To mask or not to mask, this is the question

One of my WhatsApp chat groups had a heated discussion on the merit of wearing masks during this COVID-19 pandemic. The chat group consists of participants from three different countries: Singapore, Malaysia, and Australia. Interestingly, I observed different attitudes towards mask-wearing in these three countries. Singaporeans are abiding with the directive of ‘mask up when unwell’ as per the official government guidelines. Malaysians, in general, agree that wearing a mask in public places during this period is a socially responsible way to protect oneself and others. To Australians, however, mask-wearing is a very ‘Asian’ thing, and they have split opinions over the need to wear a facemask.

Can surgical mask protect against COVID-19 transmission?

Different country different advice

The differing in attitudes over facemask is also reflective in the formal public health advice issued by the three countries.

  • Singapore government’s message to the public is unambiguous, “Do not were a mask if you are well. Wear a mask only if you have fever, cough, or running nose; or recovering from illness” [1].
  • The Australian Government Department of Health issues similar advice, “Most people will not benefit from wearing a surgical mask. Masks are of benefit to people who are sick, so they don’t cough on others, and health care workers who have frequent, close contact with sick people. If you are well, you do not need to wear a surgical mask as there is little evidence supporting the widespread use of surgical masks in healthy people to prevent transmission in public.”[2]
  • Across the causeway, however, health advice is different. The Malaysian Ministry of Health FAQ on coronavirus states that “Wearing a surgical or 3-ply facemask is recommended since it helps to reduce transmission of the virus and it is more practical for the general public to use (compared to N-95 mask). Mask helps to block the wearer’s droplets from reaching others” [3].
Health advice on the use of mask issued by the Singapore government.

Indeed, there are inconsistencies in public health advice among these countries. This situation is not unique. A recent article published in The Lancet also pointed out the dissimilarities in recommendations on mask-wearing across nations, after comparing advice issued by the World Health Organisation (WHO), China, Hong Kong, Singapore, Japan, The United States of America, United Kingdom, and Germany [4]. Such inconsistencies are mainly due to the lack of scientific evidence proving the effectiveness of mask-wearing as a public health measure for the prevention of COVID-19 [5].

Cultural paradigms at play

Wearing facemask is common and considered a hygiene practice in many Asian countries.

Theoretically, mask-wearing can potentially help to protect COVID-19 transmission. Available evidence shows that both N-95 and the surgical mask can be protective against common forms of respiratory infectious viruses, such as H1N1, SARS, and rhinovirus. Still, the effectiveness is hard to quantify [5]. Nevertheless, encouraging mask-wearing in the community has become a norm in many Asian countries, including China, Hong Kong, Taiwan, South Korea and Japan. This phenomenon can be due to the cultural paradigm of considering mask usage as a ‘hygiene practice’ [5].

In contrast, mask-wearing is a symbol of potential risk in Western cultures. As one Canadian writer exclaimed, “Remember the sinister-looking beaked plague mask from the Middle Ages that instilled fear in onlookers? Wearing a mask reinforces fear. The cosmesis provided by the mask creates more risk of an affective kind.” [6] Such dichotomous cultural views on mask-wearing can induce stigmatisation and racial aggravations. Incidentally, one Hong Kong student studying in Hobart, Tasmania was punched in the face for wearing a mask in a local supermarket, just a few days ago [7].  

Plague doctor Wellcome L0025222
Beaked plague mask is a symbol of fear in Western cultures as it is linked to the plaque of ‘Black Death’ in the Middle Ages.

Masks are essential for health care workers

While the effectiveness of mask-wearing against COVID-19 transmission in the community remains unknown at this stage, in a high-risk hospital environment, donning a mask for protection is essential. A recently published study from China reported that wearing mask reduced the risk of COVID-19 infections among healthcare workers. COVID-19 infected 10 of 213 medical staffs with no mask while none of the 278 personnel wearing masks was infected [8]. To this end, health authorities all over the world have no qualms over the need of personal protective equipment, inclusive of masks, gloves, and gowns, among healthcare workers due to their frequent contact with the patients [9].

Surgical mark is an essential personal protective equipment for healthcare workers.

However, due to the massive demand for surgical masks and excessive hoarding by certain quarters, the global shortage of disposable surgical masks is a real concern. China is the largest producer of surgical masks in the world and it has a reported daily production capacity of 20 million pieces. During this period, the daily demand is said to exceed 50 million per day, and the demand is not expected to ease soon [10]. Therefore, one of the underlying rationales to advise against wearing a mask if one is well is to prevent the depletion of the stock unnecessary, conserving the marks for those who need them more, like the health care workers.      

Any mask is better than no mask?

Many have argued that ‘absence of evidence of effectiveness’ should not be equated to ’evidence of ineffectiveness’ [4,5]. To encourage everyone to wear a mask even when well can add another layer of protection, as it is now known that COVID-19 virus can transmit even when a patient exhibits no symptoms at all [11]. “Any mask is better than no mask”, as advised by four senior doctors in Singapore in a signed letter to the public, contravening the official health advice of the authority [12].  

Is any mask better than no mask?

According to Associate Professor Kenneth Mak, Singapore’s Chief Medical Officer, such a suggestion, although well-intended, overemphasises the usefulness of wearing masks. As droplets spread the virus mainly through contacts, measures such as frequent washing of hands and social distancing are more critical in reducing the transmission of the disease [13]. Instead, wearing a mask can instil a false sense of security, notably when they are not properly fitted or if the wearer disregards the other necessary preventive measures [6]. As pointed out by WHO, “masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water,” and proper disposal of masks after use is equally important to prevent the spreading of disease [14].   

Conclusion

To mask or not to mask? This is a question that has no universal consensus. During this health crisis, it is best to adhere to the local health advice wherever you are. Governments around the world need the compliance of every single member of the community to fight this pandemic. When in Rome, do as the Romans do. Give your full cooperation for the protection of not only oneself but the benefits of others. May all be well and may the world be free from this pandemic soonest.  

During this health crisis, it is best to adhere to the local health advice wherever you are.

References

[1]        Ministry of Health Singapore, Masking Up How and when you should do it | gov.sg, (2020). https://www.gov.sg/article/masking-up-how-and-when-you-should-do-it (accessed March 24, 2020).

[2]        Australian Government Department of Health, Coronavirus disease Information on the use of surgical masks Should I wear a surgical mask ? How do I get a surgical mask ?, 4 (2020) 19–20. https://www.health.gov.au/resources/publications/coronavirus-covid-19-information-on-the-use-of-surgical-masks.

[3]        Kementerian Kesihatan Malaysia, Soalan Lazim – Penyakit Novel Coronavirus (COVID-19), (n.d.). https://www.infosihat.gov.my/images/media_sihat/lain_lain/pdf/SOALAN LAZIM COVID-19.pdf (accessed March 24, 2020).

[4]        S. Feng, C. Shen, N. Xia, W. Song, M. Fan, B.J. Cowling, Rational use of face masks in the COVID-19 pandemic, Lancet Respir. Med. (2020). doi:10.1016/S2213-2600(20)30134-X.

[5]        Q. Wang, C. Yu, Letter to editor: Role of masks/respirator protection against 2019-novel coronavirus (COVID-19), Infect. Control Hosp. Epidemiol. (2020) 1–7. doi:DOI: 10.1017/ice.2020.83.

[6]        S. Neilson, The surgical mask is a bad fit for risk reduction, CMAJ. 188 (2016) 606–607. doi:10.1503/cmaj.151236.

[7]        E. Baker, Hong Kong student “punched for wearing a face mask”, accused of having coronavirus, ABC News. (2020). https://www.abc.net.au/news/2020-03-20/coronavirus-hong-kong-student-assaulted-for-wearing-face-mask/12075470 (accessed March 24, 2020).

[8]        X. Wang, Z. Pan, Z. Cheng, Association between 2019-nCoV transmission and N95 respirator use, J. Hosp. Infect. (2020). doi:10.1016/j.jhin.2020.02.021.

[9]        J.G. Adams, R.M. Walls, Supporting the Health Care Workforce During the COVID-19 Global Epidemic., JAMA. (2020). doi:10.1001/jama.2020.3972.

[10]      A. Gunia, The Global Shortage of Medical Masks Won’t Be Easing Soon | Time, Time. (2020). https://time.com/5785223/medical-masks-coronavirus-covid-19/ (accessed March 24, 2020).

[11]      T. Singhal, A Review of Coronavirus Disease-2019 (COVID-19), Indian J. Pediatr. 87 (2020) 281–286. doi:10.1007/s12098-020-03263-6.

[12]      Medical practitioners issue signed letter to advise everyone to wear a mask always when leaving home, Online Citiz. (2020). https://www.theonlinecitizen.com/2020/02/12/local-medical-practitioners-issue-signed-letter-to-advise-everyone-to-wear-a-mask-always-when-leaving-home/ (accessed March 25, 2020).

[13]      S. Khalik, Coronavirus: Chief medical officer responds to view that everyone should wear a mask to avoid infection, Health News & Top Stories, The Straits Times. (2020). https://www.straitstimes.com/singapore/health/coronavirus-chief-medical-officer-responds-to-view-that-everyone-should-wear-a-mask (accessed March 25, 2020).

[14]      World Health Organisation (WHO), When and how to use masks, (n.d.). https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks (accessed March 25, 2020).

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