THE RATIONALE BEHIND “FACE MASKS FOR ALL”

Evidence suggests that facemasks play a pivotal role in the prevention and control of infectious respiratory disease transmission,^{Reference Sim, Moey and Tan15,Reference Chu, Akl and Duda16} and nose-mouth barriers reduce—to an extent limited according to their technical characteristics (for example, cloth masks have proved to be less effective than medical masks)^{Reference MacIntyre, Seale and Dung17}—the exposure of healthy people to infection, and to a higher extent the capacity of infected people to spread infection by means of droplets.^{Reference van der Sande, Teunis and Sabel18}

Furthermore, it has been reported that SARS-CoV-2 can be transmitted by mildly ill or even asymptomatic people^{Reference Rothe, Schunk and Sothmann19,Reference Bai, Yao and Wei20} ; thus, limiting the use of face masks to symptomatic people may allow wide uncontrolled spread of the virus. The importance of adequate protective barriers, for both symptomatic and asymptomatic people becomes self-evident, suggesting that, during epidemics, nose and mouth protection should be universal in all situations where appropriate distancing is not possible or unpredictable, especially in closed spaces. Some of the countries that seem to have been more successful in the control of the epidemic enacted policies toward that goal.

In South Korea, for example, health officials have urged all citizens to wear filtered masks, with the Seoul government seizing near total control of face-mask production, distribution, and sales.²¹ A similar approach was implemented by Taiwan, where the government, recognizing the importance of ensuring an adequate supply of medical equipment, first, stopped exports of surgical face masks and requested local companies to increase production; second, took control of face mask distribution from the private sector, to ensuring no hoarding of supplies or exploitative pricing; and third, established a purchasing policy.²² This policy allows every Taiwanese to buy a certain amount of adult and children’s masks per week from pharmacies and clinics for a controlled price.

THE RATIONALE BEHIND “ALL FOR FACE MASKS”

If we agree on the usefulness of appropriate universal use of masks to limit the spread of the virus by means of droplets, the new challenge becomes providing masks to everybody, ensuring their effective and safe use, and making the production as sustainable as possible, which suggests local availability, affordability, and reusability.

Regarding availability, where capability for industrial production of high standard PPE exists and can be increased to the needs, this would possibly be the best choice. Import instead may not be an intelligent option for granting an effective national pandemic response. According to WHO modeling, an estimated 89 million medical masks are required for the COVID-19 response each month. To meet rising demand, manufacturing should increase globally by 40%.¹ However, the pandemic also challenged the functioning of the global market, with producing countries banning their exports to meet the foreseeable increase in national demand. When the epidemic was peaking, even China—the world’s main producer—asked for international support for medical masks and other PPEs. In Italy, despite the initial official recommendation of the Ministry of Health, there was a general rush to buy all possible kinds of medical masks and respirators, enormously increasing costs and hindering supply to first-line workers.

Limiting use to disposable PPE will come with an additional burden to national systems, due to the need to dispose of it adequately. The Chinese experience highlights this problem: at the peak of the COVID-19 outbreak, hospitals in Wuhan increased the medical waste from PPE by 6 times—to nearly 270 tons/d.^{Reference Zuo23}

With the need increasing, in social media homemade solutions flourished, mostly without any evidence about their effectiveness, but creativity and commonsense. As this movement cannot be stopped—people are mainly moved by their individualistic desire of personal protection—then it should be managed.

Local community production may be a viable option and possibly the most appropriate one in socially and economically disadvantaged settings. However, best possible solutions need to be identified and promoted according to effectiveness, safety, availability, affordability, and sustainability criteria.

Despite WHO initial advice against cloth masks³ and although cloth masks have lower filtration capacity compared with disposable medical masks, evidence suggests that any type of mask use is likely to decrease viral exposure and infection risk on a population level, despite imperfect fit and imperfect adherence, still offering some level of protection.^{Reference van der Sande, Teunis and Sabel18,Reference Davies, Thompson, Giri, Kafatos, Walker and Bennett24}

In addition to cloth, some combination of different materials easily available at community/domestic level could be more effective, with protection increasing according to the fineness of the fabric and the number of layers.^{Reference Chughtai, Seale and MacIntyre14} In a study, vacuum cleaner bags and double layer tea towels proved to have a filtration power very near to that of surgical masks, although due to a too high a pressure drop causing insufficient breathability, these materials could not be considered good mask materials. T-shirts or pillowcases made of 100% cotton are suggested as the most suitable homemade mask material.^{Reference Davies, Thompson, Giri, Kafatos, Walker and Bennett24}

The standard for industrially produced medical masks is mainly based on nonwoven material. Widely commercialized domestic tools are also made of nonwoven material (such as cleaning towels or cotton pads), giving the opportunity to widely test them for the domestic production of protective masks.

A recent systematic review and meta-analysis concludes that policy-makers across the globe should guarantee and protect equal access to face masks for every social group. Government interventions should facilitate and increase the production capacity of facemasks, enabling widespread use by the general public and for those with limited access to facemasks.^{Reference Chu, Akl and Duda16}

The local production of face masks comes with several pros and cons, these are presented in Table 1. Among others the diffuse production and universal use of masks may improve the perception of public health risks and strengthen the public sense of both personal and community control.^{Reference Syed, Sopwith, Regan and Bellis25}

TABLE 1 Pros and Cons of Local Production of Face Masks

The promotion of community production and universal use of facemasks, should be supported with ad hoc guidelines. Their development may need further interdisciplinary research. Indeed, it should not be limited to technical aspects (safety and biological effectiveness of materials and models, decontamination procedures), but include epidemiological (health outcomes), social and anthropological aspects (correct and effective use), impact on local economy, and the characteristics of effective communication strategies.

In any case, to avoid possible increased risk of transmission associated with the incorrect use and disposal or maintenance and decontamination of face masks, appropriate and widely diffused instructions should necessarily accompany the promotion of masks use and production³ and always insist on the fundamental need to combine the use of masks with the prioritarian hand hygiene and other infection prevention and control (IPC) measures.