The controversy of facemasks for Covid-19

No one is an island 

Authors: Dr Colin Michie, paediatrician, Mr Luca Fusi, Obstetrician and Gynaecologist

Covid-19 is catching. It has spread rapidly, bringing illness and premature demise to over 100,000 individuals. In the face of this pandemic, hopefully peaking now, we have searched for ways to protect ourselves, our families and our communities. How we envisage Covid-19 inside our heads is important in this search.

Languages have never been good at describing very small creatures such as this vile virus, so our comprehension of them is limited. Many of us picture an invisible miasma invading our homes. The germs stop us touching, limiting our emotional lives. Where now can we worship, celebrate or dance as a family or community?

Even now, there is much we do not know about the new coronavirus. Without long-term experience of testing and contact tracking in communities, or even islands, there remain many points for debate and discussion. However, here are some crucial points.

Covid-19 usually spreads at close range. Most infections develop in communities and our homes. Many individuals with Covid-19 do not have symptoms. For 2.5 days prior to experiencing symptoms, patients shed virus. An estimated 50% of infections are spread by individuals without symptoms.

Virus particles in the air

Covid-19 genetic material can be found in the air of crowded spaces, such as in department stores in Wuhan during their coronavirus outbreak, or in isolation cubicles where Covid-19 patients are being treated. But genetic material is not always infectious – dead virus can be genetically identified as Covid-19, but cannot infect us. In a laboratory, a coronavirus can survive for three hours in the air.

It is not known which airborne particles spread Covid-19. The highest risk seems to be from large particles thrown out of a patient’s body in coughs or sneezes. Much superstition surrounds coughs and sneezes, whatever your culture. Whether or not they are linked to your future in some supra-normal dimension or not, coughs and sneezes can throw droplets of mucus and the many organisms living there for several meters. This may include Covid-19.

Does using a facemask block out infectious Covid-19? We do not know for sure. Earlier this month, a rigorous study of patients infected with different viruses (but not Covid-19) found that in a laboratory setting, surgical facemasks cut down the numbers of infectious viruses produced by patients in their breath. Masks did not block all rhinoviruses, but were more effective for influenza. A surgical facemask therefore did not block all infectious particles all of the time.

If you think you have an upper respiratory tract infection, surely it would be sensible to wear a facemask at home or in public, on the basis that anything is better than nothing? Please wait! If you think you have an infection, or if you have a temperature, it is important to isolate yourself from others for two weeks! Facemasks are unlikely to protect others from your Covid-19.

What can go wrong with using a facemask?

Would a facemask protect you from the Covid-19 out there on the streets, as it were? Again, we do not know: there are no good studies of the healthy. The principle risk is that facemasks do not always work. They may then convey a false sense of security. Masks cannot cover your eyes, so this route of infection remains exposed. So we cannot deduce whether wearing “domestic” or homemade masks, or even surgical masks, reduces the risk of catching a virus like Covid-19 when walking down a street, jogging, driving or travelling in a bus.

Take some examples of possible mask malfunction. Those who are infected with Covid-19 and do not know it, even if they are wearing masks could unknowingly infect others. Alternatively, if you have put masks on your vulnerable elderly parents, you need to observe great care in doing so. These masks will require regular checking and changing. You need care, discipline, training and consistency to ensure optimal mask function because they are not perfect.

Facemasks are fashion items in various communities: these are not always designed for protection against a small coronavirus. They have been found to be poor filters in several studies. Facemask issues – as they concern the fibre, size, construction and fitting – mean many masks now being manufactured are not effective! Mask use needs to follow complex procedures to reduce contamination; masks have to be disposed of safely, or washed regularly. Many agencies, such as the World Health Organisation, provide safety guides.

If wearing any mask will stop you from smoking, go for it! Smoking will worsen your outcome with Covid-19 infection. Interesting issues develop with using facemasks for hours at a time. Because they hide one’s face, they can challenge good communication. Nurses often have reservations wearing masks when caring for those with dementia, for instance. From a national perspective, does unnecessary purchase of masks compromise critical supplies of these for key workers? We are all aware of stockpiling passions shown during this pandemic!

Regulation of facemasks

Factory-produced facemasks should bear a quality code: Filtering Face-piece Particle (FFP) ratings range from FFP 1 to FFP 3. These denote increasing levels of filtration and reducing levels of leakage. Surgical facemasks are designed for use in surgical or dental environments, protecting the wearer against most incoming or outgoing large droplets and splashes. They are not perfect. If contamination has to be minimised, in some surgical procedures for instance, the surgeon wears a respirator.

Respirators seal to the skin and are not for public use. The N95 respirators meet the standard of blocking 95% of particles of 0.3 microns in size (Covid-19 viruses are 0.1 microns in diameter, respiratory droplets are approximately 5 microns across). They are not for use by children, in those with facial hair or by those with difficulty breathing. These devices can be used to prevent occupational dust exposure too.

Changes and the precautionary principle

Although the World Health Organisation has not changed its guidelines significantly following its recent review of the evidence in early April, many countries and agencies recommend that facemasks be worn in public spaces. Supermarkets, banks, police forces and bus drivers have retreated behind them. Media outlets are disseminating instructions for creating domestic masks and it seems manufacturing sufficient masks is going to prove a major challenge whatever our governments recommend.

With no clear answer to harvest from science – and as lockdowns loosen – perhaps we could follow the precautionary principle. This suggests that when the evidence is unclear, even a very low level of protection given by masks to communities may be worthwhile in a world trying to move on.

We need to revive economies, re-open schools, support our foundations and charities with minimal rebound of infections. We need to rebuild those emotional links for our minds to heal. Core benefits of social distancing, hand hygiene and cautions relating to coughs and sneezes are crucial foundations not to be abandoned. Perhaps a facemask should become a recommended add-on extra. Take care as you protect yourself and your neighbour.

History and Away

What we do with time

And what time does with us

Is the way of history

Spun down around our feet

~Andrew Salkey