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Face Masks during Pandemics: Science, Technology, Policy and Belief

ISSUE 2020
No 06
Release 31 st March 2020
By SUN Molika*, BA, CHHEM Sirika**, PharmD, PHLONG Pisith***, MA, and CHHEM Rethy****, MD, PhD (Edu), PhD (His)

Executive Summary

❖ The public fear of the Coronavirus Disease (COVID-19) has caused the demand and price of face masks to skyrocket; hence, limiting the availability of masks required for healthcare professionals.

❖ Masks, as essential forms of Personal Protective Equipment (PPE), are more needed for healthcare workers than for the public. However, masks are overused by the general public to protect against air pollutants or airborne viruses during disease outbreak.

❖ There are different types of masks with distinctive filtration and performance levels. They are designed to match various procedures or risks levels.

❖ Policy Options: o Implement and monitor compliance in the use of PPE for healthcare professionals and staff working in healthcare settings, following WHO guidelines; establishing clear guidelines for healthcare workers, administrative staff, cleaners and visitors. o Practice frequent hand washing, cover mouth and nose when sneezing or coughing, and comply with social distancing, as suggested by the WHO. o Stop panic buying and stockpiling masks, in order to reserve important resources for healthcare professionals. o Optimise the use of masks in healthcare settings due to the shortage during the COVID-19 pandemic. Regulate mask purchase through the use of quotas for the public who wish to buy masks for their own protection. o Follow strictly the WHO advice for the public on when and how to use masks.

COVID-19 & Masks at A Glance

In late December 2019, the first case of Coronavirus was found in Wuhan city of Hubei province, China. On 11th February 2020, the virus was officially given the scientific name of “Coronavirus Disease” (COVID-19) and “Severe Acute Respiratory Syndrome Coronavirus” (SARS-CoV-2) by the World Health Organisation (WHO) and International Committee on Taxonomy of Viruses respectively. By 15th February 2020, UN News reported that COVID- 19 had infected approximately 63,000 people and caused around 1,300 deaths, making it a global health threat2 and these numbers are growing by the day. As the morbidity and mortality rate increased steadily, the panic-stricken population started to massively consume and adopt various prophylactics such as surgical masks, respirators, hand sanitisers, mouthwash, etc. The widely accepted belief that wearing a mask is one of the most effective, fast and affordable ways to prevent virus transmission has caused its demand and price to skyrocket. Empirically, Tedros Adhanom Ghebreyesus, the Director-General of the WHO stated:

“Demand is up to 100 times higher than normal and prices are up to 20 times higher.”

Mike Bowen, the Executive Vice-President of the N95 mask manufacturer named Prestige Ameritech, said that mask sellers have increased the price dramatically from 1 USD for two normal masks to at least 10 USD per mask. Similarly, the surgical mask price in Phnom Penh increased from a regular 1 USD per package of 50 masks to 25-30 USD at markets and pharmacies , creating public indignation and thus pushing regulators to reduce that price for public use. With this dramatic proliferation of using masks as a preventive tool, one may question whether it is due to its medical effectiveness or some other socio-cultural reasons. As a matter of fact, people, especially East Asians, are fond of wearing masks despite this current pandemic.

The History of Masks

In 1910, the pneumonic plague struck China. In response, a young and brilliant Cambridge- educated Chinese doctor, Wu Lien-The, was appointed by the Chinese authorities to deal with the epidemic. Through his efforts, he determined that this plague was airborne, so he created face masks to prevent patients from transmitting the virus to others and to protect the general public from being infected. This proved effective, and as a result, people started wearing masks regardless of where they went to or who they were with. More importantly, this made Chinese people look at gauze masks as talismans and a symbol of a modern and scientific nation compared to the West.

Socio-cultural Root Cause of Wearing Masks

In the United States, wearing masks in public spaces was legalised by some cities as a medical initiative to prevent its citizens from catching the Spanish flu in 1918.7 For the East-Asian population, especially in Japan, wearing masks was perceived as a social and cultural norm. Japanese people began wearing facial masks during the massive influenza epidemic of the early 20th century.8 This custom was continued when Japan suffered from several subsequent respiratory-infected diseases and accidents: the Great Kanto Earthquake in 1923, “Severe Acute Respiratory Syndrome” (SARS) in 2003, Swine flu in 2009, Fukushima radiation disaster in 2011, “Middle East Respiratory Syndrome” (MERS) in 2016, and the current COVID-19. However, health concerns are not the only reason why Japanese people love to wear masks. A research showed that, in Japan, women wear masks to avoid tanned skin in order to look like westerners, to hide their make-up free face or emotions, and to get rid of unwanted communication or harassment. Moreover, wearing masks is a fashion trend exemplified by some famous Korean celebrities and artists, who wear them during their fan tours or performances. Norm-wise, wearing masks in a public space represents public spiritedness and discipline9 , courtesy and etiquette for Japanese people. For example, wearing masks in a commuter train symbolises the social responsibility of a person to avoid infecting other people. Furthermore, it is also a legal duty of workers to wear masks in order to protect themselves from catching a flu so that they can contribute better to their jobs and economy.10 Therefore, despite the panic of an epidemic, the Japanese wear masks to show that they are a committed workers and citizens.

Types of Masks

Wearing masks has undeniably become a wider public health strategy to counter new disease emergence, yet the effectiveness of this prophylactic tool remains unproven. Hospitals started using surgical masks in the late eighteenth century with the purpose of preventing a patient’s surgical wound from droplets released by a surgeon’s breath. Nowadays, different types of masks with distinctive filtration and performance levels are designed to match various procedures and risk levels. “Maximum Filtration” or “N95 Particulate Respirator” is the most effective in preventing airborne viruses and pollutants, if worn properly. It has a high fluid resistance of 160 mmHg11 and is used against airborne diseases such as tuberculosis or influenza. In a setting where there are vast amounts of fluid, spray and/or aerosols, ASTM Secure Fit Masks are used. This kind of mask is certified by the American Society for Testing and Materials (ASTM) and is created by using Secure Fit Technology to reduce contracting floating particulates in the atmosphere, as its aluminum pieces help reduce space around nose and chin area. ASTM certified masks of level 3, 2 and 1 have fluid resistance levels ranging from high (160 mmHg), moderate (120 mmHg) to low (80 mmHg). They are used in a heavy, moderate and light particle-concentrated environment respectively. Another type of mask is called a “Utility Mask”, used solely as a physical barrier. They have low or minimum performance, and have no filtration efficiency level.

Are Masks Effective?

A professor from the University of London, Dr. David Carrington, suggested that surgical masks do not effectively protect wearers from airborne viruses or bacterias in the public due to its loose, non-air filter and eye-exposing features. However, it may decrease the risk of contagion from a splash of small droplets such as a sneeze or a cough and hand-to-mouth transmission.13 Another study has shown that face masks provide a six-time virus exposure reduction in a well-controlled environment (e.g., hospital),14 but it is not effective in a community setting, especially when not worn properly15. Since surgical masks are not regulated, their filtration level may provide only minimal protection from viruses and air pollution particles (e.g., nitrogen dioxide). However, when worn correctly with frequent change and disposed safely, masks are moderately effective. They help prevent wearers from contracting viruses from a droplet, sneeze or cough, and hand-to-face self-contamination.

Even though medical experts seem to agree that frequent and rigorous hand washing is even more effective in protecting people from the novel COVID-19, people persist in wearing masks. On Amazon, for instance, even the price of masks went as high as 800 USD for 160 masks, the supply is no longer available as of Saturday [29th February 2020].16 This is a witness to the fact that public fear of this pandemic is stronger than the virus itself. In 2009, during the Canadian pandemic influenza, the Public Health Agency of Canada (PHAC) stated that panic might occur if the availability of masks were limited despite their ineffectiveness. The misconception of using masks and other personal protective equipment (PPE) (e.g., hand gloves, goggles, respirators, face shields, gowns, and aprons) created a massive public purchase, which will limit the availability of masks required in healthcare settings, and thus, put the lives of public health workers at risk, as they are in direct contact with COVID-19 patients.17,18 Therefore, the US Surgeon General, Jerome M. Adams, and the WHO19 called for the public to stop panic buying and stockpiling masks, in order to reserve important resources for healthcare professionals. If the public wishes to buy masks for their own protection, the government should regulate mask purchase through the use of quotas. Moreover, due to the shortage of masks during this COVID-19 pandemic, optimising the use of masks in healthcare settings is extremely important.

Policy Options: Learning from the Past

The WHO suggested that wearing masks is only needed for healthy people when they are taking care of COVID-19 suspected or infected patients.20 In addition to wearing masks, both the WHO and the National Health Service (NHS) in the UK recommended exercising other hygiene measures, which include frequent and rigorous hand cleaning with alcohol hand sanitiser or soap and water; covering mouth and nose when sneezing or coughing; avoiding the touching of eyes, nose and mask while using it; and maintaining a fit and healthy lifestyle to reduce risk of contracting viruses21. The Center for Disease Control and Prevention (CDC) also added another crucial point of social distancing by avoiding direct contact with patients or staying home when one is sick.22 However, to combat the current global threat of COVID-19, smart and cooperative policy options are needed more than just the above-mentioned individual protection and prevention measures. 

By learning from the past, the International Plague Prevention Conference created during the Manchurian Plague in 1910s portrayed the importance of international collaboration. Opening door to welcome outside expertise and assistance, plus extensive sharing of public health and social data amongst experts not only helps mobilise resources, but also improves trust within the international community. This could potentially reduce xenophobia.23 Moreover, quarantines and movement restrictions should be meticulously considered and practiced as they give time for both virus-outbursts and for infected countries to structure their countermeasures. 24 For unaffected countries, the report of the WHO-China Joint Mission on COVID-19 urged them to prepare and test the effectiveness of their immediate response plans and non-pharmaceutical measures, enhance surveillance and awareness of COVID-19, and enforce infection prevention and control measures in all healthcare facilities. Lastly, since we are living in the pandemic interval, initiating a well-prepared combat plan for future outbreaks is significantly important. As a part of mitigation efforts, further studies should focus on how human interactions affect the spread of the disease; how state, societal, and individual responses affect disease, and how public health shapes public trust, governance, and the economy.

In conclusion, the increasing pandemic across the globe is causing a severe shortage of masks, despite its increasing industrial production. As a call to action and message to the general public: Don’t panic buy and stock masks, save them for healthcare workers!

The opinions expressed are the author’s own and do not reflect the views of the Asian Vision Institute.