Wearing face masks are an essential aspect of the fight against the COVID-19 pandemic. Although medical face masks are reportedly in very short supply in many countries especially low-income countries, cloth face masks seem to be gaining ground in terms of popularity and usage. In Cameroon, where the government has mandated wearing face masks to prevent the spread of COVID-19, with hefty fines for violators, cloth face masks are becoming more and more ubiquitous. They are a natural choice for community face mask users due to the ease of access (relatively low cost of production, accessibility of materials), potential reusability, and esthetic variability.
The usefulness of cloth face masks to prevent the spread of respiratory viruses, however, has been subject to a lot of debate. The scientific community is torn between outright restriction of use because of a lack of evidence supporting protective ability and the ethical dilemma of appearing to prefer a ‘no face masks’ policy (where medical masks are unavailable).
Studies have been carried out to investigate the usefulness of cloth face masks, with the most notable being the randomized cluster trial involving 1,607 hospital Health Care Workers (HCWs) aged 18 years and above in Vietnam. They set out to compare the efficacy of cloth face masks to medical masks in the hospital setting. They found that the risks of contracting a laboratory-confirmed respiratory virus infection were 1.7 times higher with cloth faced masks while the risk of developing an influenza-like illness was even higher (6.6times) [1]. The major limitation of this study, however, was that they only compared cloth face masks to the standard of care, which is medical masks. They did not compare cloth face masks with “no masks” and in the context of COVID-19 which is ravaging through
communities with varied access to any type of face masks, this later information if it were available, would have been a much better guide for public policy.
We know that medical face masks are superior to cloth face masks. However, with the paucity of scientific evidence, it is difficult to attribute any benefit (or lack of) to the use of cloth face masks.
However, a few observations can be made for us to reconsider and better position cloth face masks for greater impact in the context of a pandemic like the one the world is facing with COVID-19.
First, the act of wearing a mask is an added behavioral change in the context of preventing the spread of a pandemic, and behavioral change has been proven to be effective in reducing the spread of disease [2,3]. The fact that anyone adopts such a behavioral change points to some degree of consciousness about the pandemic and the possibility that they may associate other measures (like frequent washing of hands) must be considered.
Secondly, although the protective ability of the cloth face masks in terms of preventing a healthy person from being infected is debatable, its ability to significantly reduce the number of expelled micro-organisms from an infected person is proven [4]. If all suspected cases and all persons with flu-like symptoms wear cloth face masks, we will significantly reduce the burden of microorganisms in the air and on surfaces. With fewer viruses to go around, we may see a reduction in new infections.
Thirdly, Social Learning Theory stipulates that people can learn new behaviors by observing others [5]. By simply seeing someone or a group of persons wearing masks, irrespective of the type, a question and its answer may follow, or just a discussion and in some cases, a conviction.
We cannot underestimate what impact seeing masks on our streets can have on persons in terms of increasing awareness of the presence of the COVID-19 threat. A few more minds changing progressively may be all we need to flatten the curve of spread in some communities.
Fourthly, the superiority of medical masks compared to cloth face masks [1] requires that those who are most at risk, notably HCWs, should have priority to medical masks. In the context of widespread shortages in medical masks, recommending the use of cloth face masks by nonHCWs may limit the scarcity of medical masks where they are needed most.
To maximize the utility and impact of cloth face masks, we must emphasize that they should not in any circumstances, be used by healthcare workers in the workplace. If an HCW does not have another option, then they should not be in that workplace. Finally, cloth face masks should be actively recommended for use in the community as a cheaper and more accessible alternative, especially by those who have any respiratory symptoms and those who may have been in contact with a COVID-19 case.
Dr Ronald Gobina is a Nephrologist, working with the Regional Hospital in Buea. He is a Health Fellow and the Director of the COVID-19 taskforce for the DLF foundation. He is member of the International Society of Nephrology (ISN) and the Initiative to Strengthen Health Research Capacity in Africa (ISHReCA).
