COVID-19: To Mask or Not to Mask?

By Dato’ Dr Amar-Singh HSS
Senior Consultant Paediatrician

As we enter the second phase of our movement control order (MCO) and start to plan for the future, there are many issues that need to be thought through and one of them is whether we should wear masks more often. The wearing of masks is an issue that is currently being hotly debated in many parts of the world. Some are calling it the “great mask debate”. I had planned earlier this week to write a full article on this but I think it would serve us better to read some of the very valuable commentaries that have already been done. What I hope to do is to summarise the key points to help us come to a better understanding on whether the general public should wear masks.

I start by making very clear some critical points. These are fundamental to preventing coronavirus (COVID-19) spread and supporting our health care professionals.

1. Safe Distancing is the single most important measure to prevent the spread of the coronavirus. If you wear a mask and then think you do not need to do physical distancing, then you’re fooling yourself. Safe distancing is more important than any other measure in preventing transmission. The second important measure would be to wash or sanitise your hands after every exposure, don’t ever touch your face outside home and disinfect surfaces frequently. These two are the pillars of our ‘new normal’ long term lifestyle. During the MCO staying at home is vital.

2. The second issue is that anyone who is unwell should wear a mask. If you have a fever, running nose or cough you should wear a mask if outside the home. But the key is, if you are unwell please stay at home. You should also keep away from family members.

3. Thirdly, those who are caring for someone who is infected with COVID-19 at home should wear a mask. Currently all these patients are quarantined in hospital. But I anticipate that, as numbers rise in the future, we may have to do home quarantine for asymptomatic or mildly symptomatic persons at home. In this situation the carers should wear a mask if looking after them.

4. Finally the people who really need masks are healthcare professionals (HCPs). We need to reserve 3 Ply Surgical masks and N-95 masks especially for them. We cannot afford for HCPs to run out of masks. If this happens it will threaten our last line of defence, the health care services. We must be clear on this, that until supply is very, very good, all medical-grade masks (especially N-95 masks) should be reserved for HCPs and those caring for COVID-19 infected individuals.

So now we come to the difficult issue of “should the general public wear masks?” We have seen some conflicting advice being given, even locally, with some saying it is not necessary and others placing restriction on people entering facilities or travelling without masks. There are many good commentaries available and three good ones are by Ed Yong from the Atlantic, Tara Haelle from the Forbes and Zahra Hirji from BuzzFeed News; all good reads.

I have tried to answer this question with a series of FAQs with links to useful sites and material. Bear in mind that the entire discussion here is focused primarily on the use of cloth or homemade masks.

Question 1: What is the recommendation from the authorities?

The World Health Organization (WHO) currently does not recommend the public use of masks routinely. However they are in the process of reviewing this decision. Although the United States health authorities initially came out strongly against the public wearing masks, they are also considering revising this. In some European nations you cannot leave your home or enter a supermarket without a mask (e.g. Czech Republic and Austria). Closer to home, China has pushed for compulsory face mask use in affected regions and in South Korea masks, especially cloth masks, are routinely used when outside the home. Locally the Ministry of Health (MOH) has said that it is not necessary for the general public to wear masks unless unwell but we also received conflicting opinions from others.

Question 2: Can wearing a mask be dangerous or harmful?

As mentioned earlier the use of masks cannot replace or be a proxy for safe distancing, that is, it must not create a false sense of security. Wearing a mask does not mean you can now stop and talk to everyone. The key fundamentals of wearing a mask are: Wear it Correctly, Don’t Fiddle with it, Remove it Safely, Dispose of it Safely. If you wear a mask and then fiddle with it off and on, you increase your risk of infection. The SARS-CoV-2 virus may be found on the outer surface of your mask and may last there for some time. As we are discussing cloth masks in this article, we need to remove it safely, put it immediately into a container with soap and water (to wash and reuse) or into a plastic bag if outside the home. We need to wash (or disinfect) our hands with soap and water before and after we take off the mask.

Question 3: Do cloth masks work?

There have been some fake graphics circulating suggesting that cloth masks are useless against viruses. It is possible that the authors of those graphics have a vested interest in selling medical masks. Some kind individuals have summarised some of the studies done on DIY (homemade) masks protection against coronavirus; one here and another here. The data suggest that the surgical mask was three times more effective in blocking transmission than homemade masks. Homemade masks were not as good with aerosol transmission and do not fit as well, especially for children. However they can filter ~ 50-60% of virus-sized particles and last for at least 3 hours (a cotton handkerchief filtered 28%). Cloth masks made of cotton t-shirts or dish cloth (‘tea cloth’) were the most useful. The quality of these DIY masks can be improved (see below on making them).

Some good work done on real-time imaging of human exhaled airflows shows that when two persons are having a normal conversation, their exhalation airflows overlap and interact (as we well know). The airflow is spread even further when someone is coughing, sneezing or laughing.

We are all also well aware, from a number of studies, that a significant proportion of persons (20-50%) infected with the coronavirus are asymptomatic or pre-symptomatic. So we have to assume and live as if every ‘well’ person we meet is infected.

Hence any mask used is better than no protection (a ‘last resort’) and may decrease viral exposure and infection risk. In addition using a mask protects others from our respiratory droplets. Remember that cloth masks are not recommended for HCPs as they are in a much higher risk environment.

Question 4: Should I also wear a face shield?

We do know that the coronavirus can also cause infection through the mucosa of the eyes. It is imperative that all HCPs in high risk areas wear face shields. I do not think that the general public needs to wear face shields or goggles. However those facing a large volume of clients each day (service persons and police) should consider them. Remember to put on and take them off carefully with handwashing and cleaning of the shields.

Question 5: When should we use masks?

During the MCO we should probably use a cloth mask whenever we go out for an essential trip like buying groceries at the supermarket, visits to the petrol station or when going to tapau some food. When the MCO is relaxed we should consider wearing a cloth mask when we are going to the office, travelling in public transport, doing our shopping; perhaps most of the time of the day when outside the home. This may mean we should carry more than one cloth mask and change it carefully at lunch time. Wearing a mask all the time may not be easy for everyone to do. Some, with medical problems, may find it even more difficult.

Question 6: How can we make effective cloth masks?

There are numerous online tutorials and templates that teach us how to make a cloth mask. See some of these sites: mask 1, mask2, mask 3, mask 4, mask 5, mask 6. You may need different sizes for children and adults.  In addition, as I mentioned earlier, there is guidance on how to make a higher quality DIY mask that might even better filter viruses – see here.

Question 7: How can we make cloth homemade masks for all Malaysians?

This sounds like an odd question but it is a serious one. Many Malaysians will need masks, not all can make them, not all can afford them. At least all service individuals (cashiers, delivery persons, food businesses, police, etc) should wear masks. I think we as Malaysians can make these for them, as well as for the poor. I am extremely impressed by the people of the Czech Republic who have made hundreds of thousands of cloth face masks for all their citizens and distributed them within 5 days. These two good videos (video 1 and video 2) from them say it well.

The “great mask debate” is not over and I doubt it will be resolved easily in the next few months. Wearing a cloth mask may offer us some protection as well as protect others from us. It may have a role to play in muting this challenging COVID-19 pandemic.