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Author: Robyn S.

Third Year Medical Student

Introduction

In this article I am going to explore the use of facemasks, how effective they are and why and how they have been used during the corona virus pandemic. Covid-19 will be a historical outbreak, with millions of cases and hundreds of thousands of confirmed deaths worldwide due to infection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). Due to the sudden onset and vicious nature of the disease the world has had to act fast with precautions like social distancing, hand hygiene and masks, even when we are unsure of the evidence behind them.

 

How are face masks used?

PPE: Personal protective equipment is exactly what it says on the tin! Things that will protect the user from potential hazards, this could be hi-vis jackets and steel toed shoes on a building site, to surgical masks and disposable gloves in A&E. These should be provided by the workplace to protect staff and others. If PPE is needed for a specific task or in a specific area it should be used no matter how long the task will take (even if it will still take a few minutes we need to have the right equipment to ensure safety).Throughout the corona virus pandemic facemasks were one of the most valuable assets of PPE available and there was a huge uproar within the public about the amount of PPE available to NHS and care home staff. The level of PPE needed to help sustain the NHS throughout this period was greater than ever before and resources lacked in many trusts, according to news providers.

Face coverings: This is anything that covers the wearers face and mouth, they can be reusable or single use. These are not PPE and are used mainly to protect others, not the user. Ideally the World Health Organisation recommends they are 3 layers thick and should be washed regularly if not single use. Things are changing dynamically as to when the public should wear face coverings, but generally it is encouraged as much as possible, especially in an enclosed or busy place and is being enforced in shops and on public transport.

Some exemptions for face coverings:

– Young children

– Physical/mental impairment that causes difficulty with a mask

– Wearing it causes severe distress

– Accompanying someone who relies on lip reading

– Avoid harm or injury to the wearer and others

– To eat, drink and take medication

– When a police officer or official requests the face covering to be removed

 

Are they working, if so, how?

The science behind the mask:

You may be shocked to hear that respiratory viruses (which is the family coronavirus is part of) are actually spread through touch and contact more than droplets via our breath. Therefore, the key to controlling the spread is handwashing and being careful to avoid touching your face and mouth without having clean hands. However, the droplets we touch mainly end up on surfaces because an infected person has coughed or sneezed on it and then someone else has touched that, hence facemasks being important in controlling the spread of corona virus.

As we know the virus is spread through droplets of an infected person, the person wearing the facemask to prevent the transmission should be the one who has symptoms. As Covid-19 has a long incubation period (of about 2 weeks) we aren’t aware we’re infectious, therefore as a precaution we should all wear a mask.

As different masks originally have different uses and mechanism behind them, they will all have a different level of effectiveness as preventing spread. Overall, the main aim of the facemask is to contain the wearers respiratory droplets, therefore face fitted masks, particularly HEPA mask filters may be more effective.

Different types of mask:

– HEPA – these are air filtered masks, otherwise called respirators, for example KF94 and N95 masks (named differently because of their shape and how they fit the wearers face). Currently we are using FFP3 masks which filter 99.95% of particles, including bacteria and viruses. They should be face-fitted so the people wearing them know that that specific mask is tightly sealed to their face, this is done by putting them in an aerosol filled hood and adding a solution they can taste (like Bittrex or a sweet taste), if they can taste it then they know the mask isn’t fitted properly and will try another style of mask. This is done so there’s very little risk of droplets coming out of the sides of the mask, the more fitted the more effective! Although they do have limitations as they can get wet due to the user’s breath and therefore should be changed every 4 hours, but clinically are usually changed hourly. Respirator masks are needed when dealing with Covid patients undergoing an aerosol generating procedures, mostly seen in critical and intensive care departments. Therefore, they should not be needed by the public.

– Surgical Masks – usually used in surgery to stop droplets from medical staff entering body cavities and open wounds. They are used routinely in practice and are effective. Their pleating structure allows them to stay dryer and therefore more effective. However, they are not as tight fitting and do not form a seal so are not as effective for controlling leakage.

– Homemade/cloth masks – they can reduce transmission when coughing/sneezing but are only 33% as effective as surgical masks!

How helpful are they?

The science behind the mask and the discussion of face-fit seals may seem well and good when looking at it from the outside. However, being a healthcare professional or citizen wearing these devices may not be the most comfortable thing. I think there is a big flaw when deciding if facemasks are simply effective or not as we need to look at the science behind them but also how well they work for the user. They must be comfortable enough to wear all day, especially as nursing shifts are often 12 hours!

 

Face covering use with the general public

One of the reasons COVID-19 is so deadly is because there are “super spreaders” who have mild or no symptoms but still can transmit the virus to others, meaning everyone is a potential suspect! With other respiratory viruses, the ill person will often have symptoms (and therefore be more identifiable as a risk) and therefore the transmission is more controlled as they can avoid being in contact with vulnerable people and healthcare professionals can take appropriate precautions. This may be why the public has been urged to begin to wear face coverings, especially in areas like shops where social distancing is difficult.

COVID-19 is like nothing the world has ever experienced before. Most of our previous data and trials from respiratory viruses are from influenza, which isn’t as contagious or serious as COVID-19. This may be why there has been changes to the advice given about social distancing and facemasks as we learn more about this virus.

 

How to talk about facemasks at a medical school interview:

Potential points to think about if you might have to discuss facemasks in a medical school interview.

– Could facemasks be the new norm?

Many people have issues wearing facemasks but should we be prepared to wear these for a long time and how would you approach explaining the importance of this to patients that may struggle (such as asthmatics, patients with claustrophobia, patients with learning difficulties)?

– If every member of staff, student and patient needs to wear a mask within hospital grounds, how are we going to keep up our resources? 

Remember global demand for PPE was at the highest levels ever. Some countries banned exports on it – so countries like the UK were unable to buy it. The stockpile of PPE the UK had before corona virus didn’t seem to meet the demand. Could increasing our stockpiles or having more UK produced PPE be part of the solution?

– What are the financial impacts of Covid-19 on the NHS and UK?

Remember that NHS staff with health problems were also shielding so not at work during the pandemic, often meaning health professionals on staff banks and out of retirement were taking on additional work which would cost extra. How much impact would this have on doctors and should they even be concerned? (Should we treat no matter the financial cost?). PPE is expensive! Especially as most of the PPE used initially is single use. Further into the pandemic there has been use of re-usable masks such as a half mask which can be wiped down between patients.

– What are the environmental problems that go with the demand of PPE in a pandemic (that is a huge amount of waste!)?

Sources:

https://covid19.who.int/?gclid=CjwKCAjwxqX4BRBhEiwAYtJX7WEdYdCz0E5X2_7msPVSUJ5WEgNkchG8jSa211PX0ZpyJD5XQ9hgkBoCyxIQAvD_BwE

https://www.hse.gov.uk/toolbox/ppe.htm

https://www.gov.uk/government/publications/face-coverings-when-to-wear-one-and-how-to-make-your-own/face-coverings-when-to-wear-one-and-how-to-make-your-own

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7246185/

https://www.nhs.uk/conditions/coronavirus-covid-19/social-distancing/what-you-need-to-do/

https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/faq-ffp3-24-march-2020.pdf

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