Face masks for the public during the covid-19 crisis

Dear Editor

Greenhalgh and colleagues are correct: face masks are needed but this needs to be part of a multi-pronged strategy to prevent excess deaths. Coronavirus isn’t going to go away; the current strategies are only delaying spread, and of course protecting the NHS, and other health systems in other countries, from collapsing. And that of course is a good thing. But when we (gradually) loosen the lockdown, it is clear we need a bundle of measures to reduce transmission by keeping the R as low as we can:

Wear face masks where possible, especially where social distancing is difficult, e.g. in schools, shops and on public transport

Maintain social distancing and the, essentially common-sensical, hygiene measures currently in place

Institute large-scale testing of those who are symptomatic, then isolating and contact tracing, using the already existing systems of PHE and local government

Treat, in properly constructed and registered trials, all those who have coronavirus diagnosed in order to identify the correct/best treatment(s). And note that this isn’t simply those who are antigen positive as the test is not 100% sensitive

Develop vaccines ASAP. Only when effective vaccines are available and vaccine rates are high enough for true herd immunity can the other measures above be relaxed.

And our leaders, of all types, not just politicians, should lead the way and be seen to wear masks. Prominent people in other countries are wearing masks, usually home-made (as, of course, ‘proper’ masks should be reserved for health and social care staff).

Dear Editor,

While the article’s title is “Face masks for the public during the covid-19 crisis” I get the distinct impression that Professor Greenhalgh et al. would really rather the great handwashed (sic) adopted them en masse, in perpetuity, you know, just in case. No convincing evidence, but hey – fingers crossed, touch wood, pop your homemade mask on…

COVID-19 joins a long list of zoonoses, diseases that have manged to leap the chasm between their animal origins and their new human hosts. Inevitably, the first time a microorganism manages this feat it meets a population with zero immunity, and if its infectivity and case fatality rates are high then many millions will die. Imagine if Ebola manged to achieve airborne transmission? Scary stuff. However, there is no indication that COVID-19 is that dangerous.

Nick Triggle (BBC Health Correspondent) wrote an interesting article on April 14th (https://www.bbc.co.uk/news/health-51979654) looking at the death toll associated with COVID-19, pointing out that we will not know how much extra mortality has been caused in 2020 until we have the benefit of retrospect. 600,000 people die every year in the UK, many of them old and/or frail, and a significant proportion of current COVID deaths will be in those who would have died later in the year. Sounds harsh I know, but viruses and statistics don’t care about human emotions.

Meanwhile, let’s not forget the fear factor. It’s become apparent to me over the last few weeks that the government are happy for people to be scared, since that makes them more likely to comply with unpleasant things like the social lockdown. The media – of all varieties – have also been obliging, as a tsunami of human tragedies and steeply ascending graphs fill their airtime. So, maybe once the scared population are allowed out again, blinking in the bright Spring sunshine, they could be persuaded to wear facemasks…

Probably not for long though. Asia has a very different culture regarding many things, facemasks among them. Let’s face it, in large swathes of Asia wearing a facemask might help fool the facial recognition software that seeks to suppress free speech in its population. In the UK an actual increase in safety seems highly unlikely given the absence of evidence, so what about the law of unintended consequences? A division between the mask wearers and the naked faces? Maybe, we love tribal divisions. A marring of communications between individuals? Certainly, facial expressions matter, and subconscious lip-reading is something you only realise you needed when it’s not possible (DOI: I have high frequency hearing loss). Maintenance of public fear levels? Only a fool – or a power-hungry administration – would consider that a good thing.

COVID-19 does not threaten our survival directly. Maybe one day a disease will come along that curbs the logarithmic growth of our species (the Earth’s population was half its current level in 1972), but not today. Our fearful reaction to it may have far worse effects, both economically and culturally. The article’s thrust is “this seems sensible” without offering any convincing evidence, just as my grandmother maintained that sugared butterballs were the ideal treatment for the common cold; perhaps as a profession we should avoid such superstitious behaviour, in case the public stop clapping and start jeering.

Recent guidance from CDC for using face mask by general public has created a lot of commotion and confusion. This has certainly rubbed salt into the wound of fear and apprehension of COVID-19 that some were already living with. Many are still not clear which type of mask will protect them but everyone is eager to grab the best for themselves and in maximum number. While healthcare workers are feeling the pinch of PPE shortage, this new chaos is not helping anybody. Most importantly, hand hygiene and physical distancing, which are more important preventive measures of transmission of infection, have taken a backseat.

While we are still trying to understand this novel corona virus, it is not certain which mask and how effective they are going to be in preventing COVID-19. Many do not know that the new recommendation for using a face mask in public areas is to protect others rather than themselves. In addition, they are also not clear as to in which situation these face masks are to be worn as many are seen wearing one whilst driving, in a car park, jogging and so on. It is therefore vital to advocate the awareness that the face mask should be worn when they are less than six feet from another person and also that it should not be removed to make your talking easier as this may be the main mode of transmission of infection for most asymptomatic carriers. In addition, the masks should be changed or cleaned frequently as practical.

Sadly, if masks are not used judiciously and adequate care is not taken for other priorities, this may become an additional risk for increasing the spread of this novel corona virus.

Dear Editor

Though the evidence for face masks is marginal the fundamental principle is that masks either prevent a cough aerosol spreading from an infected person or reduce the liklihood of inhalation by attending staff.

I accept that the justified anxiety has for the present meant a back-tracking on masks being of little or no proven value; certainly to my observation many users seem to fiddle with their masks frequently which clearly undermines the benefits.

May I make several observations.

Firstly, to quantify the risk could the masks of frontline staff be swabbed after use just to understand what level of exposure is actually happening this might inform practice

Secondly, having worked most my professional life with older people may I point out that most frail elders have a poor cough not an olympian cough producing a long range aerosol: indeed this is often a factor in pneumonia developing.

Finally, whilst masks, PPE and testing along with social distancing have dominated recently, general hygiene management has received less attention though it only takes a contaminated toilet or sluice door handle to undo most other measures.