To mask or not to mask—that has been the question that has been gaining traction as the COVID-19 pandemic sweeps across the world.
There are conflicting reports on whether or not wearing a mask will help reduce the spread of the virus. In Canada the standard advice has been—only wear a mask if you are ill or caring for someone who is ill. And this is good advice. You should definitely wear a mask in these circumstances, but the west is beginning to look to the east and rethinking this strategy.
In the east, it is and has been for many decades, common practice to don a surgical mask in the winter season when cold and flu bugs are at their height or when a known pathogen is running through the region. I lived in Thailand through several serious outbreaks—SARS and Bird Flu-- and it was common to see everyone wearing masks. I’ve spent a few winter seasons in Taiwan, and again, not all but many people wore masks. Japan, Hong Kong, South Korea—all commonly wear masks to reduce the risk of contagion. And that practice has been ramped up in the age of COVID-19. But not in the west.
In the early days of COVID-19’s introduction into the United States, a friend of mine, who is Taiwanese, wrote on Facebook that she was criticized for wearing a mask in public. She saw it as a preventative measure and a normal course of action. I don’t remember now what the content of the criticism was, but it was fuelled by the uncomfortable feeling face coverings of any sort seems to cause in the psyche of many Americans.
Three months into the pandemic, North American and European governments are starting to change their tune on the wearing of masks as a preventative measure. In the early days of the contagion, these same governments said there was no concrete evidence to suggest that the wearing of masks would reduce the spread of the disease. Some suggested that the improper use of masks might actually increase the spread of the virus as people might touch their faces more to secure the masks, or otherwise use them incorrectly.
Now we are realizing such concerns may have been wrongheaded. The number of infections that could have been prevented by the wearing of masks by the general public may far surpass the number that might have been caused by incorrect usage.
There’s no hard data behind this theory only observational evidence deduced from the number of cases in countries that typically wear masks to those that don’t.
Canada first reported case January 15, total cases April 3 – 12, 537
United States first reported case January 20, total cases April 3 - 277,985
Japan first reported case January 16, April 3-2,855
South Korea first reported case January 20, April 3-10,156
Hong Kong first reported case 23 January, April 3 - 862
Taiwan first reported case January 20, April 3- 355
These numbers are only part of the story. To really see the discrepancy between the spread of COVID-19 in the west versus that in the east you have to look at the cases per million people in each country.
Canada cases per million 332
United States cases per million 839
Japan cases per million 23
Taiwan cases per million 15
Hong Kong cases per million 115
South Korea cases per million 198
Canada should perhaps be judged separately as the population density is so much less than any of these Asian countries or the United States and higher population density should increase infection rates if measures aren’t taken to counteract that factor.
Population density in Canada is 4 people per Km2, Japan - 347 per Km2, Taiwan – 649 per Km2, Hong Kong - 6,659 per Km2, and South Korea – 503 per Km2. Population density in the United States is 36 per Km2. Population density of New York City, one of the epicentres of the pandemic in the U.S, is 10,194 per Km² while Seoul, South Korea has a population density of 17,000 per Km2.
Based on these numbers alone, it seems that wearing surgical masks may be part of the answer to reducing the spread of COVID-19. It certainly isn’t something we should ignore and not adopting this measure in January may have contributed to the rates of infection seen today in Canada and the U.S.
Where do we go from here? Should we all start wearing surgical masks? In a perfect world, the answer would be yes. It can’t hurt. But this is not a perfect world and every day brings news of frontline health care workers voicing concerns about the dwindling supply of PPE (personal protective equipment) including surgical masks.
The new hope has focused on homemade masks. A new cottage industry, often not-for-profit with volunteer labour, for the construction of cloth masks to supplement factory made surgical masks has arisen. Fuelled by social media, instructions for mask fabrication are breathing new life into old machines that were abandoned because we didn’t have time to use them until the pandemic left us little else to do.
But are homemade masks effective protection from COVID-19? There isn’t much research published in this area. Experiments that have been conducted and published in the past 10 years suggests that homemade cloth masks are not effective in reducing the spread of viruses.
A paper published in the Annals of Occupational Hygiene in 2010 studied the performance of sweatshirts, T-shirts, towels, scarves, and cloth masks in filtration of virus-sized particles. The results of various tests showed that all of these fabrics had near instantaneous penetration by particles; almost completely ineffective in protecting wearers from virus particles.
Another research paper published in 2015 comparing the use of cloth masks versus medical masks in healthcare workers came to a similar conclusion; rates of infection were highest for workers wearing cloth masks.
The authors of this paper recently released an update in light of the recent mask shortages reported during the COVID-19 pandemic. As one of the few clinically based research papers published on this now pressing issue, the authors have been bombarded by questions from the medical community. Their advice to workers who choose to wear cloth masks, which isn’t really a choice but the line of last possible defence, is “have at least two and cycle them, so that each one can be washed and dried after daily use. Sanitizer spray or UV disinfection boxes can be used to clean them during breaks in a single day. These are pragmatic, rather than evidence-based suggestions, given the situation.”
The takeaway from what little evidenced-based information we have on the use of cloth masks to prevent the spread of COVID-19 is that an almost completely ineffective measure is better than nothing. A desperate message if ever there was one.
The question of masks currently comes down to what is currently available and what is a last-ditch effort. When supplies of effective PPE are running low, only those workers on the front lines should be allowed to wear them starting with our health care workers- they are obviously in the most at risk environment. Next on the priority list is anybody’s guess—all essential workers should have protection but when supplies are low, that may not be possible.
The COVID-19 pandemic will resolve itself in time, but we need to take heed of the lessons learned today. We need more PPE for health care workers. We in the west need to adopt the Asian practice of wearing masks whenever a serious virus is on the move. We need to have a supply of surgical masks that can cover every face on the planet. It is only then that we will be free to live as we please when invisible invaders threaten the health and economy of the world.
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