Why wear a face covering during COVID-19? The evidence

November 17, 2020

Dr Deborah Lee from Dr Fox Online Pharmacy discusses why we need to wear a face covering during the current COVID-19 pandemic, stating the evidence in this illuminating analysis

COVID-19 is a tiny virus – 100 million fit on a pinhead. We have no cure and no vaccine. There is no magic wand. The only way to control it is with hard work – social distancing, hand-washing, and wearing a mask. I’m writing this to try and help everyone understand the contribution that you can make by wearing a face mask.

Face masks – what’s going wrong?

Recently, I became aware of three mask-wearing incidents –

I heard a man screaming and shouting on a late-night radio programme about having to wear a mask. I can’t repeat the expletives, but his anger was startling – as was his ignorance about viral transmission.
I queued behind a lady at the doctor’s surgery as she had an appointment. When the receptionist opened the door and asked her, she had no face-covering- “because she has asthma”. Bearing in mind she was smiling and chatting to me, and right as rain. (In general, asthma is no reason not to wear a face covering.)
I heard a story on the radio. Three young men were observed coming out of a shop. One came out wearing a mask, took it off and handed the mask to his friend, who put it on and went into the shop. He then came out and handed to the third chap, who did the same! This, of course, flies in the face of achieving any infection control! You should never share or borrow anyone else’s face mask.

It seems some members of the British public don’t want to be told to wear a face mask and are finding ways to refute the rules or pay lip service to them.

Here’s an important fact –

If 80% of the country wore masks as advised, this would have a greater effect than the country being in lockdown (Population Research Institute – 21^st April 2020).

And another important fact –

In any pandemic, 20% of the population cause 80% of the infections (Stein 2011).

We all need to be following the guidance, without exception, but especially areas of the country where virus levels are high. If people in these areas had all done so assiduously since the summer, many people might have retained their jobs and business might once again be flourishing. Those who belligerently don’t stick to the guidelines – that 20% – are putting the whole population in danger and delaying any hope of economic recovery.

This is not a time for anger or divisive behaviour. It’s time to come together. We could make real progress with getting our lives back to some form of normality if only everyone would follow the rules. The virus has wreaked havoc on us all in so many ways, and people are hurting. Surely, we want the pain to stop.

Below, I want to set the record straight with facts about COVID and mask-wearing, which I hope will encourage those who haven’t been cooperating, to decide to join in instead of opting out.

How deadly is the virus?

I often hear people say ‘COVID is only about as dangerous as the flu’. This is not the case. The death rate from COVID is about three times the death rate of the flu (BBC, 8^th Oct 2020 – ONS).

In the eight months January to August 2020, there were 48,168 deaths from COVID-19 and just 394 deaths from the flu. Some have argued that this is not a fair comparison as this year, there has been an unusually low number of cases of flu. However, when the five-year averages of numbers of deaths from both infections were examined, COVID was still found to be approximately three times more likely to be fatal.

How does COVID-19 differ from influenza?

COVID-19, although it is primarily a respiratory infection, also affects numerous other organ systems in the body. The virus seems to activate the blood clotting mechanism and increases the risk of thromboembolic disease (blood clots) which can occur anywhere, for example, in the brain to cause a stroke or in the lungs to cause pulmonary emboli. This is not a feature seen with infection from influenza. Stokes and pulmonary emboli are often fatal. COVID-19 is a very different infection from influenza.

COVID-19 affects the following –

The respiratory system – COVID-19 causes pneumonia, which can be severe and mechanical ventilation may be required. The infection can be overwhelming causing a ‘cytokine storm’ as the immune system is kicked into action. COVID causes adult respiratory distress syndrome (ARDS).
The cardiovascular system – COVID-19 can damage the heart by causing myocarditis, inflammation of the heart muscle. It can also cause cardiac arrhythmias, heart failure and sudden death.
The brain and nervous system – COVID-19 increases the risk of stroke. It somehow affects nerve transmission for example reducing the sense of taste and smell. COVID can cause psychiatric complications including depression, psychosis, PTSD and dementia-type symptoms.
The renal system – COVID-19 affects the kidneys and can cause acute kidney failure, resulting in the need for dialysis.
The liver – COVID-19 can cause abnormal liver function tests but the extent to which it causes liver damage is unclear.

The effects of COVID-19 on the different organ systems of the body are not seen with influenza, making COVID-19 a much more serious and deadly infection.

It’s not a conspiracy – it’s real

The virus is real. Do you think our government would have allowed the devastation to our lives and the destruction of our economy unless there was a serious reason to do so? Debunk the conspiracy myths – there’s no beating about the bush. It’s real. So far only around 10% of the population has been infected. Unchecked this would mean 60-80% or more of the population becoming infected and millions would die.

I often hear people saying – ‘it only affects older people’. In fact, there have been nearly 6,000 deaths from COVID-19 in people in the UK aged under 65. One of the youngest was a 13-day-old baby. This is a virus which can infect anybody and kill people, even those with no other comorbidities. Older peoples’ lives are as also just as precious. No-one can afford to be complacent.

Numbers of COVID-19 infections are rising, as are hospital admissions

To date, the UK statistics show that the COVID-19 pandemic has caused 854,010 positive infections, and there have been 44,745 COVID-related deaths (The Guardian – 25^th Oct 2020).

After the initial peak in May 2020, numbers of new cases started to fall, as lockdown measures seemed to be successful in controlling the spread of the virus across the UK. But since lockdown measures have eased, numbers of cases have been climbing again since September, and gathering pace. We are now in the grip of a second peak, which is a much bigger peak than the first, and by no means over yet. The number of people admitted to hospital with COVID has been increasing, as has the death rate.

Some have argued that there have been relatively fewer hospital admissions in those who test positive, in this second wave, and that the virus is now less aggressive. However, this is incorrect, for two reasons. Firstly, many more people are now being tested – at the start of the pandemic, if you had symptoms you were not tested but told to stay at home. Now, anyone can be tested if they have symptoms and many more tests are being taken. Secondly, it takes time for those who test positive to become ill enough to require hospital admission, and if you look at the graph, the hospital admission peak is rising steeply.

Face masks and Spanish flu

There’s nothing new about face masks. In the second wave of the 1918 Spanish flu pandemic, which resulted in 50 million deaths, mask-wearing was made compulsory in many parts of the world.

“Wear a mask and save your life! – A mask is 99% proof against influenza” was the public health message.

In San Francisco, anyone caught not wearing a mask could be fined between $5 – $100, or even imprisoned for up to 10 days. Around the world, some people were even shot for refusing to wear a mask.

Why use a face mask?

The COVID-19 virus is spread in exhaled air and respiratory droplets when you breathe out, cough, or sneeze. Respiratory droplets are heavy because they are attached to particles of mucus and fall quickly to the ground. More recently the importance of aerosol spread has been recognised – this is the spread of much smaller particles which are airborne and can hang in the air for many hours after exhalation.

One way we can control the spread of the virus is to cover the airway by using a face covering.

The problem is compounded by the fact that up to 80% of people who are infected do not know they are infected, as they have no symptoms, but are often infectious. This means you can be spreading the virus quite unknowingly.

Do face masks work?

Medical evidence that face masks are effective

In a comprehensive report by the British Academy (26^th June 2020), the authors reviewed the medical evidence on the use of masks and their effectiveness. After a very careful and detailed assessment, they concluded that wearing cloth face masks does reduce the outward transmission of the virus – that is they help protect you if you are infected, from passing the virus on to other people. This is assuming the mask is of sufficient quality. It should be high-grade cotton, multilayered, fitted to cover nose and mouth, and worn correctly.

Wearing a mask is only one strategy – to be most effective in controlling the virus, we also need to be socially distancing, and washing our hands.

People tend to underestimate their risks and think it will never happen to me. It can happen to any one of us. It’s important to be realistic. Wearing a mask does reduce the risk of transmission.

Did you know, you are less likely to become infected if you wear a mask within 0.5 m of a person than if you don’t wear a mask and are 2 m away?

In countries where mask-wearing is mandatory, death rates are lower

One research study (June 2020) compared the death rate from COVID-19 infection in 194 countries. They found a statistically significant lower death rate in countries where mask-wearing was compulsory. There was an increase in the death rate of 8% per week, in those countries who had mandated the use of masks, compared to an increase of 54% per week in those which had not.

A COVID-19 positive passenger wore a mask on a flight and protected all the other passengers

In one case report, a man who had symptoms and subsequently tested positive to COVID-19 flew from China to Toronto. He wore a mask for the whole flight. None of the 25 people seated within 2 metres or in the rows around him, tested positive after active monitoring and testing at 14 days after travel.

Which mask is best?

A study in the journal Science Advances (22nd September 2020), compared the effect of 14 different face masks on their ability to filter out respiratory droplets during speech.

The best filtration was seen with the use of an N95 respirator mask – the transmission fraction was only 0.1%. This has no valve.
The fleece mask was the worst-performing mask with a transmission fraction of 110%. This was a higher rate of transmission than wearing no mask at all!
The polycotton and cotton masks had both reduced transmission by a similar amount to an N95-valved respirator mask – the valve is fitted to allow inhalation and exhalation. The transmission fraction was between 0.2 – 0.4%.
The most poorly performing mask was a bandana – sometimes called a gaiter. Wearing one of these around your neck and pulling it up and down to cover your nose and mouth, may encourage larger respiratory particles to break into smaller ones.

How to choose a mask

When choosing a non-medical mask, the World Health Organization (WHO) recommend you use one with three layers: an inner layer of cotton, an outer layer of polypropylene or polyester, and a middle layer of either cotton or polypropylene. It should have a close fit across the cheeks so as not to allow air around the edges of the mask as far as possible, meaning the air must pass in and out through the fabric of the mask.

Avoid single layers or stretchy elasticated fabrics. A bandana gives the worst protection of all.

Be aware many manufactures make unsubstantiated claims about the efficacy of their masks. A simple cotton mask is all that is required. What is actually more important — is now so much which mask you are using — but how you are using it.

Tips on how to get the best from your face mask

Here’s how to make sure you get the best protection from your mask –

Have your own mask. Don’t share your mask or borrow one from anyone else.
When removing your mask, don’t touch the front of the mask, lift it off using the straps around your ears.
Fold your mask and keep it in a clean bag.
Wash your hands after you’ve removed your mask.
Wash your mask frequently. Use hot water – 60 degrees is recommended – and soap.
Don’t forget to wash your hands regularly and stick to social distancing. The mask will not protect you by itself – these other steps must be followed too.
Try not to touch your face or eyes.

Who says we must wear a face mask?

Since September 2020 it has been the law in the UK, that we must all wear face coverings when out of our own homes and visiting anywhere where social distancing is difficult. For more information about when to wear a face-covering click here.

If you don’t wear a face mask, you can be fined by the police, £200 for a first offence, but this doubles each time you are caught, up to a maximum of £6,400.

Who doesn’t need to wear a face mask?

In truth, there should be only very small numbers of people who are exempt.

Children under the age of 11 do not need to wear face masks, and small children and babies under three years old must never wear them.
The British Lung Foundation has reassured those with lung conditions that most people with respiratory disease should be able to wear a face mask. They state that the mask will not reduce your supply of oxygen or reduce your ability to expel carbon dioxide. They suggest you should practice with the mask at home. However, if you are very breathless and wearing a mask makes your breathlessness worse, then you should not wear a mask. They suggest people in this situation could try a face shield instead. They have also created a graphic you can download on your phone to show any officials you are exempt from wearing a face mask.

There should be very few people who cannot wear a mask because of chest/lung diseases. One U.S. respiratory physician, Dr David Kaufman, though not unsympathetic, commented ‘If you can wear a headscarf, you can wear a face mask!”

Other respiratory specialists have commented that if your breathing becomes so difficult when you apply a cloth face covering, you would probably better not to go out and to stay at home. After all, if your condition is this delicate, you are at exceptionally high-risk if you do develop COVID-19 infection, and it would be better if you did not go out at all.

People with various mental health conditions may find wearing a mask triggers some unpleasant symptoms such as –
Increased anxiety, and/or panic attacks.
Feelings of paranoia or hearing voices.
Feelings of self-harm or suicide.

If you find wearing a face mask difficult for these reasons, you can read tips on how to get used to wearing a face mask here. If you cannot tolerate a face mask, could you manage a face shield?

Using a face shield does not seem to offer as good protection as a mask. There are some good points about face-shields – they are made of clear plastic and good for all-round vision, they also cover your eyes, they can be re-used indefinitely and are easy to clean. Communication is easier than it is with a mask.

However, research suggests that although a face shield may give better protection, if someone coughs right in your face, if you are wearing them at work, where you are moving around, respiratory droplets can more easily pass round the sides of the shield. In fact, in these situations, the face shield is only 45% effective at reducing transmission.

For those who cannot wear a mask, wearing a face shield is better than wearing nothing at all.

If you really feel you cannot wear a face mask for a health reason, you do not need to see a doctor. It might help if you download the ‘I am exempt logo’ for your mobile phone.

Final thoughts

Frustrating, upsetting, and annoying as it is, we can’t just magic this virus away. We can only control it by the measures we have in hand – social distancing, hand-washing, and mask-wearing. And none of these three tactics will work on their own – all three must be in place.

The COVID-19 virus is real. Wearing a mask is effective. Remember this – if 80% of people wore a mask as they were being asked to, it would have a greater effect on the UK than lockdown. If you want to see businesses thrive again, more jobs and prosperity, please, follow the rules.

When you wear a mask

You are protecting others, including your family and friends and those you love.
Helping to reduce the spread of the virus.
Following national guidance.
Obeying the law.
Helping the country get back on its feet.

Please wear a mask. Let’s all pull together and not pull apart.

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