Why use of face masks by everyone outside their homes is still mandatory during the COVID-19 pandemic!

INTRODUCTION

The SARS-CoV-2 (COVID-19) pandemic continues unabated across the world, especially in India. Speculations about extreme of weather, rain, and herd immunity somehow controlling the spread of the virus have been debunked.^[1,2] With the vaccine trial of Astra Zeneca being shelved after SAEs, the possibility of safe and effective immunization has also been pushed back.^[3]

India occupies a unique position in this fight against COVID-19. While our absolute number of positive cases is increasing daily, the mortality per million population remains one of the lowest in the world.^[4] This could be misleading or potentially be explained by pre-existing (partial) immune protection in our general population.^[5]

After 6 months of lockdown (of varying degree) in India, there is frustration, fatigue, and surrender to fate among the common citizens, termed as coronavirus behavioral fatigue.^[6] Compulsions of many kinds are forcing the working class to return to earn their livelihood. The authorities also have to balance the effect on the economy with the need to contain the pandemic. But nothing can be further from the truth. Relaxation of lockdown accompanied by disdain for COVID-19-related precautions has resulted in a serious second wave in cities such as Mumbai and Delhi. Private hospital beds allotted for COVID-19 patients are completely full. What has led to this current situation? Once exiting their homes, people are following the herd mentality and becoming casual about maintaining social distancing as well as not following COVID-19 precaution guidelines issued by local authorities. Crowds on the streets and in public transports are behaving as if the COVID-19 pandemic does not exist.^[6]

It is clear that the COVID-19 general mortality is dramatically different between health-care professionals and the general community, being significantly lower for the later.^[7] Health-care professionals and hospitals are facing challenging times from all fronts. It is said that several thousands of nursing homes are facing bankruptcy. Centers are having shortage of doctors, forcing the government to deploy medical students, interns, and doctors from other disciplines of medicine (AYUSH).

Under these circumstances, it is necessary to remind our citizens that it is of vital importance that they continue to diligently follow all recommendations to contain COVID-19 and prevent its spread. Use of masks outside of homes is the crucial factor that can slow down the pandemic and keep our family, friends, colleagues, and others safe. In fact, the general public should be aware that not wearing a proper mask is akin to committing murder and suicide at the same time. Now that the possibility of reinfection has been proven beyond doubt, wearing of masks needs to be self-enforced by each and every one of us.^[8]

Asymptomatic SARS-CoV-2-infected individuals are responsible for 80% of community transmission cases. High viral shedding leading to droplet-based transmission and might be accompanied by aerosol transmission irrespective of respiratory symptoms – a major risk to the community.^[9]

Let there be no doubt that use of a face mask is the only protective intervention currently available to break the chain of transmission. This is to first protect one’s self and simultaneously protect others from SARC-CoV-2 infection.

Everyone must be wearing face masks outside of their homes at all times. Studies from the influenza pandemic have confirmed the transmission of droplet and airborne infection is reduced by 5 times when face masks are used.^[10]

• The “Variolation” effect of masks depends on the type of mask and its proper consistent use. The best evidence is the difference between two cruise liners which had COVID-19 outbreak, in the first instance, where strict mask use was not warranted saw as high incidence of symptomatic COVID-19 infections as opposed to the second cruise liner that ensured face masks for all and reported 81% asymptomatic COVID-19 infections.^[11,12]

  This is also supported by the low case-fatality rates seen in food processing plants and other industries where face masks were mandatory even before the COVID-19 pandemic. Opponents of the face mask raise the bogey of local skin irritation, breathing difficulty, fatigue, and CO₂ retention. These fears are unfounded. Doctors and disaster management professionals who require prolonged use of N95/FFP2 or higher filtration efficiency masks are well aware of safe periods of duty while donning personal protective equipment (PPE). The social media is full of fake messages about the futility of wearing face masks. There is also a video being circulated where a “doctor” is shown saying that face masks are necessary only in special circumstances.^[13] Let there be no doubt that such social media propagations are misleading and illegal with consequences under the IT Act and Disaster Management Act in India.

• The first parameter is that the face mask should be worn and fitted properly.

For general use, a homemade mask made of dense woven fabric could be sufficient. If possible a multi/three-layered mask should be used. In case, there is suspicion of contact with infected individual or while going into crowded places, a 3-ply surgical mask is better. While visiting hospitals and if prolonged contact with large groups is likely to occur, N95 masks are preferred. And hospital staff in high exposure areas needs the additional use of face shields as well as full PPE.^[14]

The general public must also follow the correct technique for wearing and removing face masks. It requires close attention to hand hygiene (with soap and water or alcohol based hand rub) before and after contact with the mask or the face. Also unnecessary touching the face or the front of the mask should be avoided. People need to be reminded that improper use of face masks is likely to be counterproductive. Hence letting it slip below the chin, keeping nose exposed or removing it for chatting are to be strictly avoided.^[8]

Commercial reusable masks must be used only as per the recommended guidelines (duration of use and frequency of change). Reusable but non-washable commercial fabric masks may be air dried at 70° for 30 min.^[15] Reusing N95 masks should be done only if absolutely essential and requires a rotation pattern every 4^th day.^[9]

Homemade cloth masks should be washed with soap or laundry detergent allowed to dry completely before reusing them.^[16]

If the society is grateful to the untiring efforts of the health-care professionals in saving their lives, they must ensure that not a single doctor or hospital worker gets infected with COVID-19 due to their careless attitude. It is time to return the favor and protect and support those that deliver care amid these testing circumstances.^[17] Remember that more than 100,000 health-care professionals have been affected by COVID-19 and more than 500 doctors have already lost their lives.

Recent data also show that proper use of face masks will increase immunity of individuals.^[12] This happens because the mask reduces exposure to viral load, stimulates the immune system, and allows the development of protective antibodies with developing clinical features of infection or requiring hospitalization.

CONCLUSION

Continuous use of face masks outside the homes is still vital to save yourself, your immediate family, your friends, and also the community at large.