reduce virus transmission within the public community at the start, the need for medical intervention could be reduced.  This is one approach taken by Czechoslovakia, are they correct in their approach to masks up in public, only time will tell.  There is insufficient data to prove or disprove their theory, and in many respects, they have become one large test laboratory with human lab rats?

Whatever approach the government takes within this pandemic, they will need the support and cooperation of the people to make it succeed. Within their decision on an exit strategy out of this crisis, they need to consider the social, mental, financial and physical limitations. The people's resilience will certainly be tested in the forthcoming year and possibly beyond.  

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