Face masks Q&A: What is the advice and do they work?

What is the advice around the wearing of face mask in Ireland?

On Friday the Government said it is advising people to wear face coverings on public transport and in crowded places indoors, but this is not a legal requirement.

The Chief Medical Officer Dr Tony Holohan has warned that face coverings did not provide “some kind of magic shields against the disease” and has cautioned those wearing them not to forget the requirement for social distancing.

Where do face masks fit into the Covid-19 response picture?

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The average punter going about their daily restricted business probably wants to continue contributing to the national effort on curbing the spread of Covid-19 but is finding the “we’re in this together” bit a little grating by now.

Thoughts have turned to re-emergence but there is utter confusion about whether to wear a mask or not in public.

Unofficial advice varies wildly from the local expert declaring they don’t make a whit of a difference in curbing spread of the virus to strong believers in science who say a homemade cloth mask, even a folded scarf, works.

There is a third cohort of people who politely suggest wearing them is good respiratory etiquette at this time as we will be closer to other people who will inevitably cough or sneeze.

The Government has updated its advice, based on recommendations from the National Public Health Emergency Team (NPHET), taking into account the emerging science.

Why has wearing face masks become such a hot issue?

During the early stage of the pandemic, the World Health Organisation said there was little evidence to support the wearing of masks in public. There was plenty to suggest people in non-medical settings put them on and take them off incorrectly, and so facilitate Covid spread.

What’s more, they provide a false sense of security, they declared, and people tended to ease off on other actions – especially on “wash your hands” and physical distancing. But much has changed since.

The US Centers for Disease Control and Prevention broke ranks after seeing new evidence, notably on droplet spread outlined by the New England Journal of Medicine – a small video clip instantly change attitudes in favour of masks.

Upwards of 50 countries struggling in coming to terms with Coronavirus decided to make wearing of masks mandatory. Meanwhile health authorities in Asian countries – well used to tackling epidemics where masks are worn routinely – looked on in disbelief at the failure to give clear instructions as cases mounted in Europe.

The health message even got caught up in the latest American culture war with many liberals and conservatives taking opposing sides, much as they have on climate change.

But the horrible unpredictability of coronavirus invariably asserts itself. This week it prompted less politically-motivated people to switch to wearing them.

Just look at how White House staff have started using masks after recent cases were confirmed at the highest levels of government – though their boss continues to go without.

Meanwhile growing numbers of mask wearers view mingling mask-free in public places as both offensive and unhealthy; a social "No-No". For some who wear them, it's in response to what the science is now saying as they see it. That trend has grown in Ireland in spite of lack of clarity from public health authorities.

What is the scientific case for wearing face masks?

A growing number of prominent infectious diseases specialists now believe the scientific case for wearing them has shifted appreciably in their favour, though evidence is based on small studies.

Science is rarely black and white, however, it’s about evaluating risk and probability based on the evidence. Not all agree on what the latest research is saying.

That said, applying the precautionary principle, including the concept of doing no harm, shifts the weight further in favour. Some of the UK most eminent scientists (and epidemiologists) published analysis last week suggesting “their use could reduce onward transmission by asymptomatic and pre-symptomatic wearers if widely used in situations where physical distancing is not possible or predictable”.

That means if you have the disease and are showing no symptoms, or are at the very early stages of getting it, you can prevent spread to another person by wearing a mask. This is in contrast to the standard use of masks “for the protection of wearers”.

Their verdict was emphatic: “If correctly used on this basis, face masks, including homemade cloth masks, can contribute to reducing viral transmission.”

What are the key differences between masks?

Medical-grade masks provide excellent protection in surgery or dealing with patients with highly infectious diseases such as Covid-19 where healthcare staff cannot maintain physical distancing.

Also known as respirator masks, they must be worn with other PPE, such as gowns, aprons, gloves and visors/shields.

Their filter capacity means they remove viruses and bacteria in the vast majority of cases, especially minute levels of a bug contained in a droplet that might be transmitted in a cough, sneeze or saliva.

Typically, they are referred to as N95 – filtering out at least 95 per cent of particles of all sizes from the air – FFP2 and FFP3 masks. Designed for single use and not cheap, they are like gold dust in the throes of a pandemic.

Cloth masks, non-medical masks made from strong tissue and dust masks (usually worn to stop construction workers or decorators from breathing in dust particles) provide nowhere near the same level of protection but increasingly it is believed they are of benefit in public settings.

A bandana can stop 15 per cent more of your cough. While a cloth mask with no filter could give 70 to 80 per cent coverage. Another study found a cloth mask can trap 95 per cent of “viral load”.

How have the WHO and NPHET responded to the changed scenario?

NPHET, which advises the Government on how to respond to Covid-19, has remained firmly in the WHO camp; both remained to be convinced but undertook to review their advice in light of latest research.

There is no doubt that acute shortages of medical-grade masks globally – and escalating cost – is a big factor in this. In Ireland there is no shortage of masks at present but it is a risk. Shifting attention away from key actions that force down transmission rates is another concern.

The Government is now advising face coverings be worn , though the scientific argument in favour of their widespread use has strengthened. Clearly, there is an emphasis on the public wearing face “coverings” to make a distinction from specialist face masks.

Wearing them will not be compulsory and applies to when people are on public transport or in busy enclosed indoor spaces such as shops where social distancing cannot be practised to limit the spread of coronavirus.

It doesn’t apply to children under 13 or those who may have allergies or conditions that might make wearing a mask difficult.

This will be followed up with public health guidance on types of masks, how to make coverings and on how to wear them correctly.

This is intended as an “additional hygiene measure” and not a substitute for other actions. “Face coverings are not some kind of medical shield,” stressed chief medical officer Dr Tony Holohan.

Both have shifted to accepting there are benefits from wearing them in some circumstances. That said, it is far short of the strong advice in many countries and cities, including those making it a mandatory requirement if going about in public with fines for those not adhering to the decree.

Should the advice be more emphatic... should it have come sooner?

Given hundreds of thousands of people are likely to be out and about more in coming weeks, it can be argued that wearing face masks will help reduce transmission of Covid-19, though cases will rise as lockdown is eased.

Moreover, it would reduce risk of resurgence in the form of Coronavirus 2 in months to come.

The “super-spreader” is a constant risk, especially where there is slow processing of tests and poor contact tracing.

In that scenario, there was a case for issuing clear guidance sooner, so people could make masks or source them elsewhere and get used to wearing them properly. In addition, because the main benefit of a cloth mask is to protect other people, it only works if most people are wearing them.

Obviously, masks will have to be provided for older people, and those who are sick or have underlying conditions.

Are homemade masks good enough?

The homemade mask is more than adequate if going out and about where you cannot maintain physical distancing.

And they have the benefit of multiple use – after washing in a high temperature. There are many guides to making these masks online. Even at its most basic; a folded scarf and two elastic bands does the trick.

Using stronger material and two layers while ensuring the mask is not too tight but easily covers the nose and mouth is advisable.

Where can basic masks be located?

Commercially-made cloth masks are available online and in many retail outlets ranging price from €5 to more than €20 each; likewise higher grade masks including some used in healthcare settings – which must be a source of concern to health authorities given persisting PPE shortages.

They may look flimsy but they are made with two pieces of strong tissue with a breathable plastic filter in between, and can be worn over a longer period though not reusable.

Dust masks are available in DIY stores and online. Sometimes they have an air valve which make them less effective – they are not reusable.

So what’s the bottom line, should we make masks mandatory?

Many infectious disease specialists and immunologists who are becoming increasingly aware of Covid-19 devious characteristics would say yes.

Ireland needs to make the wearing of masks mandatory and there is a particular risk essential workers, including gardaí, could become super- spreaders, according to disease control expert Prof Gerry Killeen of UCC. "I wince every time I see a well-meaning Garda without a mask at a checkpoint," he said this week.

They should be made mandatory immediately, “but not necessarily everywhere or all the time”.

Widespread use should be encouraged, he believes. It’s ideal to always assume one may be quietly carrying and shedding the virus and behave accordingly.

He would like to see masks made absolutely mandatory for anyone working in any essential service, especially anyone handing food, stacking shelves, moving goods, or working in any venue visited by members of the public.

The critical issue is to cut down on transmission between households and across the communities through contamination of the spaces, surfaces and goods we share with others.

Is this mass exercise in the interest of the public health of citizens doable?

This pandemic has prompted a remarkable response from the public; at household level in particular. We took on board complex health messaging and acted appropriately. That curve was flattened and R0 – the number of people infected by a single carrier – forced down below 1. We were surprisingly good at understanding medical science.

We can do it again in wearing basic face masks in public settings in the right way, and understand it is just one part of the armoury to be deployed at this phase of re-engagement with one another in a gradual way.

It is not as effective as washing your hands, not touching your face and maintaining physical distancing but wearing face masks can play its part in crushing Coronavirus in months to come.