Who should wear a face mask? Experts weigh in on Canada’s COVID-19 response

Lauren Vogel

doi:10.1503/cmaj.1095863

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RE: Who should wear a face mask
Murray Trusler [BA, MD, MBA, CCFP, FCFP, FRRMS]

Posted on: 01 May 2020
RE: Comment on "Who should wear a face mask?"
Mohammad Saeed Kalantari Meybodi [Ph.D. Student of Persian Medicine]

Posted on: 30 April 2020
RE: Dr Mustafa Y G. Younis
Mustafa Younis [Assistant Prof Biochemistry]

Posted on: 25 April 2020
RE: Face mask and COVID-19
Dhastagir Sheriff

Posted on: 23 April 2020
RE: Experts weigh in on the COVID-19 response
Hans-Bernd Bludau [MD] and Sergei Jargin [MD]

Posted on: 23 April 2020
Who should NOT wear masks during COVID-19 pandemic? Please don't point fingers at the public
Eugene Y.H. Yeung

Posted on: 22 April 2020

Posted on: (1 May 2020)
Page navigation anchor for RE: Who should wear a face mask
RE: Who should wear a face mask
Murray Trusler [BA, MD, MBA, CCFP, FCFP, FRRMS], Family Physician, Retired; Assistant Professor of Family Medicine, Queen's University; Associate Professor of Family Medicine, NOSM
The use of cloth masks by the general public is doable, better than the status quo (no masks), and is cheap.

Other countries use cloth face masks (e.g. the Czech Republic) and they work (22 deaths per million population in the Czech Republic vs. 90 deaths per million population in Canada).

And masks in general work (e.g. Hong Kong 0.5 d/m pop, Taiwan 0.3 d/m pop, Thailand 0.8 d/m pop, Vietnam 0 d/m pop vs. Canada at 90 d/m pop as of today May 1, 2020).

As a retired physician who used cloth masks in the face of many infectious diseases prevalent in the pre-vaccine era and in operating theatres as well, I can tell you that we are completely underestimating the utility of the humble cloth face mask.

I am also disgusted by the assumption that the general public does not have enough intelligence to use a cloth face mask. Simple instructions are all that is necessary.

The main reason we are having this discussion in the first place is the lack of N95 masks in Canada. Whose fault is this? We have had pandemics before. Who is responsible for our national lack of preparedness? Unfortunately, it's the same "experts" who are now telling us that cloth face masks are not effective. I surmise that this is blatant nonsense designed to protect their collective backsides.

As we open up our economy and "social distancing" becomes more problematic, what's the game plan to prevent infection? Wear nothing or wea...
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The use of cloth masks by the general public is doable, better than the status quo (no masks), and is cheap.

Other countries use cloth face masks (e.g. the Czech Republic) and they work (22 deaths per million population in the Czech Republic vs. 90 deaths per million population in Canada).

And masks in general work (e.g. Hong Kong 0.5 d/m pop, Taiwan 0.3 d/m pop, Thailand 0.8 d/m pop, Vietnam 0 d/m pop vs. Canada at 90 d/m pop as of today May 1, 2020).

As a retired physician who used cloth masks in the face of many infectious diseases prevalent in the pre-vaccine era and in operating theatres as well, I can tell you that we are completely underestimating the utility of the humble cloth face mask.

I am also disgusted by the assumption that the general public does not have enough intelligence to use a cloth face mask. Simple instructions are all that is necessary.

The main reason we are having this discussion in the first place is the lack of N95 masks in Canada. Whose fault is this? We have had pandemics before. Who is responsible for our national lack of preparedness? Unfortunately, it's the same "experts" who are now telling us that cloth face masks are not effective. I surmise that this is blatant nonsense designed to protect their collective backsides.

As we open up our economy and "social distancing" becomes more problematic, what's the game plan to prevent infection? Wear nothing or wear a cloth face mask until N95's are available? Since it is difficult to spit through a tea towel, I think we are better off with a cloth mask than nothing at all.

Please stop the debate, use some common sense and get on with a crystal clear message to all Canadians on the use of cloth face masks in the coming weeks as we open up the nation. Something is better than nothing! And doing nothing will most certainly guarantee the "second wave". We have nothing to lose and many lives and our economic health to gain.
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Competing Interests: None declared.
References
Lauren Vogel. Who should wear a face mask? Experts weigh in on Canada’s COVID-19 response. CMAJ 2020;192:E440-E441.
Posted on: (30 April 2020)
Page navigation anchor for RE: Comment on "Who should wear a face mask?"
RE: Comment on "Who should wear a face mask?"
Mohammad Saeed Kalantari Meybodi [Ph.D. Student of Persian Medicine], Ph.D. Student of Persian Medicine, Department of Persian medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
In response to the CMAJ News article by Lauren Vogel,1 I want to say that not only Canadians but also most people around the world have a question about who should wear a mask?
Several studies have been conducted on this subject and different results have been obtained.2-4
These results have confused people, patients, physicians, health workers, and researchers. It seems that wearing a mask alone is not enough for protection.

I believe that to prevent the outbreak of the COVID-19, the structure of the health care system of each country, and the culture of the people of that country must be taken into account.
For example, what was done in China may not be suitable for European countries. But it seems that social distancing along with wearing the proper mask can be effective.
Competing Interests: I wish to confirm that there are no known conflicts of interest associated with this publication. There has been no financial support for this work that could have influenced its outcome.
References
. RE: Comment on "Who should wear a face mask?". 2020;:-.
Feng S, Shen C, Xia N, Song W, Fan M, Cowling BJ. Rational use of face masks in the COVID-19 pandemic. The Lancet Respiratory Medicine. 2020
Leung CC, Lam TH, Cheng KK. Mass masking in the COVID-19 epidemic: people need guidance. Lancet. 2020;395:945.
Klompas M, Morris CA, Sinclair J, Pearson M, Shenoy ES. Universal masking in hospitals in the COVID-19 era. New England Journal of Medicine. 2020.
Posted on: (25 April 2020)
Page navigation anchor for RE: Dr Mustafa Y G. Younis
RE: Dr Mustafa Y G. Younis
Mustafa Younis [Assistant Prof Biochemistry], Teaching member, Dept of Biochemistry. Faculty of Medicine
It's difficult to provide face masks for everyone in the society.
Competing Interests: None declared.
References
Lauren Vogel. Who should wear a face mask? Experts weigh in on Canada’s COVID-19 response. CMAJ 2020;192:E440-E441.
Posted on: (23 April 2020)
Page navigation anchor for RE: Face mask and COVID-19
RE: Face mask and COVID-19
Dhastagir Sheriff, Professor, Faculty of Medicine, Benghazi University, Benghazi,Libya
COVID-19 is a pandemic that haunts more 180 nations of the world. Day in and day we hear how doctors face patients in the ICU unit. How increasing number of patients exceed the capacity to handle the cases with scarcity of protective equipment including the Face Mask N95. Statements made by leading health Organization and center for Disease Control of USA regarding face masks are controversial. From the early statement that all must wear face masks to spare face masks to Health Professional creates anxiety as well as uncertainty among ordinary citizens. They do not how to react to a pandemic as community health programs have not been in place to train the community to face such a situation. The question whether N95 masks be reused, whether cotton fabric masks be used by the citizens where they cannot follow social distancing and whether they need to wear face masks or not, remains uncertain. The leading nations must come under one umbrella like WHO to speak one language to fight the pandemic. The directives or advisories given must be unambiguous and straight forward. Spare special Face Masks N95 for the health professionals and cases with the infection, wear face mask when needed say visiting the patient. Until then stay home, maintain social distancing and follow hand hygiene may be the slogans everyone needs to follow. Medicine is an art and science of uncertainty. Until a vaccine is in place, community immunity may be safest bet to rely one.
Competing Interests: None declared.
References
Lauren Vogel. Who should wear a face mask? Experts weigh in on Canada’s COVID-19 response. CMAJ 2020;192:E440-E441.
Posted on: (23 April 2020)
Page navigation anchor for RE: Experts weigh in on the COVID-19 response
RE: Experts weigh in on the COVID-19 response
Hans-Bernd Bludau [MD], General Practitioner, Clinica Dr. Bludau
Other Contributors:
Sergei Jargin, Pathologist
In view of the strict measures, increasing numbers of people will hide respiratory diseases behind face masks, especially in those regions, where work or outdoor activities are necessary to survive. Generally, COVID-19 as a cause of death seems to be overestimated. When numbers of deaths are reported, the baseline mortality is often disregarded. The mean age of patients with COVID-19 who died in Italy was reportedly 81 years while about two-thirds of them had comorbidites [1]. Of note, “died with COVID-19” is not the same as “died from COVID-19”. The currently estimated CFR depends on the population coverage by the testing [2]. The autopsy would be helpful to more precisely determine causes of death and hence the CFR. There are no reasons to assume that risks for the mortuary personnel are higher than those in the clinical departments; and the safety measures should be commensurate.
Influenza spreads around the world in yearly outbreaks, resulting in millions of cases of severe illness. Presumably, seasonal flu kills 250-500 thousand people yearly, which may be an underestimation [3]. Influenza pandemics resulted in millions of deaths. The effectiveness of travel restrictions, quarantines, etc. appears questionable because SARS-CoV-2 is spreading worldwide like influenza did repeatedly in the past. In future, the countries implementing strictest measures and losing more money might find themselves to have a weaker protection against COVID-19 by the natural immunity....
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In view of the strict measures, increasing numbers of people will hide respiratory diseases behind face masks, especially in those regions, where work or outdoor activities are necessary to survive. Generally, COVID-19 as a cause of death seems to be overestimated. When numbers of deaths are reported, the baseline mortality is often disregarded. The mean age of patients with COVID-19 who died in Italy was reportedly 81 years while about two-thirds of them had comorbidites [1]. Of note, “died with COVID-19” is not the same as “died from COVID-19”. The currently estimated CFR depends on the population coverage by the testing [2]. The autopsy would be helpful to more precisely determine causes of death and hence the CFR. There are no reasons to assume that risks for the mortuary personnel are higher than those in the clinical departments; and the safety measures should be commensurate.
Influenza spreads around the world in yearly outbreaks, resulting in millions of cases of severe illness. Presumably, seasonal flu kills 250-500 thousand people yearly, which may be an underestimation [3]. Influenza pandemics resulted in millions of deaths. The effectiveness of travel restrictions, quarantines, etc. appears questionable because SARS-CoV-2 is spreading worldwide like influenza did repeatedly in the past. In future, the countries implementing strictest measures and losing more money might find themselves to have a weaker protection against COVID-19 by the natural immunity. The misapplication of healthcare resources can imply discontinuation of non-urgent outpatient activities. Cancer surgeries are rescheduled or cancelled [4]. The resulting mortality jump might be erroneously ascribed to COVID-19 afterwards. The mass use of disinfectants will contribute to the antimicrobial resistance. All said, individual protection measures are certainly reasonable: staying home if ill, cough etiquette, frequent hand washing and others. As for procedural masks, if supplies of masks were not limited, an argument could be made that they may provide some degree of benefit [5].
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Competing Interests: None declared.
References
1. Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet 2020;395:1225-8.
2. Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA 2020; doi: 10.1001/jama.2020.4683
3. Iuliano AD, Roguski KM, Chang HH, et al. Estimates of global seasonal influenza-associated respiratory mortality: a modelling study. Lancet 2018;391:1285-300.
4. Nelson B. Covid-19 is shattering US cancer care. BMJ 2020;369:m1544.
5. Vogel L. Who should wear a face mask? Experts weigh in on Canada's COVID-19 response. CMAJ 2020;192(16):E440-1.
Posted on: (22 April 2020)
Page navigation anchor for Who should NOT wear masks during COVID-19 pandemic? Please don't point fingers at the public
Who should NOT wear masks during COVID-19 pandemic? Please don't point fingers at the public
Eugene Y.H. Yeung, Resident Physician, University of Ottawa
As a resident, I am equally as confused as the public on whether to wear masks. In some departments, I am told to put on a mask regardless of seeing patients or not; in other areas, I am prohibited to wear one or bring in any PPE myself. I am not alone, as some physicians and nurses are also told to remove their masks.<1><2>

Rather than deciding who should wear masks, should we be asking "who should NOT wear masks?" A recent review by Public Health Ontario concluded self-contamination risk is "theoretical."<3> Although this non-systematic review concluded lack of demonstrated benefit of the public wearing masks, it referenced 4 studies that demonstrated the contrary.<4>

A meta-analysis showed a protective effect of masks against clinical respiratory illness, influenza-like illness, SARS among healthcare workers.<5> But is this ethical to justify only healthcare workers deserve masks, and the rest of the population don't? I understand public wearing of medical masks may result in shortages of masks to protect front-line healthcare workers; however, the lives of other professions, including police and groceries workers, are equally important. By wearing masks, they are doing their parts to flatten the COVID-19 curve, as pre-symptomatic individuals have been shown to transmit SARS-CoV-2.<6>

When data on public wearing of masks is inconclusive, are we acting on the public best interest by denying...
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As a resident, I am equally as confused as the public on whether to wear masks. In some departments, I am told to put on a mask regardless of seeing patients or not; in other areas, I am prohibited to wear one or bring in any PPE myself. I am not alone, as some physicians and nurses are also told to remove their masks.<1><2>

Rather than deciding who should wear masks, should we be asking "who should NOT wear masks?" A recent review by Public Health Ontario concluded self-contamination risk is "theoretical."<3> Although this non-systematic review concluded lack of demonstrated benefit of the public wearing masks, it referenced 4 studies that demonstrated the contrary.<4>

A meta-analysis showed a protective effect of masks against clinical respiratory illness, influenza-like illness, SARS among healthcare workers.<5> But is this ethical to justify only healthcare workers deserve masks, and the rest of the population don't? I understand public wearing of medical masks may result in shortages of masks to protect front-line healthcare workers; however, the lives of other professions, including police and groceries workers, are equally important. By wearing masks, they are doing their parts to flatten the COVID-19 curve, as pre-symptomatic individuals have been shown to transmit SARS-CoV-2.<6>

When data on public wearing of masks is inconclusive, are we acting on the public best interest by denying their use of masks? Rather, as CanMEDS leaders and health advocates, we should advise safe and proper use of masks, in addition to social distancing and hand hygiene. This would help effectiveness of public wearing of masks to be on par with healthcare workers.

Perhaps, because of my skin colour, I have been told my support for mask use is simply based on cultural belief.<7> This comment does not surprise me as xenophobia incidents have been reported in this pandemic.<8> By the same token, I wonder whether wearing decorative headwear has minimal health benefits and theoretical risks of self-contamination. Is it our position to judge what others wear?
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Competing Interests: I have been paid for working in primary and secondary care settings, but not for writing this letter. Opinions expressed are solely my own and do not express the views of my employer.
References
1. https://www.npr.org/2020/04/02/825200206/doctors-say-hospitals-are-stopping-them-from-wearing-masks. 2. https://www.huffingtonpost.ca/amp/entry/canadian-blood-services-nurses-masks_ca_5e8786dec5b609ebfff0e704/.
3. https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/what-we-know-public-masks-apr-7-2020.pdf?la=en. 4. https://www.bmj.com/content/369/bmj.m1435/rr-39
5. Offeddu V, Yung CF, Low MSF, Tam CC. Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis. Clin Infect Dis. 2017;65(11):1934-1942.
6. Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 - Singapore, January 23-March 16, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(14):411-415.
7. https://www.scmp.com/news/hong-kong/society/article/3076109/wearing-mask-has-little-do-cultural-differences. 8. Coates M. Covid-19 and the rise of racism. BMJ. 2020;369:m1384.