21 October, 2020

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Mask Off Or Mask On?

By Dilip H. Liyanage –

Dr. Dilip H. Liyanage

As the Covid-19 global epidemic rapidly progresses, one debate among the scientific community and public is, use of face masks to prevent further spread of the infection. 

Many governments impose measures in place to control the infection for a reasonable and proportional response. Part of this planning is to mitigate any extra burden of the infection and to ensure the safety of the nations in many countries, while they adopt many other different measures. One of such measure is, general public were urged to wear face coverings in crowded areas.

Currently there is no strong evidence base to show the effectiveness of wearing face masks by the general public in order to reduce the infection rate (R Rate). Ideally there should be a community intervention trial showing the effectiveness of the strategy. Though there are comparisons of the countries that used face masks and not used faced masks, those result could have been affected by a lot of unknown confounding factors.

However, guidance on use of face masks widely varies among international health bodies and governments. Whether wearing a face mask can help prevent the spread of coronavirus has been a divisive subject among health professionals, particularly in the absence of effective pharmacological treatments. The question is, how useful are facemasks during CoVid-19 crisis? What is expert opinion on them? Should we wear it? If so how and who should where them? Do they protect you or the other person and which type of mask makes the most sense? 

This document provides the opinion on the suitability of face masks and other face covers in the community by individuals who are not ill in order to reduce potential transmission of CoVid-19 from the mask wearer to others.

What is the cultural and countries practices?

Many Asian countries regarded facemask as a magic weapon, in the fight against the Covid-19. Some Asian countries even forbid presence on the streets without a mask. But, in Europe mixed feeling regarding wearing mask in a time of resource scarcity. Many believed mask should be reserved for health care workers and sick people to protect other people. Recommendation on such, even in Europe this seems to be change over the time. Now many local authorities do recommend wear face mask in public settings where other physical distancing measures are difficult to maintain especially in areas community-based transmission is significantly high. 

Wearing medical grade masks in public settings 

The World Health Organisation (WHO) is currently only advising those who are sick and showing symptoms of coronavirus to wear a mask, such as coughing or sneezing. If you do not have respiratory symptoms like fever, cough, running nose, you do not need to wear a surgical mask. Masks may create a false sense of security, with neglect of other essential measures such as hand hygiene practices and physical distancing. They may lead to touching the face under the masks and under the eyes. Mask usage may result in unnecessary costs and take masks away from those in health care who need them most, especially when masks are short in supply.  

Mask in the community

Include various forms of self-made or commercial masks or face covers made of cloth, other textiles, or other materials such as paper. They are not standardised and are not intended for use in healthcare settings or by healthcare professionals. It should be emphasised that use of face masks in the community should be considered only as a complementary measure and not as a replacement of the core preventive measures that are recommended to reduce community transmission including physical distancing, staying home, hand hygiene etc. However, there is currently limited or no evidence that the wearing of a mask (whether medical or other types) by healthy persons in the wider community setting, including universal community masking, can prevent them from infection with respiratory viruses, including Covid-19. 

Cloth face coverings

Though evidence on the efficacy and acceptability of the different types of face mask in preventing respiratory infections during epidemics is sparse and contested, millions of people are wearing flimsy masks in the absence of a randomized controlled trial (RCT). In the absence of evidence and evidence of absence, some authorities are asking or compelling public to wear non-surgical masks, to manage scarcity rather than speaking honestly about the effectiveness. 

In addition, masks should not be placed on children under age 2, anybody who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

Rational usage of medical grade masks in the context of short supply 

Currently for any type of mask, appropriate use, worn and disposal are essential to ensure that they are effective and to avoid any increase in transmission. Many health care institutions make recommendations on correct use of mask if you feel the need to wear.

* Before touching the mask, clean your hands with alcoholic hand rub or soap and water. 

* Inspect the mask for tears or holes. 

* Wear the right side (usually white colour inside) and metal peace is on the top of the mask.

* Fit the mask on your face, pinch the metal strip or stiff edge which it moulds to the shape of the nose. 

* Adjust the mask on your face covering your mouth and chin. Make sure there are no gaps between the face and the mask to avoid the contamination.  

* Remove the mask using the appropriate technique: untie/remove the elastic from behind without touching the front and keeping it away from the face. 

* Discard the mask immediately in closed bin and clean your hand with alcoholic hand rub or soap and water.

* It is important not re-use single-use masks and replace masks as soon as they become damp with a new clean, dry mask.

However, the use of a mask alone is insufficient to provide an adequate level of protection, and other measures should also be adopted. Whether or not masks are used, maximum compliance with hand hygiene and other infection prevention and control measures is critical to prevent human-to-human transmission of Covid-19.

What is the new advice? 

Centre for disease control (CDC) advises and many governments advice, people should wear mask in public places (specially enclosed spaces) in where social distancing measures are “difficult to maintain,” such as supermarkets and pharmacies. The recommendation clearly states that the face coverings should be made at home with low-cost materials and should not lead to the use surgical masks and N-95 respirators which should be reserved for healthcare professional use. 

Could it have negative effects? 

Experts have warned several explanations as to why face masks have not generally been found to be effective if worn by the general population and which can also lead to complacency.

* Do not protect against the virus getting into the eyes (only close-fitting goggles do this); 

* May not fit the masks properly, frequent touching (self-contamination) or take them on and off; and

* False sense of reassurance and thus pay less attention to other key behaviours reducing transmission, such as hand hygiene and physical distancing.”

* Potential reusing contaminated mask

* Potential breathing difficulties, depending on type of mask

* Diversion of mask supplies and consequent shortage of mask for health care workers 

Government responsibility

Whatever approach is taken, it is important to develop a strong communication strategy to explain to the population the circumstances, criteria, and reasons for decisions. The population should receive clear instructions on what masks to wear, when and how and on the importance of continuing to strictly follow all other IPC measures (e.g., hand hygiene, physical distancing, and others).

Acknowledgments

I would like to acknowledge my supervisor Dr. Ian P Reckless, Medical Director, Milton Keynes University Hospital NHS FT, UK and my colleague Dr. Mapa Prabhath Piyasena, Postdoctoral Research Fellow from Ministry of Health – Sri Lanka for their input, support, and expertise in this work.

References

Carver, P. E., & Phillips, J. (2020). Novel Coronavirus (COVID-19): What You Need to Know. Workplace Health & Safety, 68(5), 250-250. 

Centre for disease control and prevention. How to Protect Yourself & Others. Coronavirus Disease 2019 (COVID-19) Prevent Getting Sick. Available here

Chan, A. Y., Leung, C. C., Lam, T. H., & Cheng, K. K. (2020). To wear or not to wear: WHO’s confusing guidance on masks in the covid-19 pandemic. BMJ Blog.

Cheng, K. K., Lam, T. H., & Leung, C. C. (2020). Wearing face masks in the community during the COVID-19 pandemic: altruism and solidarity. The Lancet.

Chughtai, A. A., Seale, H., & MacIntyre, C. R. (2013). Use of cloth masks in the practice of infection control—evidence and policy gaps. Int J Infect Control, 9(3). 

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, 8(5), 434-436.

Greenhalgh, T., Schmid, M. B., Czypionka, T., Bassler, D., & Gruer, L. (2020). Face masks for the public during the covid-19 crisis. Bmj369. 

Leung, C. C., Cheng, K. K., Lam, T. H., Migliori, G. B., & Scientifici Maugeri, I. R. R. C. S. Mask wearing to complement social distancing and save lives during COVID-19.

MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open2015;5:e006577. doi:10.1136/bmjopen-2014-006577.pmid:25903751https://bmjopen.bmj.com/content/bmjopen/5/4/e006577.full.pdf

Mahase, E. (2020). Covid-19: What is the evidence for cloth masks? BMJ 2020;369:m1422 https://www.bmj.com/content/369/bmj.m1422.short [Accessed 04 May 2020].

Peters, M. D. ANMF EVIDENCE BRIEF COVID-19: WEARING MASKS AND FACE COVERINGS IN THE COMMUNITY. http://www.anmf.org.au/documents/ANMF_Evidence_Brief_COVID-19-Public_Masks.pdf [Accessed 10 May 2020]. 

World Health Organisation. Advice on the use of masks in the context of covid-19: Interim guidance. 6 Apr 2020. https://www.who.int/publications-detail/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak [Accessed 09 May 2020].

World Health Organization. (2020). Advice on the use of masks in the context of COVID-19: interim guidance, 6 April 2020 (No. WHO/2019-nCov/IPC Masks/2020.3). World Health Organization.

World Health Organization. Home care for patients with COVID-19 presenting with mild symptoms and management of contacts: interim guidance (accessed 29 January 2020)

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Latest comments

  • 6
    1

    “Mask Off Or Mask On?”
    oh this is a medical blog?…how disappointing

    ask Gota and Rajapakse criminals to take off their democracy ..hold election mask off

    and show their true mask on …

    Dictatorship

    • 5
      4

      Indeed disappointing. Ignore this which is coming out from an arm chair pundit, a mere pen pusher calling himself a medical administrator. If masks are not proved to prevent infection, in future surgeons and nurses working in operating theaters should stop wearing them. I have worked in cardio-thoracic unit, where surgery on one patient goes on for six to eight hours non stop and I never had any breathing problem. There was a video in social media where it was demonstrated how to make a mask with cloth used at home, which is easy and cheap, and reusable after washing with soap.

      • 3
        3

        Dr. Sankaralingam

        As a guide, the National Heart, Lung, and Blood Institute (NHLBI) state that a coronary artery bypass takes 3 to 6 hours.

        Can you enlighten me . Are you a Surgeon or playing Organisational and Leadership role. Out of interest where did the extra 2 hours come from were you an anaethetist needing the extra 2 hours to bring the patient back to consciousness If you were playing an administrative role were you required to wear Masks.

        • 4
          2

          Kali do not display your ignorance. My statement is through experience of working in cardio-thoracic unit and not through reading literature. Why don’t you check with doctors before making such stupid comments. For you cardio-thoracic surgery is only coronary artery bypass. Have you heard of single valve replacement which takes six hours and double valve replacement which takes eight hours, from opening the chest to closing the chest. To connect a patient to the bypass machine and cool the body by circulating cold blood from the machine itself will takes at least one hour. Without ensuring that the heart is protected by hypothermia by covering it with ice and paralytic agents like KCl injected into coronary arteries, you do not open the heart. This does not include time taken by anaesthetist to induce and reverse the patient. These surgeries were done routinely in Colombo forty years ago, six days a week. There are surgeries like total correction of Fallots not done in Sri Lanka which could take much longer. You are proving age old saying that fools only tread into unknown areas. Have you ever seen an administrator wearing a mask to ask this silly question.

          • 3
            2

            Part 1

            Dr. Sankara
            Kali do not display your ignorance.
            *** Let us see who is ignorant. Don’t try to be too smart. You claim to be a Dr but I am not sure because your comments are full of false statements.
            1) My statement is through experience of working in cardio-thoracic unit and not through reading literature.

            *** If it was true how will you make the following statement as if it were the norm.
            “ on one patient goes on for six to eight hours non stop”
            You claim to be a Dr. if so you should have said in” some cases it might take
            Up to 8 hours”. I cant blame you if you don’t understand.

            • 3
              2

              Part 2

              2) Why don’t you check with doctors before making such stupid comments.

              *** My friend yes I have. I was born with a leaky valve and I had an Aortic Valve replacement 16 years ago. My surgeon who was one of the best had a waiting list of 6 months. When I was referred to him by my GP he told me it was leaking like a torrent and the heart could collapse. To stay alive I spent awful lot of money and had it done privately by him at Wellington Hospital with a mechanical valve and attend Warfarin Clinic. I have not seen him since as I am in perfect health . Yes after reading your comments I spoke to him he told me mine took 5 hours and not all the surgeries last 8 hours unless there are complications. He told to my embarrassment that may be in Sri Lanka they take 8 hours.

              • 3
                2

                Part 3

                3) Have you ever seen an administrator wearing a mask to ask this silly question.

                *** In Criminal Law there are leading questions ( not allowed) and I knew the above will put you on the Defensive because you made the following statements.
                I have demonstrated leadership and organisational skills, and therefore I can judge anyone about his skills.
                In contrast Rajapkase brothers have both
                Chandrika then as chief minister of western province with same limited power demonstrated it.

                I hope you regret the above Statements for the rest of your life. I don’t normally read your comments because sometimes an Article is littered with your comments
                At least I now know you don’t know how to make factual statements , a Gotha and an MR lover an Ardent believer that Tamil problems are due to Lack of TAMIL LEADERSHIP and not Sinhalese RACISM.
                I also know now that Sri Lankan Doctors are Sub Standard.

                • 3
                  0

                  Kali, I am a person who has openly stated in these columns that Mahinda and Gotabhaya are murderers, swindlers, liars and racists. Can you name any other Tamil writing in his own name had done this. I have time and again stated that the root cause of the problem is Sinhala racism borne out of inferiority and fear complex and their attempt since independence to create mono-ethnic Sinhala Buddhist Sri Lanka. Problem with you is your inability to understand English.

              • 4
                0

                Kali just because you had a leaky aortic valve (aortic incompetence) replaced 16 years ago, you know everything about cardio-thoracic surgery. Are you aware that at present a valve can be replaced without opening the chest or heart, by entering the heart through arteries in either wrist or thigh unlike in the past. Your doctor describing as torrential leak and heart collapsing is exaggeration. Defective aortic valve leaks only in Diastole ( heart relaxation) and not in Systole. This is in contrast to defective mitral valve which leaks in Systole (heart contraction). Due to aortic valve leak, left heart enlarges and after sometime gradually fails. Your surgery took five hours because only one valve was replaced, which corroborates with what I said about taking six hours for a single valve replacement. Secondly technique of chest opening and connecting to by pass machine has improved since, which could cut the total time by one hour. Sri Lanka may be behind developed countries in cardiac surgery, but definitely single valve replacement did not take more than six hours even 40 years ago.

            • 4
              0

              Kali, I obtained my first degree in Colombo medical school way back 50 years ago when the degree was internationally recognized. I was a past president of Sri Lanka Medical Association in UK, which I would not have got unless of some standing. My comments are absolutely spot on based on facts. You could ask any doctor who has worked in cardio-thoracic surgery whether it is correct or not. I have stated that is=n cases like double valve replacement and total correction of Fallots Tetralogy it could take eight hours. Problem with you is your inability to understand plain English due to swabasha education in Jaffna

              • 1
                2

                Dr. Sankaralingam

                Dont teach me English. Let me correct you once again and I hope for the last lite before you make a fool of your self. Frankly I never read your comments as I said the whole place was littered with your comments so I paid no attention and have no time. But what caught my attention was your statement that problems faced by the Tamils such as

                Waging a Freedom Struggle From Sinhalese Tyranny
                Fighting against Colonisation
                Reeling from effects of Race Riots
                Memory of Krishanthi Rape and Murder and I can go on and I know for you these are Trivial as you have never been to Jaffna and have gone through suffering.
                All you were privy to was annual Royal Thomian Cticket Match which was your small World .
                As for what I wanted to clarify you cant seem to understand your mistake
                Just go back and read what you wrote
                on one patient goes on for six to eight hours non stop”
                The above is not a norm and accept your mistake. If you cant it amounts to saying “ The Muyal I caiught has only 3 legs.
                I am not prepared to take lectures from you as I also have an Hons Degree in Biochemistry & Physiology from Kings College , MSc in Experimental Pathology for which I did a Project on Ulcerative Colitis at Royal Postgraduate Mrdical School before I moved on to Law.

      • 2
        1

        “Ignore this which is coming out from an arm chair pundit, a mere pen pusher calling himself a medical administrator. “
        What an amazing sense of humility!
        *
        Social space is not quite like an operating theatre.
        What the author says makes sense and seems supported by credible sources.
        *
        The central point is that masks alone are inadequate to prevent infection and warning is against complacency of those who feel fully protected by the mask.
        *
        We are expected to accept things from some armed chair pundits on a range of subjects, but the very pundits are protective about what they claim to be their patch.

  • 7
    2

    Use of masks in Sri Lanka should be based on risk and reward. It should not be based on CDC or WHO guidelines. It is ridiculous for the police to insist that everyone should wear a mask when there are no Covid-19 clusters in Sri Lanka, other than the Navy cluster, which is a part of the Covid19 task force. The rule should be anyone with a cough, cold or catarrh should wear a mask. If a Covid Cluster is discovered in any area, it should be cordoned off immediately. Insisting on a mask in such an area may be justified.

    • 3
      0

      Lal
      I agree. Insisting on a mask can be justified only in areas with Covid clusters.
      But then we have curfew imposed on areas absolutely free of infection (except tea plantations where cheap labour is precious).
      How can they justify the curfew without insisting on masks?

  • 4
    0

    In Srilanka, we have different approach by the government for different regions, different ethnic groups and different personalities. It is the military who are responsible for deciding on who should wear mass, who should be isolated, how long should you isolate. In the national military victory celebrations, President of Srilanka did not wear mask or national dress whereas Prime Minister was in national dress and with mask like many others. In Northern lands some politicians who went to remember those who died in the war maintained the social distance, wear face masks were aressted and asked to isolate for 14 days by police. What a beautiful democracy and corona advice?

  • 1
    2

    Dr Sankaralingam

    Dont get me wrong. I never show disrespect to an Intellectual although I had to be rude to a few who happened to be from the other side as some of them are pretenders and I understand that . When it comes to Tamils I consider those people as traitors as I expect them to Join the Chorus as one singing the songs of Suffering.

  • 1
    0

    The renowned medical writer, Dr. Atul Gawande, wrote in The New Yorker magazine recently about how he and frontline medical personnel in New York prevent the coronavirus from spreading among each other. First, by testing almost daily. Second, by frequent hand washing. Third, by wearing surgical face masks, and finally by social distancing.

    The masks are the surgical masks commonly worn by most people. They block respiratory globules, produced by coughing, sneezing, and loud talking. These globules carry the coronavirus.

    Hong Kong, with a population of 7.2 million packed into just 500 square miles, with a direct railway line to Wuhan and sharing a border with China, has only 1045 infections and 4 deaths. Having learnt their lesson during SARS, Hong Kongers wear face masks at the first sign of infections.

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