key: cord- -zghq mcg authors: sugrue, michael; o’keeffe, derek; sugrue, ryan; maclean, lorraine; varzgalis, manvydas title: a cloth mask for under-resourced healthcare settings in the covid pandemic date: - - journal: ir j med sci doi: . /s - - - sha: doc_id: cord_uid: zghq mcg introduction: covid pandemic poses a global threat, with many unknowns. the potential for resource limited countries to suffer huge mortality is of major concern. prevention and risk reduction strategies are paramount in the current absence of effective treatment or a vaccine. there is a global shortage of personal protective equipment. aims: this short paper describes the rationale for and development of a cloth homemade mask and has a step by step video. results: the template is reproducible around the world and is both washable and cheap. conclusion: this article describes a simple way to make a cloth mask, suitable if medical masks are not available. the covid pandemic drives the need to maximise the use of available resources to protect people from contracting the virus to minimise morbidity and mortality. there are universal reports of limitations on personal protective equipment (ppe), and many countries in resource-challenged regions have minimal or no reserves [ ] . this will result in an inability to control the pandemic and poor outcomes. there are a wide range of ppe and very robust criteria to assess its efficacy and suitability [ ] . facial morphology and hair may confound the standards of protection and tolerance of the protection [ ] . doremalen and colleagues have recently shown that sars-cov- remained viable in aerosols for over hours, with a reduction in infectious titre from . to . tcid per litre of air [ ] . over a decade ago, van der sande identified that a tea towel offered some protection, all be it suboptimal compared to an ffp commercial mask [ ] . the aim of this report is to share the details for the design and rapid fabrication of a cloth face mask, with the potential to provide the population with alternatives when medical grade face masks are not available. a dress maker (mv) designed multiple prototypes of cloth face masks and after six versions came up with the pattern shown in fig. . the base of the parabolic curved pattern for this full size adult mask was cm. the curve of the mask creates a duckbilled design similar to a commercial ffp mask, with a facial cup, nasal bone bridge and two elastic bands. the material used was a polycotton with a tight weave. the nasal bone was created from a coated -mm metal garden wire obtained from a hardware shop. the first step was to fold the material in two and pin the pattern to the material. this is cut with a scissors (a view of the step by step mask manufacture and application is available in supplementary video www. dcra.ie) [ ] . a small hem is added to the lateral edges to allow the elastic strap to be inserted with ease (marked as b in fig. ). folding the top flaps over, the leaves are sewn together and then stitched to the bottom unfolded leaf. the free flap of the bottom end is then stitched to the top but leaving a -cm opening to allow it to be inverted. the mask is then turned inside out. the apical defect of approximately cm is hand stitched closed. all the seams are on the inside so an overlocking stitch was not necessary. at both bases, a -mm tunnel was created by stitching to allow the passage of the elastic bands, which can be facilitated by a small round safety pin (marked as a in fig. in video) . the nasal bridge bone was made from a cm length of -mm wire coated in plastic and an additional layer of insulating tape was wound the exterior of the wire. the elastic strapping used was mm in width and cm in length for both top and bottom straps. the mask fitted comfortably and provides a good seal (fig. ) . the elastic bands are placed over the crown of the head and the occiput. there is an additional opportunity to apply tape to the superior edge of the mask to increase the seal or reduce fogging. the cost of the material was less than €. the measurements shown in the mask fit an adult male face and adjustment would need to be made according to facial size and features. this work reports the design and fabrication steps of a simple cloth face mask, which may be considered as a last resort for those wishing to have some protection and protect others from aerosol and droplet spread. the enormity of this covid pandemic remains to be seen, but apart from china and korea, it remains unabated, with over , , cases and , deaths [ ]. protective effects of face masks have been studied extensively, often involving personal respirators for professionals under idealized conditions, involving protection of specifically trained personnel. van de sande has suggested the deployment of masks in the general population during an outbreak of an infectious disease, where anyone may encounter the infectious micro-organism, implying much greater heterogeneity, fig. the pattern for the home made mask in training levels (experience and understanding), goodness of fit of a mask and activities interfering with mask use and thus reducing potential reduction of transmission [ ] . transmission barriers, isolation and hygienic measures are effective at containing respiratory virus epidemics. surgical masks are most consistent and comprehensive supportive measures and are not inferior to n masks [ , ] . face masks are only a part of the overall approach but together with personal distancing, hand hygiene and other measures form a bundle which may overcome this disease [ ] . the protection conferred by face masks appeared stable over time and was not dependent on activity [ ] . given doremalen's recent results indicating that aerosol and fomite transmission of sars-cov- is plausible, and since the virus can remain viable and infectious in aerosols for hours and on surfaces up to days, extra caution is required [ ] . these findings echo those with sars-cov- , in which these forms of transmission were associated with nosocomial spread and super-spreading events [ ] . the centers for disease control and prevention recommends a -ft ( -m) separation [ ] . however, bourouiba et al. suggest that these distances are based on estimates of range that have not considered the possible presence of a high-momentum cloud carrying the droplets long distances. given the turbulent puff cloud dynamic model, recommendations for separations of to feet ( - m) may underestimate the distance, timescale and persistence over which the cloud and its pathogenic payload travel, thus generating an underappreciated potential exposure range for a health care worker. for these and other reasons, wearing of ppe is important for health care workers caring for patients who may be infected, even if they are farther than ft away from a patient [ ] . this may apply to patients and their families also in clinical areas. there is increasing global suggestions that face masks should be worn at all times, but this strategy has yet to be proven. in its current guidance to optimise use of face masks during the pandemic, the centers for disease control and prevention (cdc) identifies three levels of operational status: conventional, contingency and crisis [ ] . this mask would be in the crisis category and would intuitively offer more protection to the wearer than no ppe at all. well-resourced countries are increasingly becoming under-resourced in ppe. innovative ideas are required to ensure adequate supplies. the cloth face mask is simple, cheap and made from materials that are globally available. we would not advocate its use in preference over proven medical masks that have been rigidly tested, rather as a last but important option, in the fight against the covid pandemic, and is consistent with the application of the precautionary principle [ ] . critical supply shortagesthe need for ventilators and personal protective equipment during the covid- pandemic hase guidance on respiratory protective equipment (rpe) fit testing, indg if the mask fits: an assessment of facial dimensions and mask effectiveness aerosol and surface stability of sars-cov- as compared with sars-cov- professional and homemade face masks reduce exposure to respiratory infections among the general population physical interventions to interrupt or reduce the spread of respiratory viruses surgical mask vs n respirator for preventing influenza among health care workers: a randomized trial travelers from countries with widespread sustained (ongoing) transmission arriving in the united states turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid- sourcing personal protective equipment during the covid- pandemic face masks for the public during the covid- crisis publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgments seamus hughes letterkenny for providing some test material. marite vilcane dressmaker with zip yard letterkenny donegal ireland. we thank seubp and inter regional eu support. key: cord- -x errh authors: lee, j.; bong, c.; bae, p. k.; abafog, a. t.; baek, s. h.; shin, y.-b.; park, m. s.; park, s. title: fast and easy disinfection of coronavirus-contaminated face masks using ozone gas produced by a dielectric barrier discharge plasma generator date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: x errh face masks are one of the currently available options for preventing the transmission of the severe acute respiratory syndrome coronavirus (sars-cov- ), which has caused the pandemic. however, with the increasing demand for protection, face masks are becoming limited in stock, and the concerned individuals and healthcare workers from many countries are now facing the issue of the reuse of potentially contaminated masks. although various technologies already exist for the sterilization of medical equipment, most of them are not applicable for eliminating virus from face masks. thus, there is an urgent need to develop a fast and easy method of disinfecting contaminated face masks. in this study, using a human coronavirus (hcov- e) as a surrogate for sars-cov- contamination on face masks, we show that the virus loses its infectivity to a human cell line (mrc- ) when exposed for a short period of time ( min) to ozone gas produced by a dielectric barrier discharge plasma generator. scanning electron microscopy and particulate filtration efficiency (pfe) tests revealed that there was no structural or functional deterioration observed in the face masks even after they underwent excessive exposure to ozone (five -minute exposures). interestingly, for face masks exposed to ozone gas for min, the amplification of hcov- e rna by reverse transcription polymerase chain reaction suggested a loss of infectivity under the effect of ozone, primarily owing to the damage caused to viral envelopes or envelope proteins. ozone gas is a strong oxidizing agent with the ability to kill viruses on hard-to-reach surfaces, including the fabric structure of face masks. these results suggest that it may be possible to rapidly disinfect contaminated face masks using a plasma generator in a well-ventilated place. . a schematic diagram describing the disinfection of a face mask contaminated by a disinfecting face masks contaminated with a coronavirus. similar results were obtained for face masks experimentally contaminated with either influenza a virus (h n ) (table s ) or gram-positive bacteria staphylococcus aureus (table s and figure s ) when exposed to ozone gas. these results suggest that virus and bacteria on face masks can be inactivated by ozone gas at a concentration of about ppm within a short time ( - min). dried at room temperature for min in a biosafety cabinet before exposed to ozone gas. difference (p > . ; student's t-test) in the amount of amplifiable rnas between the unexposed and exposed masks, indicating that the short exposure may not fully degrade the viral rna (table ) . similarly, the rna of either h n (table s ) or s. aureus (table s ) with and without exposure to ozone gas. to test if the exposure of face masks (kleenguard®) to either plasma or ozone gas causes any damage to their filter layer, uncontaminated face masks were exposed to ozone gas for min (five -minute exposures). we did not see any noticeable damage on the front and back side of the face masks with eyes and under a light microscope, either (data not shown). their inner filter layer composed of polypropylene meltblown non-woven fabric was further examined under a sem. as shown in figure , there was no detectable structural damage caused to the filter layer of the exposed face masks. the result showed that the repeated exposures ( times) of face masks to ozone gas did cause structural damage to the face masks. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . ± . (n= ) a the lab is certified and registered as a testing lab by the ministry of food and drug safety (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / respiratory virus shedding in exhaled breath and characterization of human coronavirus etiology in chinese adults with acute upper respiratory tract infection by real-time rt-pcr assays inactivation of surface viruses by gaseous ozone comparison of pressure drop and filtration efficiency of particulate respirators using welding fumes and sodium chloride absorption cross-sections of ozone in the key: cord- -x xijo m authors: ogoina, dimie title: covid- : the need for rational use of face masks in nigeria date: - - journal: am j trop med hyg doi: . /ajtmh. - sha: doc_id: cord_uid: x xijo m because of the pandemic of covid- , the federal government of nigeria has instituted a mandatory policy requiring everyone going out in public to wear face masks. unfortunately, the nigeria media is awash with images of misuse and abuse of face masks by the public, government officials, and healthcare workers. medical masks are used widely in community settings amid reported scarcity within healthcare facilities. it is observed that some people wear face masks on their chin and neck, and mask wearers give no attention to covering their mouth and nose, especially when talking. used face masks are kept with personal belongings or disposed indiscriminately in public spaces, leading to self and environmental contamination. inappropriate use and disposal of face masks in nigeria could promote the spread of the novel coronavirus in the country and negate the country’s efforts to contain the covid- pandemic. in the implementation of the universal masking policy in nigeria, federal and state governments ought to consider local applicability, feasibility, and sustainability, as well as identify and mitigate all potential risks and unintended consequences. also critical is the need for intensive public sensitization and education on appropriate use and disposal of face masks in the country. the major strategic goals of covid- control efforts are to slow or stop transmission and spread of sars-cov- and to mitigate the impact of the virus on the health system, social activities, and economies of countries and communities. the scientific information on sars-cov- and covid- is rapidly evolving, and many countries are adopting preventive measures based on emerging evidence and local applicability. one such strategy, considering evidence of presymptomatic and asymptomatic transmissions of sars-cov- , is the use of face masks by apparently healthy persons to slow community transmission of the virus. [ ] [ ] [ ] the use of public face masks for the prevention of covid- is controversial. the who has indicated that it cannot recommend for or against public use of face masks, as there is yet no clear evidence that this practice is effective in the prevention of covid- . the who has also emphasized that "the use of a mask alone is insufficient to provide an adequate level of protection, and other measures should also be adopted." however, the who acknowledged potential advantages of the use of masks by healthy people in the community setting to reduce potential exposure from infected persons during the presymptomatic period of infection. it advised a risk-based approach for implementing policies on public wearing of face masks. as part of a comprehensive response to the covid- epidemic, the president of the federal republic of nigeria recently announced mandatory wearing of face masks by anyone going out in public. a similar policy is being implemented by almost all state governments of the country. the nigerian centre of disease control (ncdc) indicated that the major rationale for public wearing of face masks is to prevent those who are infected but asymptomatic from spreading the virus. the ncdc has emphasized that wearing of face masks may only be effective in preventing the transmission of sars-cov- if they are worn and disposed appropriately, and if mask wearing is combined with other preventive measures such as hand hygiene and social distancing. an advisory on making and proper usage of cloth masks has also been issued by the ncdc; it was recommended that cloth masks be used by the general public, with medical masks reserved for healthcare workers. unfortunately, new face mask policies are leading to widespread misuse and abuse of face masks in nigeria. [ ] [ ] [ ] [ ] the nigeria media is awash with images of members of the general public, including healthcare workers and government officials, wearing face masks on their jaws and neck, without covering their mouth or nose, or covering only their mouth while the nose is left opened. many people who use face masks are commonly observed to pull down their mask to their jaw to talk and then pull it back over their mouth and nose after talking. a variety of cloth masks of doubtful efficacy are hawked on the streets and tried by different wearers before deciding on purchase. people are also observed to repeatedly touch the front of their face masks in a bid to adjust the mask, to remove it, or during reflex touching of the face. some wear one mask for prolonged periods, without replacement when it is wet or soiled. furthermore, face masks used for the prevention of covid- by the general public are being disposed inappropriately. the rising spate of misuse and abuse of face masks is a source of worry for the nigerian covid- presidential task force, which observed "unhygienic and ill-advised use and sharing of masks, especially multiple fittings before buying from vendors." it is noteworthy that medical masks meant for healthcare workers, such as surgical masks and respirators, are being routinely worn by the general public and government officials, when there are complaints that these masks are not available in sufficient quantities in nigerian hospitals. furthermore, n respirators with exhalation valves have become the preferred face masks by many, including top government officials, possibly because they are more comfortable. respirators with exhalation valves are, however, not effective in covid- source control, as they do not prevent the release of exhaled respiratory particles. although some state governments in nigeria are now producing large quantities of cloth masks for use by the general population, one is concerned if sufficient quantities of these homemade masks can be provided sustainably for a population of more than million. there are also challenges related to enforcement of mandatory usage, access to water and soap to properly wash and reuse homemade masks, and a false sense of security that may lead people to abandon other preventive measures because of the usage of face masks. compliance with and enforcement of social distancing measures have been identified as challenges in nigeria's response to covid- , and there are reports of people openly flouting lockdown orders and other preventive measures. many nigerians still do not have access to water and basic sanitation, and indices of hygiene are poor in the country. adopting a public face mask strategy may require extra funding to be sustainable, and this strategy could divert scarce resources from other covid- preventive measures. another concern is that face masks might become a new medium for propagation of the novel coronavirus in nigeria in view of high risks of self and environmental contamination when masks are used and disposed inappropriately. public mask wearing is most effective at stopping the spread of the novel coronavirus when compliance is high and when masks are used appropriately, especially in combination with other preventive measures such as hand hygiene. , in many of its public health advisories, including the advisory on use of face masks by the healthy community, the who cautioned on universal applicability of public health measures without consideration of local context. in the absence of an effective and intensive communication strategy on why, when, and how to use face masks, the strategy of mandatory public face mask use in nigeria carries risks and uncertainties. the federal and state governments ought to consider the local peculiarities, resource requirements, feasibility, sustainability, and potential risks and benefits before and during the implementation of public face mask policies. failure to address these may negate the potential benefits of public face mask policies and inadvertently enhance the spread of sars-cov- in nigeria. available at: https:// www.who.int/publications-detail/strategic-preparedness-andresponse-plan-for-the-new-coronavirus. accessed may , . . world health organisation recommendation regarding the use of cloth face coverings rational use of face masks in the covid- pandemic advice on the use of masks in the context of covid- covid- regulation nigeria centre for disease control, . advisory on the use of masks by members of the public without respiratory symptoms. available at advisory on use of cloth face masks available at: https:// www.nafdac.gov.ng/covid- -personal-protection-equipmentppes-masks-and-protective-clothing nids warns against misuse, abuse of face masks to prevent covid- . independent newspapers nigeria improper use, disposal of facemasks, hand gloves could trigger covid- community transmission in nigeria. the guardian newspaper bizzare! these women were seen washing used nose mask in order to resell! naija super fans remarks by the sgf/chairman of the ptf covid- at the national briefing of wednesday nma: shortage of protective equipment due to poor funding for health-the whistler ng. the whistler independent newspapers cyclists for flouting lockdown order. independent newspapers nigeria nigeria demographic and health survey covid- epidemic: disentangling the re-emerging controversy about medical facemasks from an epidemiological perspective key: cord- -bslv sqv authors: sapoval, m; gaultier, al; del giudice, c; pellerin, o; kassis-chikhani, n; lemarteleur, v; fouquet, v; tapie, l; morenton, p; tavitian, b; attal, jp title: d-printed face protective shield in interventional radiology: evaluation of an immediate solution in the era of covid- pandemic date: - - journal: diagn interv imaging doi: . /j.diii. . . sha: doc_id: cord_uid: bslv sqv abstract purpose: the purpose of this study was to report the clinical evaluation of a d-printed protective face shield designed to protect interventional radiologists from droplet transmission of the sars-cov- . materials and methods: a protective face shield consisting in a standard transparent polymerizing vinyl chloride (pvc) sheet was built using commercially available d printers. the d-printed face shield was evaluated in interventional procedures in terms of ability to perform the assigned intervention as usual, quality of visual comfort and tolerance using a likert scale (from , as very good to , as extremely poor). results: the mean rating for ability to perform the assigned intervention as usual was . ± . (sd) (range: - ). the mean visual tolerance rating was . ± . (sd) (range: - ). the mean tolerability rating was . ± . (sd) (range: - ). conclusion: the d-printed protective face shield is well accepted in various interventions. it may become an additional option for protection of interventional radiologists. j o u r n a l p r e -p r o o f materials and methods: a protective face shield consisting in a standard transparent polymerizing vinyl chloride (pvc) sheet was built using commercially available d printers. the d-printed face shield was evaluated in interventional procedures in terms of ability to perform the assigned intervention as usual, quality of visual comfort and tolerance using a likert scale (from , as very good to , as extremely poor). the mean rating for ability to perform the assigned intervention as usual was . ± . (sd) (range: - ) . the mean visual tolerance rating was . ± . (sd) (range: - ). the mean tolerability rating was . ± . (sd) (range: - ). the d-printed protective face shield is well accepted in various interventions. it may become an additional option for protection of interventional radiologists. abs: acrylonitrile butadiene styrene ir: interventional radiology in the context of the current pandemic, the risk of human-to-human transmission of covid- during patient interaction has dramatically increased [ ] [ ] . interventional radiologists, nurses and technicians are at high risk of direct contact with covid- patients while performing interventions. in a significant number of patients, the covid- status is unknown at the time of intervention. scientific societies have defined a list of high-risk interventions, either because of risk of aerosolization or because the operator is close to the face of the patients [ ] . several countries and healthcare institutions are facing shortage of personal protection equipment (ppe) because of insufficient anticipation, poor manufacturing capacity or other reasons. the need for additional options to limit dissemination between healthcare providers and patients, who are both potential sources of severe acute respiratory syndrome coronavirus (sars-cov- ) dissemination, must be addressed with an urgent, practical and efficient answer. the purpose of this technical note was to report the clinical evaluation of a new protective face shield designed to protect caregivers from droplet transmission of the sars-cov- in interventional radiology. d care.org is a consortium of physicians, academics, mds, phds, engineers and students we conducted a prospective evaluation in our ir unit aiming at evaluating the acceptability of the protective face shield in real conditions. ir personnel with different levels of experience were equipped with the d care face-shield. immediately after the intervention, they were asked to complete a standardized questionnaire based on a likert scale (rated from as very good to as extremely poor) evaluation. they quoted on the scale the following items: (i), ability to perform the assigned intervention as usual; (ii), quality of visual comfort; and (iii), musculo-skeletal tolerance. to evaluate the feasibility of re-using the pvc sheet we assessed the potential reduction in visual quality of the shield after cleaning in a subset of interventions. the cleaning was performed according to the recommendation of the manufacturer with a detergent/disinfectant (didecyldimethylammonium chlorure and polyhexamethylene biguanide chloride) using a soft sponge for one minute and allowing for spontaneous drying before using. the evaluation was conducted by a total of operators in consecutive interventions our evaluation demonstrates that the face shield designed by d care can be used to perform various interventions without alterations by comparison with the usual working conditions. the ability to perform interventions as usual was not hampered by the use of the device, the visual tolerance was good and we did not observe any discomfort, even during long intervention. the various types of interventions that we monitored as well as the diverse level of experience of participating interventional radiologists allows to foresee that this experience could be easily reproduced in other countries/teams. this validation re-enforces the potential value of using this additional ppe, in order to contribute to fill in the gap of ppe for interventional radiologists during the covid- pandemic. in the setting of the covid- pandemic, ir procedures can be performed both for complication of the disease and for usual interventions especially for oncologic patients (i. e., tumor ablation, implantable ports, intra-arterial treatment and supportive care) [ , ] . a subset of intervention have been defined as high-risk interventions because of close proximity to the patient's face or highrisk of aerosolization ( ). because sars-cov- dissemination is recognized to be related to droplets of saliva or discharge from nose from patients when coughing, speaking, breezing or sneezing, the use of surgical face masks is recommended in association with goggles. face shields provide protection to other facial areas in addition to eyes and better protection from splash or spray of any respiratory secretion from the patient. in the current situation of emergency the need for a readily available solution is of utmost importance. due to the acute and unforeseen spreading of covid- pandemic as well as to the unpreparedness of several healthcare systems, our consortium designed the d care face shield. the actual production of this mask requires less than hours for a complete mask. a small farm of commercial d printers working / and / can produce a large number of face shield protections. in our hospital, the design, printing and initial testing of the face shield was conducted in a approximately hours, allowing to start the present study on the third day after the initial decision had been taken. we acknowledge that a limitation of this study is the absence of evaluation of protection offered by the face shield in terms of viral count exposure. however, this would have required a controlled and specific environment non feasible in an emergency setting [ ] . accordingly, the action of the d care consortium was focused on immediate access to this ppe in relation to covid- pandemic. in conclusion, the d care face shield is well accepted in various interventions. it could become an additional option for protection of interventional radiologists. it is hoped that its rapid diffusion will confirm our preliminary findings. coronavirus: update related to the current outbreak of covid- what is needed to make interventional radiology ready for covid- ? lessons learned from sars-cov epidemic activité de radiologie interventionnelle en phase d'épidémie covid- + recommandations de la fédération de radiologie interventionnelle pour la société française de radiologie (fri-sfr) diagnostic and interventional radiology is a milestone in the management of renal tumors in birt-hugg-dubé syndrome percutaneous thermal ablation of primary and secondary lung tumors: comparison between microwave and radiofrequency ablation transcatheter arterial embolization for iatrogenic bleeding after endoscopic ultrasound-guided pancreaticobiliary drainage aerosol and surface stability of sars-cov- as compared with sars-cov- the authors have no conflict of interest relevant to this article to disclose. all authors attest that they meet the current international committee of medical journal editors (icmje) criteria for authorship. key: cord- - qsqj d authors: matuschek, christiane; moll, friedrich; fangerau, heiner; fischer, johannes c.; zänker, kurt; van griensven, martijn; schneider, marion; kindgen-milles, detlef; knoefel, wolfram trudo; lichtenberg, artur; tamaskovics, bálint; djiepmo-njanang, freddy joel; budach, wilfried; corradini, stefanie; häussinger, dieter; feldt, torsten; jensen, björn; pelka, rainer; orth, klaus; peiper, matthias; grebe, olaf; maas, kitti; bölke, edwin; haussmann, jan title: the history and value of face masks date: - - journal: eur j med res doi: . /s - - - sha: doc_id: cord_uid: qsqj d in the human population, social contacts are a key for transmission of bacteria and viruses. the use of face masks seems to be critical to prevent the transmission of sars-cov- for the period, in which therapeutic interventions are lacking. in this review, we describe the history of masks from the middle age to modern times. in last few months, many communications were brought to the public that face masks are ineffective during a pandemic crisis. since april , face masks have become mandatory for shopping and in public transportation in germany. in the netherlands, it became mandatory only for public transportation, from june , onwards. however, in asian countries people have been wearing masks in public for ages. although new york and hong kong are both metropolitan areas, the corona virus pandemia was devastating in the us and not in hongkong. this fact alone implies a necessary, and a more distinguished view of the normative application of facemasks. in two manuscripts, we are now describing the use of masks during this viral pandemic. this first review describes the history of facemasks. the second will concentrate on benefits and risks by wearing facemasks in modern times. on march , , this headline appeared in the new york times on an article regarding the role of face masks in times of the covid- outbreak. this is the most recent expression of the use of face masks. however, face masks have been used since the middle ages. there are pictures of medical professionals from the early modern age treating patients suffering from the bubonic plague wearing beak-like masks. these masks were supposedly filled with herbs such as clove or cinnamon as well as liquids and led to the term 'beak-doctors' [ ] (fig. ) . the doctors were dressed in black cloaks and dark hats and were considered the symbol of the deathly epidemic of the middle ages. their masks were meant to protect from the 'blight' , the miasma, which was considered the cause of the plague back then. it was proclaimed that spoiled air from the east had caused the epidemic. nevertheless, there is no proof that these 'plague-doctors with beak-like masks' really existed. there are two masks displayed in german museums that are suspected to be forgeries from a younger date. that indicates that the beak-doctors were in retrospect awarded a meaning they apparently did not have in reality [ ] . heroic stories of the introduction of antisepsis by joseph lister ( - ) and the corresponding preliminary works by louis pasteur ( - ) or ignaz semmelweis ( - ) [ ] have inspired movie productions for decades and had an impact on our culture of remembrance. in contrast, the bacteriologic era that influenced the development of surgery has only recently been analyzed for the german area by schlich et al. [ ] . ever since the works of lister and pasteur, the surgical ward and its developing special disciplines were confronted with a trend-setting discourse about wound infections and their prohibition and containment. this began in , as the 'hospital gangrene' was limiting the outcomes of operations, especially those concerning abdominal procedures and those involving bones. the introduction of mouth and nose coverage (mouth protection, face veils, face masks, mouth bandages) can be followed back to the turn-of-the- th -century. in , the hygienist carl friedrich flügge ( flügge ( - working in breslau at this time published his works on the development of droplet infections [ ] [ ] [ ] as part of his research on the genesis of tuberculosis [ ] . at that time, the respiratory system as a transmitter of germs came into focus of research and already mandated instructions to keep distance [ , ] . in the same year, , a cooperation work between flügge and theodor billroth's ( - ) disciple johannes von mikulicz ( mikulicz ( - , who also worked in breslau since , was published. their publication dealt with performing operations wearing a 'mouth bandage' . in here, mikulicz described a one-layered mask made of gauze [ ] . mikulicz, who had already been responsible for the introduction of sterile gloves made from cloth, noted concerning the applicability of surgical masks: '…we breathed through it as easily as a lady wearing a veil in the streets… ' mikulicz' assistant hübner resumed the topic and described a two-layered mouth protection made of gauze that should prevent driblet spread. more studies regarding the germ content in the operating room air followed [ , ] . until , the application of face covers was not common in surgery and the general hospitals. nevertheless, an earlier illustration of a multilayer face mask made of gauze can be found in the surgical operating teachings of the british surgeon b.g.a. moynihan ( - ) (fig. ) . in , the surgeon fritz könig ( könig ( - noted in a handbook on surgery for general practitioners: "…due to our experience of many years we consider their (mouth masks) -by the way quite irritatinguse altogether unnecessary. only those afflicted with a catarrh or angina should wear a mouth bandage when operating that is to be sterilised in steam. speaking should be limited and the direction of the operative field avoided…" [ ] the surgical mask was used first in the operating rooms of germany and the usa in the s. especially in endoscopic procedures or 'small surgery' , the mask was renounced for a long time. there was still no hint for a facemask in the book 'assistance for operating staff ' , that was widely read in german-speaking areas in , while the processing of cystoscopies for instance, also taking place in the clinical use around , was described extensively on several pages [ , ] . one year later, martin kirschner ( kirschner ( - , who held the chair for surgery in heidelberg, elaborately described the necessity of wearing a facemask in his multi-volume operational theory in the chapter 'measures to combat infections' [ ] . in the following edition of the book 'assistance for operating staff ' published in , facemasks were then mentioned [ ] , which can probably be related to the increased number of studies on the reduction of germs [ , ] . a similar situation applies for the united states. in that country, following the first world war, more and more research addressed facemasks with varying thickness [ ] [ ] [ ] [ ] . still, masks were not generally accepted, which can be seen in contemporary photographs [ ] or paintings (figs. , and ) . while interns and nurses were already wearing facemasks made of cloth or gauze, the generation of head physicians rejected them, as well as rubber gloves, in all phases of an operation, as they were considered "irritating". in the middle of the s, the research on the role of facemasks was continued in germany and the usa [ , ] . only in the s, washable and sterilizable masks gained acceptance in german and international surgery with only the number of gauze layers varying ( ) ( ) ( ) ( ) [ , ] . beginning in the mid- s, the use of disposable items made of paper and fleece was introduced all over the world after this was started in the usa. still in the s, there were only uncertain data available. therefore, an unresolved discussion was present between surgery and hospital hygiene, if wound infections could be reduced by the use of surgical mouth and nose protection [ , ] . today, following the recommendations of the rki (german robert koch-institute for hygiene), the available data indicate that surgical facemasks lower the contamination of indoor air [ ] . during the covid- pandemic, the use of facemasks seems to be an accepted procedure worldwide although a scientific discussion is going on up to now, which has its roots in the history of medicine and science. future research on efficiency and efficacy of long-term mask wearing outside of hospital settings is warranted and will allow for insights that are more detailed. daily life during the black death die pestarztmaske im deutschen medizinhistorischen museum ingolstadt die aetiologie, der begriff und die prophylaxis des kindbettfiebers the palgrave handbook of the history of surgery palgrave die verbreitung der phthise durch staubförmiges sputum und durch beim husten verspritzte tröpfchen zshr hyg infkrkh. ueber luftinfection durch beim husten, niesen und sprechen verspritzte tröpfchen zshr hyg infkrkh die uebertragung von infectionskrankheiten durch die luft das operieren in sterilisierten zwirnhandschuhen und mit mundbinde Über die möglichkeit der wundinfektion vom munde aus und ihre verhütung durch operationsmasken contributo alla studio della flora bacteria nell die therapie des praktischen arztes erster band therapeutische fortbildung handreichungen für den operationssaal ratgeber für die vorbereitung chirurgischer operationen und das instrumentieren für schwestern, Ärzte und studierende history of cystoscopy allgemeine und spezielle chirurgische operationslehre bd ; . s. - insb postoperative haemolytic streptococcus wound infections and their relation to haemolytic streptococcus carriers among operating personnel the protective qualities of the gauze face mask the value of the face mask and other measures droplet infection and its prevention by the face mask a bacteriological study of the efficiency of face masks the myths, the masks, and the men and women behind them uncovering the history of operating room attire through photographs untersuchungen über operationsschleier grundriß der gesamten chirurgie allgemeine chirurgie . abschnitt aseptik operative chirurgie new routines for prevention of postoperative infections. a review postoperative wound infections and surgical face masks: a controlled study publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations this work is dedicated to dr. med. ewald matuschek and ruth matuschek. there was no funding for this investigation. all data and materials can be accessed via cm and fm. there was no ethics approval necessary because this is a review of the literature. all authors gave consent for the publication. all authors declare that they have no conflict of interest. heinrich-heine-university, duesseldorf, germany. institute for transplant key: cord- - ruoysxu authors: howard, matt c. title: understanding face mask use to prevent coronavirus and other illnesses: development of a multidimensional face mask perceptions scale date: - - journal: br j health psychol doi: . /bjhp. sha: doc_id: cord_uid: ruoysxu face masks are an avenue to curb the spread of coronavirus, but few people in western societies wear face masks. social scientists have rarely studied face mask wearing, leaving little guidance for methods to encourage these behaviours. in the current article, we provide an approach to address this issue by developing the ‐item and ‐dimension face mask perceptions scale (fmps). we begin by developing an over‐representative item list in a qualitative study, wherein participants’ responses are used to develop items to ensure content relevance. this item list is then reduced via exploratory factor analysis in a second study, and the eight dimensions of the scale are supported. we also support the validity of the fmps, as the scale significantly relates to both face mask wearing and health perceptions. we lastly confirm the factor structure of the fmps in a third study via confirmatory factor analysis. from these efforts, we identify an avenue that social scientists can aid in preventing coronavirus and illness more broadly – by studying face mask perceptions and behaviours. but many researchers point out that preventative measures also reduce the spread of illness (chen et al., ; long et al., ; wang et al., ) . among these preventative measures are hand washing, social distancing, andthe focus of the current articleface mask wearing. face masks are cloth coverings worn on the face with the intention to prevent illness. while face masks partially protect the wearer, they are more effective at ensuring that the wearer does not spread their germs (cdc, ) . even while the number of coronavirus cases and deaths dramatically increase, those in western populations appear reluctant to wear face masks (bbc, b; friedman, ) . a recent study supported that < % of those in canada, france, germany, and the united kingdom wear face masks to protect themselves from coronavirus, whereas more than % in china, india, japan, and vietnam do so (bricker, ) . the cause of this resistance is still largely unknown. social scientists frequently study other health behaviours, such as hand washing, smoking cessation, and exercise (ogden, ) ; however, very few have investigated face mask wearing. this dearth of research is particularly damaging in the current worldwide landscape, as public health officials have little knowledge regarding effective interventions to encourage face mask wearing. if an avenue was identified to develop such interventions, public health officials argue that the spread of coronavirus could be greatly reduced and millions of lives could be saved (bbc, b; cdc, ) . the current article provides a starting avenue to study face mask perceptions, which could lead to the development of interventions to alter face mask wearing. we undergo a three-study process to develop the face mask perceptions scale (fmps), which is a -item and -dimension measure to gauge justifications for not wearing face masks. we demonstrate that the fmps produces superb psychometric properties, appropriate validity evidence, and significant relations with face mask wearing. in our discussion, we also link the current results with prior frameworks and theories associated with intervention development. we argue that the current results can be broadly framed in the com-b model (michie et al., ) , but future researchers should also apply more specific theories (arden & chilcot, ; bish & michie, ; teasdale et al., ) to develop interventions and encourage face mask wearing via perceptual change. the fmps can encourage researchers to integrate face mask wearing with studies on protective behavioursespecially those focusing on the importance of perceptions as done in the current article. notably, a significant base of research has investigated hand washing, and authors have developed complex theoretical frameworks and associated interventions regarding hand washing (aunger et al., ; lam et al., ; nicholson et al., ) . for instance, judah et al. ( ) studied the efficacy of fourteen different messages to target seven psychological mechanisms (including perceptions) and promote hand washing in public restrooms. the authors demonstrated the varied effectiveness of these messages, implied importance of the psychological mechanisms, and influence of gender on the efficacy of the messages. such findings can provide an approach to study face mask wearing, wherein the eight dimensions identified in the current article can be incorporated into associated frameworks and the fmps can be used as an indicator of intervention effectiveness. thus, we assert that it is key for future research to utilize these prior findings regarding protective behavioursand hand washing specificallyto better understand and promote face mask wearing. together, the current article provides many benefits for research and practice. first, we identify an avenue that social scientists can aid in preventing coronavirusstudying face mask perceptions. second, we identify the most common face mask perceptions as well as those with the strongest relation to face mask use, which allows future researchers to target these barriers via interventions to encourage face mask wearing. third, we show that face mask perceptions are complex. people do not simply have positive or negative perceptions of face masks, but they instead have several differentpossibly conflictingperceptions that influence their behaviours. fourth, by assessing face mask perceptions in an eight-dimensional rather than unidimensional manner, we highlight that face mask perceptions and any associated interventions are not a 'one size fits all' approach, as people have varying justifications for not wearing face masks. for all studies, appendix s includes the associated datasets, and appendix s includes the complete reporting of methods, analyses, and results. study was conducted to generate items for the fmps using mechanical turk (mturk) on april . researchers have supported that results from mturk samples are reliable and valid when sufficient precautions are taken, and we followed prior guidelines for ensuring adequate data quality when using mturk (buhrmester et al., ; mellis & bickel, ; robinson et al., ) . for all studies, we restricted participants to only those with more than mturk assignment completions at a % approval rate or better. for studies and , we included multiple attention checks and utilized time-separate research designs. via these efforts, we believe that our analyses included only those providing appropriate survey responses. in study , two open-ended questions were administered to participants in return us$ . . the first question queried participants' personal perceptions regarding face masks, whereas the second question queried participants' public perceptions. the questions read as follows: 'face-masks are often recommended to reduce the spread of viruses, but many people don't wear face masks in public. in the box below, please list as many reasons as possible that [you/ people in general] do not wear a face mask when you go out in public. please write at least three reasons'. (bolded and underlined in original questions). the primary author thematically categorized and qualitatively analysed responses following recommendations for item generation and scale pretesting (devellis, ; howard, ; presser & blair, ) . thirteen categories were identified (table ) . to ensure that an adequate scope of face mask perceptions was assessed in the fmps while being reasonably concise, we developed items for categories with more than a % frequency in participants' qualitative responses for either personal or public perceptions. this resulted in the inclusion of eight categories: comfort, efficacy doubts, access, compensation, inconvenience, appearance, attention, and independence. because we intended to develop a concise measure (~ items), we initially developed six to eight items per category ( total) to be subsequently reduced to four items per category in the following study. these initial items were developed from participants' responses to ensure content relevance. all initial items can be seen in appendix s . in study , we subject our initial item list to exploratory factor analysis (efa) to support the eight-dimension factor structure and reduce the initial item list to a more concise measure. reducing the item list results in the fmps, and we then assess its construct validity. participants participants (n = , m age = . , sd age = . , % female, % western english-speaking countries) were recruited from mturk and were provided us$ . . we included nine attention checks and removed participants' responses if they failed any. all statistics, including the reported sample size above, reflect the sample after removing these participants' responses. participants enrolled into study via mturk on april . they provided their informed consent and completed the first survey online (time ). one day later, they were emailed and completed the second survey (time ). two days after the second survey, they were emailed and completed the third survey (time ). we analysed our item list via efa using the recommendations of prior authors (costello & osborne, ; fabrigar et al., ; howard, ) . we applied a principal axis factoring method with direct oblimin rotation, as we expected our factors to be correlated. our initial efa supported an eight-factor solution (appendix s ), but some items did not produce satisfactory results. we removed eight problematic items in a stepwise process, resulting in an intermediate list of items. while these items produced adequate psychometric properties, our intent was to develop a more concise measure. we continued removing items with the lowest primary factor loading in a stepwise manner until four items remained for each factor. our final factor structure can be found in appendix s . an eight-factor solution was again observed, and each item produced satisfactory factor loadings. we label these final items as the fmps (appendix a). we assessed the relation of the fmps with other relevant variables (table ) . three variables reflected face mask wearing. none of the eight dimensions significantly correlated to face mask wearing before the prior six months (p > . ), but six of the eight dimensions significantly correlated to face mask wearing within the prior six months as well as the course of the study (p < . ). the two dimensions that did not significantly relate to these two variables were comfort and attention. further, six variables reflected general health perceptions and behaviours. efficacy doubts had the strongest average correlation with each of these variables (average |r| = . , all p < . ). inconvenience (average |r| = . , all p < . ) and appearance (average |r| = . , all p < . ) also significantly correlated to each of these variables, whereas attention (average |r| = . , five p < . ) and independence (average |r| = . , five p < . ) significantly correlated to most. lastly, comfort (average |r| = . , four p < . ), access (average |r| = . , two p < . ) and compensation (average |r| = . , two p < . ) each had smaller and fewer significant relationships with these variables. together, most of the fmps dimensions significantly predicted recent face mask usage, but more variation was seen among the dimensions regarding their relation to general health perceptions and behaviours. we confirm the factor structure of the fmps via confirmatory factor analysis (cfa). participants participants (n = , m age = . , sd age = . , % female, % western english-speaking countries) were recruited from mturk and were provided us$ . . we included five attention checks and removed participants' responses if they failed any. all statistics, including the reported sample size above, reflect the sample after removing these participants' responses. participants enrolled into study via mturk on may , . they provided their informed consent and completed the first survey online (time ). one day later, they were emailed and completed the second survey (time ). at time , we measured age and gender. at time , we administered the fmps. we followed the recommendations of prior authors to perform our cfa (brown, ; harrington, ). although our eight face mask perception dimensions are measured via a single scale, we do not consider these dimensions to form a unitary construct. instead, we conceptualize these dimensions as independent perceptions, and therefore, we modelled these dimensions as eight covaried latent factorseach with four indicators. no second-order factors were included. initially, our model fit indices (cfi = . , ifi = . , rmsea = . , srmr = . , v / df = . ) fell short of recommended cut-offs (cfi ≥ . , ifi ≥ . , rmsea ≤ . , srmr ≤ . , v /df ≤ . ). five pairs of items had particularly strong modification indices (> ) and loaded onto the same factor. when analysing the content of these pairs, each was near synonyms. we then covaried the error terms of these item pairs because they each loaded on common factors and their association could be clearly justified, which is a process recommended by prior authors (brown, ; harrington, ). the revised model fit indices each met or closely approached recommended cut-offs (cfi = . , ifi = . , rmsea = . , srmr = . , v /df = . ). each item strongly loaded onto its respective latent factor (≥ . ), and full reporting of these factor loadings is included in appendix s . despite dramatic rises in coronavirus, those in western societies appear reluctant to wear face masks (bbc, a (bbc, , b . our goal was to develop the fmps to identify justifications for not wearing face masks. via a three-study process, we developed a measure with satisfactory psychometric and validity evidence. we supported an eightdimension structure via efa and cfa, showing that face mask perceptions are complex. people may have many justifications for not wearing face masks, which poses several implications for research and practice. most broadly, the current results can be situated within the com-b model to understand their association with behavioural change and relevant interventions (michie et al., ) . the com-b model synthesizes extant models of behavioural change and provides an organizing framework to identify and interlink behavioural sources, intervention functions, and policy categories. it identifies six behavioural sources, nine intervention functions, and seven policy categories. face mask perceptions are a type of reflective motivation source, which involves evaluation and cognition in developing behavioural attitudes; reflective motivation sources are most closely associated with the intervention functions of education, persuasion, incentivization, and coercion; and these intervention functions are associated with each of the policy categories except environmental/social planning. because several face mask perceptions significantly related to face mask wearing in the current study, future authors should utilize the com-b model to develop face mask interventions associated with education, persuasion, incentivization, and coercionthe relevant intervention functions to reflective motivation sources (and the fmps). in developing these interventions, researchers should integrate frameworks associated with reflective motivation sources and these four intervention functions (arden & chilcot, ; bish & michie, ; teasdale et al., ) . notably, bish, and michie ( ) systematically reviewed determinants of prevention behaviours during a pandemic in response to h n (swine flu). they discovered that predictors of protective behaviours differ based on whether the behaviour is preventive or avoidant, and they identified predictors of face mask wearing in the scope of preventive behaviours. these included demographic characteristics (gender, age, and marital status) and attitudes (perceived severity, perceived susceptibility, social pressure, and perceived efficacy)the latter being a reflective motivation source. only one of these antecedents, perceived efficacy, represents a perception identified in the current article, and thereby their model can be expanded by incorporating the other perceptions. also, face mask perceptions may serve as mediators between certain antecedents and face mask wearing, as many of their antecedents (e.g., demographics, social pressure) are known to influence perceptions (wilson et al., ) . identifying specific perceptions (and not others) as mediators may not only increase the sophistication of face mask research, but it would also identify which face mask perceptions may be susceptible to influences and useful to target via interventions. lastly, bish and michie ( ) showed that some antecedents predicted other preventative behaviours but not face mask wearing. this finding suggests that not all relations of preventative behaviours can generalize to face mask wearing, emphasizing the need to replicate results regarding one type of preventative behaviour across each of the other types of preventative behaviours. similar assertions could be made for teasdale et al.'s ( ) findings. these authors supported that, as predicted by protective motivation theory, threats and coping appraisals predict protective behaviours. their experimental manipulations of threat and coping appraisals included the intervention functions of education, persuasion, incentivization, and/or coercionaligning with the proposed associations of reflective motivation sources in the com-b model. future research could extend their findings to face masks by incorporating face mask perceptions as mediators of threats' and coping appraisals' effects on face mask wearing behaviours. additionally, interventions to encourage face mask wearing are not a 'one size fits all' approach. instead, researchers should consider specific perceptions in developing interventions, and the most common perceptions may not be the most important to target. while comfort, for example, was among the most common perceptions reported by participants, it did not have significant relationships with face mask wearing. other perceptions, such as efficacy concerns, may be more fruitful to address. furthermore, face mask perceptions may be associated with differing theoretical frameworks. for instance, the perception of efficacy doubts may be relevant to theory associated with message framing and even fake news (e.g., prospect theory, parallel response theory; effron & raj, ; gallagher & updegraff, ; murphy et al., ) , as perceptions regarding the efficacy of face masks may be largely developed via communicated information and misinformation. other face mask perceptions, such as comfort, may be less relevant to these theoretical approaches, as perceptions of comfort may be more developed through embodied experiences than communicated information. these differences emphasize the need for future researchers to apply multiple theoretical frameworks to understand face mask perceptions and behaviours. future research should also replicate the current results and address our limitations. although face mask perceptions likely differ between eastern and western populations, we did not perform any tests of measurement invariance (van de schoot et al., ) . the fmps may not be appropriate for use with eastern populations, and future research should assess this possibility. we also did not assess test-retest reliability, which would provide insights into the stability of face mask perceptions. likewise, we did not explore participant reactions to items via think-aloud methods to identify problematic wording and cognitive burdens (devellis, ; howard, ; presser & blair, ) , and such an assessment would provide insights into the ease (or difficulty) of completing the fmps. all authors declare no conflict of interest. health psychology and the coronavirus (covid- ) global pandemic: a call for research three kinds of psychological determinants for hand-washing behaviour in kenya coronavirus pandemic: tracking the global outbreak. bbc news coronavirus: why is there a us backlash to masks? bbc news demographic and attitudinal determinants of protective behaviours during a pandemic: a review more people say they're wearing masks to protect themselves from covid- since march confirmatory factor analysis for applied research an evaluation of amazon's mechanical turk, its rapid rise, and its effective use use of cloth face coverings to help slow the spread of covid- covid- control in china during mass population movements at new year. the lancet best practices in exploratory factor analysis: four recommendations for getting the most from your analysis scale development: theory and applications misinformation and morality: encountering fake-news headlines makes them seem less unethical to publish and share evaluating the use of exploratory factor analysis in psychological research face masks are in. the atlantic health message framing effects on attitudes, intentions, and behavior: a meta-analytic review confirmatory factor analysis a review of exploratory factor analysis decisions and overview of current practices: what we are doing and how can we improve? experimental pretesting of hand-washing interventions in a natural setting hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection does health coaching improve healthrelated quality of life and reduce hospital admissions in people with chronic obstructive pulmonary disease? a systematic review and meta-analysis mechanical turk data collection in addiction research: utility, concerns and best practices the behaviour change wheel: a new method for characterising and designing behaviour change interventions false memories for fake news during ireland's abortion referendum an investigation of the effects of a hand washing intervention on health outcomes and school absence using a randomised trial in indian urban communities health psychology: a textbook: a textbook survey pretesting: do different methods produce different results? tapped out or barely tapped? recommendations for how to harness the vast and largely unused potential of the mechanical turk participant pool the importance of coping appraisal in behavioural responses to pandemic flu a checklist for testing measurement invariance a novel coronavirus outbreak of global health concern compliance to health recommendations: a theoretical overview of message framing supporting information the following supporting information may be found in the online edition of the article: . i want to prove a point against authority. note when administering scale appendix s . all datasets for the current submission, but the submission manager would not allow.zip files to be uploaded.appendix s . complete reporting of studies , , and .appendix s . original, intermediate, and final face mask perception scale (fmps) items.appendix s . exploratory factor analysis results. face mask perceptions scale (fmps) please indicate the extent to which you disagree to agree with the following statements regarding face masks, which refers to cloth coverings worn on the face typically intended to prevent the spread of disease and illness. answer each of the following items as if they began with: when i do not wear a face mask in public, it is because. health safety perceptions . people should thoroughly wash their hands whenever they go out because of coronavirus. . people should stay six feed apart when out in public due to coronavirus. . people should limit their trips to the store because of coronavirus. . people should stay at home due to coronavirus. . people should not touch others (e.g., shake hands) due to coronavirus. . people should take extra safety precautions due to coronavirus. . it is a good idea to wear a face mask due to coronavirus. . it is a good idea to wear a face mask in general. . people should wear face masks in public. . wearing face masks should be more popular. key: cord- -hswyus authors: baehr, peter; gordon, daniel title: on the edge of solidarity: the burqa and public life date: - - journal: society doi: . /s - - - sha: doc_id: cord_uid: hswyus dislike among european publics for the islamic full veil and the desire to ban it are often ascribed to nativist "islamophobia." this article questions that assumption. it argues that, in political terms, the wearing of the burqa and niqab is inconsistent with western norms of equality, the backbone of the citizenship ideal; and that, in social terms, the full veil erects a partition to interpersonal understanding and reciprocity. while the constitutional duty to protect religious freedom is a good argument in favor of tolerating the full veil, the practice of wearing it is at the edge of solidarity and injurious to the democratic public sphere. a matter of simple ignorance, or, far worse, evidence of rampant islamophobia. the obvious remedy is not to ban the burqa and niqab (henceforth n/b) but to enlighten the ignorant. puncturing double standards is a good place to start. the american philosopher martha nussbaum puts it this way: it gets very cold in chicago-as, indeed, in many parts of europe. along the streets we walk, hats pulled down over ears and brows, scarves wound tightly around noses and mouths. no problem of either transparency or security is thought to exist, nor are we forbidden to enter public buildings so insulated. moreover, many beloved and trusted professionals cover their faces all year round: surgeons, dentists, (american) football players, skiers and skaters. what inspires fear and mistrust in europe, clearly, is not covering per se, but muslim covering. these analogies fail. pulling a scarf over one's mouth in the dead of winter is an expedient to deal with a temporary situation. once one is in the company of others inside a building, however, the scarf or hat is removed. the same is true for champion skiers or football players who are interviewed after their competition and who relish public attention. dentists and surgeons wear masks for reasons of hygiene that are deemed beneficial to professional and client alike. in contrast, the n/b is not a remedy for a particular occasion; it is a permanent social impediment in all four seasons. and far from having beneficial reciprocity in mind it is a stark expression of separateness. nussbaum's views are typical of those who believe that the full-face veil is not a problem in its own right. if the problem bears no rational relationship to the n/b itself, then it follows that the real problem is in the eye of the beholder. that is in good measure true, as we will show, but not for the reason nussbaum adduces: the fear that often goes by the name islamophobia. sociologists, of all people, should be skeptical of this question begging term. is durkheim forgotten? do we intend, in all seriousness, to explain social currents in terms of individual or aggregate phobias? doubtless, some people view the n/ b as an emblem of unwelcome immigration. doubtless, some people fear muslims for no good reason. but other peopleincluding some leaders of international human rights organizations; some leftist and green politicians; and some prominent muslim intellectuals-share none of these attributes yet still favor banning full veils. those who spoke in to the french national assembly's information committee on the burqa in favor of a ban included (anri ): -sihem habchi, the president of ni putes ni soumises (neither whores nor submissives, a feminist organization founded in ) -abdennour bidar, a philosopher and commentator on the koran -andré gerin, a member of the french communist party -patrick gaubert, the president of the ligue internationale contre le racisme et l'antisémitisme (international league against racism and antisemitism) nussbaum also believes, as many do, that n/b-wearing is at root a matter of conscience, a right that demands protection. but conscience cannot be assumed to be the universal motive or defense of covering. muslim women cover for many reasons: piety, pride, tradition, political ideology, and family pressure. oppositional excitement is another factor. as one of eva chi's tunisian subjects confided, "the forbidden is desirable, and the more the government controls the veil, the more it is tempting to challenge it" ( : ). besides, in many societies and sub-societies, failure to cover is a mode of deviance that can be and is severely punished. the same is true sometimes even in the west, where in the most dramatic cases facial exposure, the wearing of make up, and the dating of western boys has culminated in planned, orchestrated murder by the shamed family, so called "honor killing" (chesler (chesler , husseini ; wikan ) . one only has to observe women -muslim and infidel both-on international flights to tehran, kabul or karachi donning scarves on entry, and removing them on exit, to appreciate the full weight of customary expectations in covering practices. nussbaum, to be sure, deplores pressures on women to conform. she simply wishes that women who choose to veil be left alone to do so in peace and dignity. yet her sympathy towards traditional practices is one sided. privileging the conscience of the covered over established western norms places the whole burden of adaptation on to the host population. it shifts the requirement to respect tradition on to everyone but the n/b wearer. western conventions of clothing and salutation can be ignored as superficial or coercive. it also bears emphasis that post-colonial writers (nussbaum is not among them), who see the west as "an imaginary formation" (al-saji : ), fail to note a telling irony of their position: that the fiercest fighters for colonial liberation were adamant about the "uniqueness," "national originality," and "national vocation" of their own cultures. "cultural destruction" was an evil to be resisted. local traditions were at the heart of national identity. anti-colonial radicals, unlike their post-colonial successors, were no cultural relativists. this article seeks to identify features of n/b antipathy that polemics and special pleading routinely obscure. two dimensions are paramount. politically, n/b wearing is by western standards an uncitizenly posture that undermines the twin practices of civic equality and reciprocity. sociologically, n/b wearing impedes cross-cultural understanding, social interaction and, a fortiori, social solidarity beyond the domestic unit. together these political and sociological features suggest that the n/b, whatever the various intentions of its wearer-religious devotion, identity statement, life-style choice, generational revoltmarks a person as a political and social outsider within a western environment. three caveats preface the argument advanced below. first, our focus on the n/b is exclusively on its public appearance on the street, in public buildings such as schools, hospitals and offices, in parliaments and so forth. the garb is typically removed in domestic, familial settings. second, we say nothing of substance about the hijab (headscarf) or the iranian chador, both of which reveal the face without serious impediment. in france and belgium, the issue of the full veil has been formulated as a problem separate from the problem of the headscarf. speaking to the french national assembly (anri: ), the sociologist nilüfer göle, whose book the forbidden modern ( ) elicited sympathy for the headscarf, described the full veil contrastingly as "a regression or, at least, a very radical will to rupture with reciprocity and exchange." the third caveat is that our comments refer exclusively to n/b wearing in western societies where it is an unorthodox attire confronting folkways and sentiments different from those in, notably, the middle east. there, and in western enclaves where middle eastern people are in the majority, matters are entirely different; the n/b is an accustomed presence of everyday life. as such it mostly prompts no comment or curiosity. in its native milieu, full-face covering is acknowledged but little noticed, whereas discarding it would drastically increase the visibility of the woman who did so. vision, as we now turn to see, is influenced by powerful cultural traditions. citizenship in western democratic regimes is based on ideals of equality. whereas other spheres of life are particularistic, asymmetric or exclusive-the family of which one is a member, religious confession, how much money one makes, how good looking, clever, socially adept or athletic one is, and so forth-modern citizenship confers on adults in a political jurisdiction the same rights (for instance, to vote) and obligations (such as tax payment) irrespective of rank, class, gender, religion, ethnicity and family (weber [ (weber [ ] . to be sure, the prerequisites of citizenship in western societies are heterogeneous (brubaker ; caldwell : - ) . and it is evident that many people who reside in a country, such as immigrants, are not afforded full political protection and rights of participation. our concern in the present argument, however, is mainly with the norm of equality as a conceptual basis of citizenship. that this is an idealized picture of the modern constitutional polity need not detain us so long as the aspirational link between equality and democratic citizenship is accepted. idealization is, in any case, an important part of citizenship; it enables citizens to demand that states lives up to their ideals. more immediately pertinent is that citizenship equality is, in fundamental ways, integrally related in western traditions to citizens being visible to one another. this expectation is registered in theories of moral judgment (consider the role played by the "spectator" in adam smith and kant's theories of judgment) and in some of our most potent democratic terms and metaphors: enlightenment, openness, transparency, illumination, recognition, social legibility, accountability, "publicity" and, not least, public, to which we return in the next paragraph. the echo of biblical revelation and ancient greek thought in these notions is audible. for the eighteenth century philosophes, enlightenment substituted holy writ with "the great book of nature, open for all mankind to read." the heavenly city of the philosophes was a city of light surpassing in its rational luminosity even the splendor of the sun king (becker ([ ] : , - ) - ). negating these images are opacity, the dark ages, the dark arts, dark times, heart of darkness, artifice, living in the closet, a shadowy realm, a troglodyte world (paul fussell's depiction of world war i trench warfare), cavelike illusion, stygian gloom, moral blindness, the id, concealment, inscrutability, subterfuge, murkiness, obscurantism, and backroom deals-notions which imply various states of ignorance, menace and deceit. in sharp contrast, liberals trumpet the virtue of the open society and liberalized marxists idealize the translucent speech-situation. socialists and radicals extol debunking, the heir of rousseau's ([ rousseau's ([ ] crusade to remove the "deceitful veil of politeness" which conceals "fear, coldness, reserve, hate, and fraud". true, prominent french intellectuals of the last century sought to demote vision's status in the pantheon of sensibility (jay ) , while conservatives still remain attached to the "decent drapery of life" (burke [ (burke [ ] ). yet these perspectives have done little to impede the centrality of seeing within the western, apollonian political aesthetic. invented in the ancient greek world, the concept of "public" has assumed since its birth a host of connotations: common property and the common good; a realm in which free and equal men are able to deliberate on and decide political affairs; a place of discourse rather than labor; the primacy of law over arbitrary rule; a domain in which the ruler is considered to be a kind of custodian or guardian of the commonweal rather than a seigneur or lord; a region in which citizens may find distinction and glory; an area accessible to the many; a vehicle of composite opinion; a community pursuing a joint purpose (habermas [ (habermas [ ] oakeshott : , , .) each of these meanings has, in turn, taken on its own inflections; for instance, robert nisbet's ( : - ) distinction between public opinion ("the sturdy filter of long-shared values and traditions") and popular opinion (the transient froth of mood and fashion). of special relevance for our enquiry is that by the mid-sixteenth century, public added to its modern meanings the sense of activities and events that are "manifest and open to general observation" (sennett [ (sennett [ ] . in the public sphere, unlike domesticity, we demand to see what is going on, we expect honest dealing, disclosure; hiding is an affront to that stipulation. hannah arendt ( : - ) claimed that the word public evokes two "interrelated phenomena". first: everything that appears in public can be seen and heard by everybody and has the widest possible publicity. for us, appearance-something that is being seen and heard by others as well as by ourselvesconstitutes reality. compared with the reality which comes from being seen and heard, even the greatest forces of intimate life-the passions of the heart, the thoughts of the mind, the delights of the senses-lead an uncertain, shadowy kind of existence unless and until they are transformed, deprivatized and deindividualized, as it were, into a shape to fit them for public appearance…the presence of others who see what we see and hear what we hear assures us of the reality of the world and ourselves… the second referent of public is "the world itself, in so far as it is common to all of us and distinguished from our privately owned place in it." the world, in arendt's usage, comprises not the terrestrial globe or earth on which we stand and from which we derive our physical sustenance, but the sphere of created things that join and separate us, the sphere of human "affairs which go on among those who inhabit the man-made world together." this formulation suggests what is discordant about the n/ b's existence in the western political space. while for its bearer the n/b may be understood as a badge of tradition and piety, from the standpoint of a constitutional pluralist citizenry it is a mode of concealment incompatible with public recognition in which visibility of face is central. the n/b denudes facial and, to a degree, vocal recognition, debilities to which we shall return in a more sociological context later. it standardizes human features and hence contributes to the very stereotyping that n/b wearers themselves deplore. faces and voices are all different, evidence of human plurality. the n/b literally effaces these variations, with the partial exception of the eyes that may sometimes be seen. the n/b also symbolically ruptures the bond of citizenship reciprocity because while its wearer can see her real or potential interlocutor, can take advantage of the visibility of others, non-wearers are denied such access. the integral importance of reciprocity to "public reason" and, its corollary, deliberative democracy, is a leitmotif of john rawls's later work. rawls says that the role "of the criterion of reciprocity…is to specify the nature of the political relation in a constitutional democratic regime as one of civic friendship" (rawls : ) . in arendtian terms, n/b apparel is an obstruction to "appearance"-"something that is seen and heard by everybody and has the widest possible publicity." to this line of reasoning at least four objections can be anticipated. n/b-clad persons, it might be protested, do appear in public; they simply appear in a different way to those uncovered. that is true. indeed one might add that concealment of the face and other parts of the body is by no means the same as general inconspicuousness. on the contrary, in western societies the n/b wearer is more eyecatching than the non-wearer of it, more subject to the stare or, conversely, more prone to evoke the embarrassment that greets attire that is deemed bizarre or inappropriate. some (notably al-saji : ), sympathetic to veiling, claim that it is western attitudes themselves that are responsible for a bizarre combination of the seen and the unseen. hence "while the veil is hypervisible as an oppressive and repressive barrier [according to its critics], muslim women 'behind the veil' are not merely invisible to the western gaze, but are made invisible as subjects" by not being respected. yet uncitizenly comportment is not about appearance as such. it is about a precise type of appearance that, concealing the face, impedes mutual openness and repels interaction as equals. frantz fanon ([ fanon ([ ] , describing what he called the "phenomenology of encounters" between the colonized veiled woman and the colonist, amplifies the point: the woman who sees without being seen frustrates the colonizer. there is no reciprocity. she does not yield herself, does not give herself, does not offer herself. the algerian has an attitude toward the algerian woman which is on the whole clear. he does not see her. there is even a permanent intention not to perceive the feminine profile, not to pay attention to women… [in contrast, the] european faced with an algerian woman wants to see. fanon cheered on this lack of reciprocity, enjoying the aggravation it caused the powerful. the colonized woman seeks to frustrate the will of the colonial man. that is not our current situation. the colonial was an interloper, unwelcome in a foreign land, bending and breaking customs so that his will be done. today, in western societies, muslim citizens are afforded equal rights in law, which is to say they are accorded the same rights as non-muslims. yet one group still veils while another is visible. denial of reciprocity to occupiers of colonial societies is extended to citizens of post-colonial ones. a second objection to the argument that hiding the face is uncitizenly might run as follows. users of the internet are often obscured from view and no one assumes that their being invisible is uncitizenly. indeed, under some definitions of politics, the internet might be considered the quintessentially modern medium of political life: informing the public of political events, orchestrating voting, requesting or inciting people to participate in demonstrations, directing attention to abuses of rule, mobilizing citizens for collective action. search engines like google ever more assume traditional government functions. its engineers claim that the company's predictions of flu epidemics and employment trends are already more accurate than those of the centers for disease control and the bureau of labor statistics. better predictions of "crime, terrorism and political unrest" may be in the offing, prompting one journalist to predict in turn that the "line between google and government is destined to blur." even so, the political effectiveness of the internet, especially in comparison with face-to-face encounters, is more dubious, or at least more complex, than it first appears. to those who claim that digital networks act "as a massive positive supply shock to the cost and spread of information, to the ease and range of public speech by citizens, and to the speed and scale of group coordination" (shirky : ) , others reply with considerable skepticism. the above statement may be true, they say, but "weak ties" rarely lead to "high-risk activism." the latter entails not only personal contact and hard graft in actually building a movement but also organizational hierarchy, even in the most democratic initiatives. loose networks are no substitute for the "precision and discipline" afforded by such centralized groups as the naacp during the civil rights' struggles of the s and s. "facebook activism succeeds not by motivating people to make a real sacrifice but by motivating them to do the things that people do when they are not motivated enough to make a real sacrifice"-for instance, giving on average nine cents a piece to the facebook save darfur coalition (gladwell : - ) . this important debate is not, however, central to the n/b issues raised here and for a plain reason. in western societies the internet is an ancillary to public display not a substitute for it, a tool to expand communication, rather than an obstacle to constrict it. computer webcams are employed between interactants and in web chat rooms; interviews of foreign job applicants conducted via skype grow daily in popularity. and it is no coincidence that the world's most prominent social networking site is called facebook. moreover, where internet use takes place without face recognition (as with email or instant messaging) it typically does so reciprocally: both users are in the same position and hence issues of visibility imbalance and citizen asymmetry do not arise. a third objection to the claim that n/b attire in public places is uncitizenly turns the tables on the authors: it draws on the graeco-roman tradition itself, the origins of western notions of citizenship. in that tradition, being a public person was considered a kind of theatricality in which an agent adopts a persona, a mask. hobbes ([ ] : - ) , before noting that "persona in latine signifies the disguise, or outward appearance of a man, counterfeited on the stage; and sometimes more particularly that part of it, which disguiseth the face, as a mask or vizard," observed: a person, is he, whose words or actions are considered, either as his own, or as representing the words or actions of an other man, or of any other things to whom they are attributed, whether truly or by fiction. when they are considered as his owne, then he is called a naturall person. and when they are considered as representing the words and actions of an other, then he is a feigned or artificiall person (hobbes's emphasis) the persona was and is, however, a metaphorical mask, not one of cloth. in hobbes' political theory, it was a means of expanding modes of public representation whereas the n/ b is a symbol of religious belonging and, in french parlance, a claustral "folding in" (repli communautaire) or a "closing off" (enfermement) (bowen : . ). in antiquity, the function of persona was not to conceal public visibility but precisely to do the opposite: to shine the light of the polis on the political actor, to dramatize the fact that the individual had entered the public stage and that, as such, had left the private world of intimacy so as to consort freely with his peers and deliberate on political affairs. the political persona was, then, an addition to, or rather a rupture with, private life, not a replication or extension of it, a vehicle of distinction, not a mantle contrived to expunge from public view the unique personality of the woman beneath its folds. politics, in western traditions, entails a split within the being that engages in it, the construction of a second self: as an equal of others who are familial strangers bound together by the common tie of citizenship; a self able to cooperate with these strangers, to "see" things from multiple points of view and be seen seeing. more generally, the western political tradition is notable for its pronounced binary structure: oikos and polis, dominium and res publica, lordship and office, king and crown, natural persons and artificial persons christopher caldwell, "government by search engine," financial times, oct. , , http://www.ft.com/cms/s/ /a be dc-d - df- e - feabdc .html#axzz k hbrfpp arendt : - . (louglin : , , , - , - ) . superimposed on these bifurcations are other contrasts that impute to religion, and religious institutions, a separate sphere of engagement to that of the political: god and caesar, piety and justice, sacerdotium and regnum, church and state, soul and city, revelation and reason, sin and crime (scruton : - , , - ) . the nb, however, is not a fictive mask designed to open up its wearer to the public recognition of peers acting in concert or in conflict; it is a carapace projected into the public space, a material mask that signals exclusivity, an emblem of segmental occlusion, of what durkheim ([ durkheim ([ ] , discussing the primacy of resemblance in tribal societies, called the politico-familial. as a badge of similitude, the n/b smacks of mechanical solidarity. nor is the n/ b artificial or dualistic. on the contrary, it signifies sharia's total claim on the individual in all her activities, the type of claim that the public-private distinction expressly repudiates. it transpires that the classical concept of the mask and the n/b have nothing substantively in common. finally, it might be objected that our argument about the uncitizenly nature of the n/b rests on an unduly restrictive notion of citizenship. after all, the meaning and practice of citizenship has expanded greatly over the past two centuries. citizenship today involves social and cultural dimensions, not simply political and juridical ones. it straddles a wide array of contents, types, conditions and arrangements (susen ) . that being the case it is strained to place, as this article does, such a burden on the political idea of equality and reciprocity to the exclusion of all other citizenship elements. yet while a political community of equals, obligated to one another, is no longer a sufficient aspect of citizenship in the west, it is nonetheless a necessary aspect of it. moreover, an inflationary conception of citizenship is not without major problems or incongruities, as a number of theorists recognize. simon susen (op. cit.: ) , for instance, insists that the "extension of civil, political and social citizenship to a potentially infinite number of different forms …leads to the relativistic impoverishment" of "contemporary accounts of the political". for if any social group can claim citizenship on the basis of its own definition, the concept degenerates into a "mere identity game". richard bellamy ( : , - ) agrees. citizenship, he says, is ever more defined as a series of global human rights. and these putative rights are constantly growing. a survey conducted by the polling organization globescan for the bbc, on a population of , adults in countries, found that four in five respondents believe that internet access is a "fundamental right." the "absence of a political dimension," however, suggests a "somewhat second-rate account of what being a citizen involves". and why is that? because the "idea of a political community of equals … lies at the heart of citizenship." bellamy ( : ) also remarks that "citizenship involves a degree of solidarity and reciprocity between citizens" and that such citizens "need to see each other as equal partners within a collective enterprise." if that is true, the n/b is a negation of citizenship. disguising the face, and avoiding contact with the kafir, disables citizens from "seeing" each other as free and equal partners. we have been discussing the ways in which n/b effacement breeches norms of political equality and reciprocity, the backbone of the citizenship ideal. n/b wearing is further accompanied by a social impairment: the partition it erects to interpersonal understanding and solidarity. making sense of the conduct of others in face-to-face, real-time encounters requires us to pay attention to more than disembodied words. unlike reading a book, which is a cognitive, reflective endeavor, albeit informed by past experience and learned competences, inter-personal understanding draws on immediate, spontaneous and practical aspects of the interaction-situation itself. these aspects are both cognitive and somatic: emotional signals emitted by the face, the voice, and the body in general. as erving goffman ( : - ) remarks, "bodily idiom … is a conventionalized discourse. we must see that it is, in addition, a normative one." he adds ([ ] : ) : during direct personal contacts…unique informational conditions prevail and the significance of face becomes especially clear. the human tendency to use signs and symbols means that evidence of social worth and of mutual evaluations will be conveyed by very minor things, and these things will be witnessed, as will the fact that they have been witnessed. an unguarded glance, a momentary change in tone of voice, an ecological position taken or not taken, can drench a talk with judgmental significance. humans in their social transactions, goffman reminds us, are constantly engaged in "face work," a semiotic traffic in which proper deference is given and where the appropriate demeanor is supposed to be maintained. "good" demeanor "is what is required of an actor if he is to be transformed into someone who can be relied upon to maintain himself as an interactant, poised for communication and to act so that others do not endanger themselves by presenting themselves as interactants to him" (ibid: ). probably the single most important sign-vehicle that humans possess, the chief corporeal building block of solidarity in situational encounters, is the face. people who look away when we are talking to them, scanning the perimeter, are apparently preoccupied with other matters; they are indicating a kind of inattentiveness that, in our culture, translates to distraction or rudeness. our response to their alienation is alienation of our own. more generally, signals of emotions-such as sadness, anger, surprise, fear, disgust, contempt, and happiness-have facial correlates that convey various kinds of information about their bearer. what makes people angry, for instance, differs to some degree among persons and cultures; but the looks of anger are universal, and spontaneously understood, part of our evolutionary hard wiring and manifested in muscular movements that differ both in intensity (ranging from irritation to fury) and type (sullen anger, resentful anger, indignant anger and cold anger) (ekman : ) . even when we seek to manage or hide our emotions, it is common for them to leak out through facial signs, bodily gestures and tone, volume and pitch of voice. accordingly people who look at us can, with a fair bit of reliability, tell how we are feeling unless we suppress our expressions (ibid: - ) or hide them as the n/b does. (botox and other similar treatments, by giving the face a stony and shiny appearance, also reduce expressive capacity and viewer reception.) even if we can see the eyes of the facially covered, as with the niqab, we may not be able to see the frame that gives their glance meaning: the forehead, the eyebrows, the mouth and the cheeks that, in various combinations of muscular movement or fixity, impart emotional information to the viewer. when people have difficulty understanding one another, this does not mean that fellow feeling between them is impossible. non-muslims, or the habitually uncovered in any society, are likely to feel sympathy for the woman in a crowded airport whose outfit must, in many circumstances, make her hotter, more confined and generally more uncomfortable than she would otherwise be divested of a niqab. or so we are inclined to think. the truth is that we do not know for sure and, out of a sense of propriety, would not wish to enquire. adam smith notes that much of our sympathy for others is not an accurate reflection of how they feel but how we imagine we would feel if we shared their situation. to illustrate this point, he ([ ] : - ) gives a consoling example: we sympathize even with the dead, and overlooking what is of real importance in their situation, that awful futurity which awaits them, we are chiefly affected by those circumstances which strike our senses, but can have no influence on their happiness. it is miserable, we think, to be deprived of the light of the sun; to be shut out of life and conversation; to be laid in the cold grave, a prey to corruption and the reptiles of the earth; to be no more thought of in this world, but to be obliterated, in a little time, from the affections, and almost from the memory, of their dearest friends and relations…. the happiness of the dead, however, most assuredly, is affected by none of these circumstances; nor is the thought of these things which can never disturb the profound security of their repose. time and again, smith reminds us that moral imagination is mediated by vision: seeing, gazing, looking on, looking upon, (his words) objects that, thereby, excites us to feel compassion, revulsion and a host of other emotions. the connection, he says, between the way we feel about a person's plight, and that person's situation, is our witnessing the former, and our "foresight" (again smith's term) into the implications of the latter. it follows that our ability to judge with confidence a person's situation is greatly limited if our seeing, gazing, looking on and looking upon, let alone our foresight, is obstructed. whether georg simmel recalled smith's comments on this matter is unknown. but he offers an intriguing gloss on them in the remark that of "the special sense-organs the eye has a uniquely sociological function. the union and interaction of individuals is based upon mutual glances. this is perhaps the most direct and purest reciprocity which exists anywhere." to return to our example of the n/b clad woman in the crowded airport: sympathy may turn to pity and indignation on her behalf if we believe that her dress is a sign of oppression. or we may feel incredulity and confusion. when people "turn off" their emotional lights, they appear blank and lifeless. covering the face turns off emotional lights in the most direct and comprehensive way imaginable. its consequences for fellow feeling and the interaction it enables in western societies are significant. to understand with greater precision why this is so, it is useful to identify three kinds of attachment among strangers: political solidarity, social sympathy, and social solidarity. these modes are ideal-types that in reality are intermingled to a greater or lesser extent. the point of sketching them is to discern whether, and to what extent, they can be extended to sartorially sequestered persons. political solidarity is an action or series of actions derived from an obligation: the duty, as we believe it to be, to support those who share similar political or quasi-political values to our own. socialists are happy to stand by other socialists who are embattled, whereas they are happy to see an abundance of liberals and conservatives in total disarray; and vice versa. political solidarity is hence a union of like with like and it is confined to that likeness. we feel political solidarity for groups to the extent they embody beliefs that we consider vital-say, of fairness or dignity-or because their predicament reveals dangers to which we could ourselves one day be exposed. people committed to constitutional pluralism, for instance, believe that all non-violent groups of citizens that obey the law are entitled to rights of participation. when british and west european trade unionists supported the polish trade union and political organization solidarity, during the s, they did so out of the conviction that workers should support one another when oppressed by the state (or employers). while political solidarity is limited to like supporting like, confined to helping people as citizens or protocitizens of a certain persuasion (e.g. liberals not fascists, political prisoners not political jailors, workers not employers), social sympathy is potentially boundless and, where it is not simply emotional, rests on the altruistic principle of assisting individuals as fellow human beings, irrespective of their political and other views. social sympathy is boundless because the suffering that prompts it is endless. and unlike political solidarity, social sympathy is deaf to political antagonisms, credentials and alliances. social sympathy is especially sensitive to individuals rather than groups; and the individuals for whom sympathy tends to be strongest are children. while political solidarity is principally a matter of adult responsibilities, nothing is more likely to trigger social sympathy than the sight of a bedraggled orphan, a crying stray, an emaciated child, or a young face ravaged by the horror of war. it is for good reason that humanitarian aid agencies use such images as their prime advertising tool. social sympathy, often shading into pity, is more affective, more immediate, less detached and less conceptual than political solidarity (arendt : - ) . and while political solidarity flags a boundary or marker of exclusion (not everyone is our ally but only those who share our convictions), social sympathy is infinitely extendable. the sense of justice that inspires social sympathy is based not on the requirements of political similarity but on the fulfillment of personal charity, common decency and elite philanthropy. those to whom we tender political solidarity are comrades and political equals, real or imaginary; those who provoke social sympathy are the abandoned with whom we have nothing in common aside from our humanity. neither political solidarity nor social sympathy requires physical proximity. nor do they require symmetry and reciprocity. a and b may strike up an alliance to assist one another, generating a vitality that neither party possesses by itself. just as often, however, the solidarity afforded by a to b is never reciprocated by b (south african trade unions under apartheid; political prisoners in china and cuba) because a, being safe and secure, has no need of reciprocation, and because b lacks the resources ever to "repay". similarly, the gifts of social sympathy are unlikely ever to occasion gifts in return because their recipients are simply too poor, too powerless and too geographically distant to give anything back. the weak are neither expected nor in a position to shore up the strong. in sharp contrast, social solidarity derives principally from face-to-face encounters and it requires reciprocity and mutual respect for its very existence. sociology still teaches introductory students to think of social solidarity as the socialization of norms and values that, where successful, permeate the reflexes of human beings, coordinating their behavior, and committing them to common moral standards. or solidarity is said to arise from increasing differentiation, the modern division of labor, whereby we become dependent on a manifold of people and services that provide conditions of our existence that we are incapable of providing for ourselves. these textbook descriptions are not so much wrong as imprecisely stated or at least stated in such a way as to mean something different from social solidarity as the term is used here. drawing on the durkheimian model, we can say that social solidarity is a mode of cohesion based on mutual recognition of worth and classificatory congruence. in turn, these properties emerge out of situations of a special type, namely those that enact interaction rituals in natural settings. these rituals, more often spontaneously slipped into than deliberately choreographed, are ever present in social relations and help create a common mood centered on common foci of attention. the more intense the attention, the more concentrated the intersubjective awareness of the ritual participants of their common bond; as awareness increases, so too, does the entrainment of the actors as they fall into a common rhythm of interactions, and share the "emotional energy" they generate (durkheim [ (durkheim [ ] and especially collins ) . human rituals require co-presence. they may span the smallest encounter between two people-a greeting at the office, a joking relationship with a colleague, a marriage proposal-or larger units such as a sports event or a political demonstration; during a major crisis, a whole city may briefly be caught up in the same set of rituals. in each case, those in contact with one another expect, and themselves cultivate, a demeanor of respect for the situation and its participants so as to allow the interaction to proceed smoothly. and ubiquitously, interaction rituals take place within boundaries of recognition that delineate outsiders in the very act of soliciting the chosen few and affirming their status. those boundaries are marked by totems such as wedding rings, flags, holy buildings, songs, coins, slogans and other representations of exclusiveness that remind ritual interactants of past deeds and past promises and arouse commitments to the interactant unit. despoilment of these totems, or betrayals of the rituals of group intimacy they signify, cause anger and aggression. as a local event, a bounded interaction among subjects who give each other face and by so doing find unity in their social commerce, social solidarity is thus also the occasion of conflict between those granted respect and those denied it, between those in the "pocket of solidarity," and those outside it, between those allowed access to the enclave of valued transactions and those denied admittance as pariahs or inferiors . in this context, one sees the difficulty of social solidarity emerging spontaneously for and with n/b clad women. if is true that "eye-to-eye looks…play a special role in the communication life of the community, ritually establishing an avowed openness to verbal statements" (goffman : ) , then it is also true that n/b, as a materialized collective representation, is an avowal of closure to familial strangers, a sharp boundary. the covered woman's eyes may well be visible, but covering itself is a disincentive towards meeting the eyes; a glance must be especially furtive if is not to push "civil inattention" too far and become offensive. in goffman's ( : , - ) lexicon, the n/b is an "involvement shield." as with all such shields, the result is a dilution of both "richness of information flow" and "facilitation of feedback" (ibid: ). more generally, the inability to see potential interlocutors is a major impediment to drawing "emotional energy" from them. the sociological irony is that a garb that signifies the danger of contamination-the male gaze-may itself be deemed dangerous by strangers because it represents tribal notions of exclusiveness as contrasted to pluralist notions of far-flung reciprocity. along these lines, stefaan van hecke, a member of the belgian ecolo-green! party, stated in the chamber of deputies that his party had supported the headscarf but that the burqa "goes too far in our eyes" because it is "a wall that permits no communication." he was immediately supported by georges dallemagne of the democratic humanist center party. "it [the burqa] represents to us a rupture with the fundamental principle of our society which holds that communication, even of a minimal kind, among the members of society implies the possibility of seeing the face of the other" (crb : - ). notice, however, that it is not public covering as such that creates alienation; it is the meaning that the covering conveys, together with its permanence. cities that experience particularly dangerous epidemic diseases such as the sars outbreak in hong kong in witnessed omnipresent mask wearing. but "efface work" (baehr : - ) in the hong kong case shows that while mask wearing was a signal of repulsion ("don't get too close to me") it acted also as a signal of common courtesy: less a prophylactic against catching the virus than a symbol of deference for the sensibilities of others, expressing the desire not to infect them. in this case distance served the purpose of reciprocity; it was a demeanor that flagged respect. mask wearing in these conditions was temporary; it was a response to crisis. it was also ubiquitous, rather than being exclusive to one group. when sars retreated, the masks were discarded. the n/b is entirely different. it is a permanent marker of a separation deemed normal. it is not irrational for muslims to wear the n/b where it is appropriate for a certain kind of life. nor is it irrational for such covering to provoke indignation in another ritual order with diverging norms of appropriateness. however, "diversity" consciousness-the idealization of multiculturalismfinds such legitimate and rational incommensurability hard to handle. if two ritual orders are in collision, one of them must be phobic. we know which one that is. this article's exploration of the n/b's appearance in the west is limited in many obvious ways. it represents neither the experiences of covered women in western lands nor offers an ethnography of covering practices and native responses to them-for instance, videotaped behavior of people in supermarkets, airports and streets. both tasks are valuable; the latter, in particular, would be able to test, qualify and refute some of the claims made above. equally this article offers no divination of public opinion polls (the pew survey referenced at the beginning of this article did not ask people why they support a burqa ban), nor does it argue on the basis of survey data or interviews conducted by the authors. we offer something else: an enquiry into the political and social frameworks that, even in the absence of hatefulness and prejudice towards muslims, make the n/b profoundly dissonant with western traditions. these traditions are no less weighty by being historically "constructed". they are the real frameworks, or shards of frameworks, within which people make sense of the world. as we have stressed, our principal concern is with what the n/b controversy reveals about western structures of thought and feeling rather than what is says about muslim women. another limitation of the foregoing is that it offers no definite public policy advice to governments regarding prohibition, no attempt at adjudication to parties involved in the dispute. this is not a debate on which a sociologist can deliver authoritative judgment. it is a matter of political argument, moral choice and, almost inevitably, conflict. nor can sociologists ignore legal traditions that play a major role in defining the rationality or irrationality of a ban. for french ultra-secularists, banning the n/b makes sense in we are also unlikely to extend political solidarity to those whose idea of politics is so very different from our own. we are just as unlikely to feel social sympathy for people who are happy to be as they are, if they are indeed happy, or who do not request our aid. light of france's republican tradition and civil religion. it also makes sense given france's tradition of regarding the public space as a controlled sphere in which egalitarian mannerisms and citizenly gestures are not merely a polite choice but a civic duty, a necessity, backed in constitutional law by the doctrine of "public order" (gordon : , - , note ; baehr and gordon ; anri : - ) . for most americans, by contrast, prohibition is largely unthinkable because a) it contradicts the first amendment of the constitution protecting "the free exercise" of religion; b) americans fear government regulation more than they do cultural diversity; and c) the american idea of "religion" is more generic and inclusive than that of the french. americans rush, in cross-religious solidarity, to faiths that are embattled, believing that infringement on the liberty of one confession is potentially a threat to them all (gordon : - ) . both the structure of american jurisprudence and american popular culture work against a burqa ban. logic and universal morality (moralität), on which philosophers and theologians pronounce, is different from situated ethicality (sittlichkeit) with which historians and sociologists are concerned. underpinning that ethicality are legal systems and popular conceptions of constitutional freedom. if the burqa controversy reveals more about what is important to western traditions than it does about muslim women, it also raises vital questions. these are questions about the rights of groups to organize their own collective life; questions about the responsibilities of the state to protect individuals within groups who are oppressed by them; questions about the indispensable nature of basic forms of citizenly, face-to-face comportment in a democracy; and questions about whether the state can legitimately require citizens to be communicative and reciprocal with each other, or whether the minima of transparency are a matter of choice. the burqa is at the edge of solidarity. it may be deemed a symbolic harm to democracy, or as a basic civil right. but the burqa controversy is certainly more than an expression of islamophobia. it is a predicament requiring us to articulate our democratic conceptions with uncustomary precision. and no matter which policy we choose, to ban or not to ban, it requires us to recognize the antimonies of democratic existence, and to sacrifice some goods for the sake of protecting others. the racialization of muslim veils: a philosophical analysis rapport d'information au nom de la mission d'information sur la pratique du port du voile integral sur le territoire nationale the human condition on revolution reflections on little rock from the headscarf to the burqa: the role of social theorists in shaping laws against the veil caesarism, charisma and fate: historical sources and modern resonances in the work of max weber the heavenly city of the eighteenth-century philosophers citizenship. a very short introduction why the french don't like headscarves. islam, the state and public space citizenship and nationhood in france and germany reflections on the revolution in france. indianapolis: liberty fund reflections on the revolution in europe. immigration, islam, and the west are honor killings simply domestic violence worldwide trends in honor killings persistent orientalism and burdened souls: a critical reading of the hijab debate through the case of la rochefoucauld and the language of unmasking in seventeenth-century france compte rendu intégrale séance plénière th session, nd legislature, plenary session how institutions think ) . the division of labor in society. translated by w.d. halls, with an introduction by lewis a. coser elementary forms of religious life. translated with an introduction by emotions revealed explaining social behavior algeria unveiled tear off the masks! identity and imposture in twentieth-century russia the great war and modern memory small change interaction ritual. essays on face-to-face behavior behavior in public places. notes on the social organization of gatherings the forbidden modern: civilization and veiling why is there no headscarf affair in the united states? historical reflections the stuctural transformation of the public sphere. an inquiry into a category of bourgeois society. translated by thomas burger with the assistance of frederick lawrence ) . the philosophy of right. translated by alan white the veil in their minds and on our heads: veiling practices and muslim women murder in the name of honor downcast eyes: the denigration of vision in twentieth-century french thought new tech, new ties. how mobile communication is reshaping social cohesion the idea of public law accommodating protest: working women, the new veiling and change in cairo phenomenology of perception. translated by beyond the veil. male-female dynamics in modern muslim society the veil and the male elite on the political prejudices. a philosophical dictionary beyond the veil: a response on human conduct niqab and burqas -the veiled threat continues the law of peoples the social contract pluralism and the personality of the state political hypocrisy. the mask of power from hobbes to orwell and beyond translated with an introduction by george schwab, foreword by tracy b. strong and notes by leo strauss the politics of the veil the west and the rest. globalization and the terrorist threat the fall of public man from innovation to revolution ) . the theory of moral sentiments transparency and obstruction. translated by arthur goldhammer, with an introduction by montaigne in motion. translated by arthur goldhammer the transformation of citizenship in complex societies suffrage and democracy in america behind the veil in arabia honor of fadime. murder and shame. translated by anna paterson peter baehr is an international editor of society and professor of social theory at lingnan university, hong kong daniel gordon is professor of history and associate dean of the commonwealth honors college at the university of massachusetts amherst. he is also co-editor of the journal historical reflections key: cord- -qwxyuuz authors: chavda, amit; dsouza, jason; badgujar, sumeet; damani, ankit title: multi-stage cnn architecture for face mask detection date: - - journal: nan doi: nan sha: doc_id: cord_uid: qwxyuuz the end of witnessed the outbreak of coronavirus disease (covid- ), which has continued to be the cause of plight for millions of lives and businesses even in . as the world recovers from the pandemic and plans to return to a state of normalcy, there is a wave of anxiety among all individuals, especially those who intend to resume in-person activity. studies have proved that wearing a face mask significantly reduces the risk of viral transmission as well as provides a sense of protection. however, it is not feasible to manually track the implementation of this policy. technology holds the key here. we introduce a deep learning based system that can detect instances where face masks are not used properly. our system consists of a dual-stage convolutional neural network (cnn) architecture capable of detecting masked and unmasked faces and can be integrated with pre-installed cctv cameras. this will help track safety violations, promote the use of face masks, and ensure a safe working environment. rapid advancements in the fields of science and technology have led us to a stage where we are capable of achieving feats that seemed improbable a few decades ago. technologies in fields like machine learning and artificial intelligence have made our lives easier and provide solutions to several complex problems in various areas. modern computer vision algorithms are approaching human-level performance in visual perception tasks. from image classification to video analytics, computer vision has proven to be a revolutionary aspect of modern technology. in a world battling against the novel coronavirus disease (covid- ) pandemic, technology has been a lifesaver. with the aid of technology, 'work from home' has substituted our normal work routines and has become a part of our daily lives. however, for some sectors, it is impossible to adapt to this new norm. as the pandemic slowly settles and such sectors become eager to resume in-person work, individuals are still skeptical of getting back to the office. % of employees are now anxious about returning to the office (woods, ) . multiple studies have shown that the use of face masks reduces the risk of viral transmission as well as provides a sense of protection (howard et al., ; verma et al., ) . however, it is infeasible to manually enforce such a policy on large premises and track any violations. computer vision provides a better alternative to this. using a combination of image classification, object detection, object tracking, and video analysis, we developed a robust system that can detect the presence and absence of face masks in images as well as videos. in this paper, we propose a two-stage cnn architecture, where the first stage detects human faces, while the second stage uses a lightweight image classifier to classify the faces detected in the first stage as either 'mask' or 'no mask' faces and draws bounding boxes around them along with the detected class name. this algorithm was further extended to videos as well. the detected faces are then tracked between frames using an object tracking algorithm, which makes the detections robust to the noise due to motion blur. this system can then be integrated with an image or video capturing device like a cctv camera, to track safety violations, promote the use of face masks, and ensure a safe working environment. the problem of detecting multiple masked and unmasked faces in images can be solved by a traditional object detection model. the process of object detection mainly involves localizing the objects in images and classifying them (in case of multiple objects). traditional algorithms like haar cascade (viola and jones, ) and hog (dalal and triggs, ) have proved to be effective for such tasks, but these algorithms are heavily based on feature engineering. in the era of deep learning, it is possible to train neural networks that outperform these algorithms, and do not need any extra feature engineering. convolutional neural networks (cnns) (lecun et al., ) is a key aspect in modern computer vision tasks like pattern object detection, image classification, pattern recognition tasks, etc. a cnn uses convolution kernels to convolve with the original images or feature maps to extract higher-level features, thus resulting in a very powerful tool for computer vision tasks. cnn based object detection algorithms can be classified into categories: multi-stage detectors and single-stage detectors. multi-stage detectors: in a multi-stage detector, the process of detection is split into multiple steps. a two-stage detector like rcnn (girshick et al., ) first estimates and proposes a set of regions of interest using selective search. the cnn feature vectors are then extracted from each region independently. multiple algorithms based on regional proposal network like fast rcnn (girshick, ) and faster rcnn (ren et al., ) have achieved higher accuracy and better results than most single stage detectors. single-stage detectors: a single-stage detector performs detections in one step, directly over a dense sampling of possible locations. these algorithms skip the region proposal stage used in multi-stage detectors and are thus considered to be generally faster, at the cost of some loss of accuracy. one of the most popular single-stage algorithms, you only look once (yolo) (redmon et al., ) , was introduced in and achieved close to real-time performance. single shot detector (ssd) (liu et al., ) is another popular algorithm used for object detection, which gives excellent results. retinanet (lin et al., b) , one of the best detectors, is based on feature pyramid networks (lin et al., a) , and uses focal loss. as the world began implementing precautionary measures against the coronavirus, numerous implementations of face mask detection systems came forth. (ejaz et al., ) have performed facial recognition on masked and unmasked faces using principal component analysis (pca). however, the recognition accuracy drops to less than % when the recognized face is masked. (qin and li, ) introduced a method to identify face mask wearing conditions. they divided the facemask wearing conditions into three categories: correct face mask wearing, incorrect face mask wearing, and no face mask wearing. their system takes an image, detects and crops faces, and then uses srcnet (dong et al., ) to perform image super-resolution and classify them. the work by (nieto-rodríguez et al., ) presented a method that detects the presence or absence of a medical mask. the primary objective of this approach was to trigger an alert only for medical staff who do not wear a surgical mask, by minimizing as many false-positive face detections as possible, without missing any medical mask detections. (loey et al., ) proposed a model that consists of two components. the first component performs uses resnet (he et al., ) for feature extraction. the next component is a facemask classifier, based on an ensemble of classical machine learning algorithms. the authors evaluated their system and estimated that deep transfer learning approaches would achieve better results since the building, comparing, and selecting the best model among a set of classical machine learning models is a timeconsuming process. we propose a two-stage architecture for detecting masked and unmasked faces and localizing them. (larxel, ) ). it consists of two major stages. the first stage of our architecture includes a face detector, which localizes multiple faces in images of varying sizes and detects faces even in overlapping scenarios. the detected faces (regions of interest) extracted from this stage are then batched together and passed to the second stage of our architecture, which is a cnn based face mask classifier. the results from the second stage are decoded and the final output is the image with all the faces in the image correctly detected and classified as either masked or unmasked faces. a face detector acts as the first stage of our system. a raw rgb image is passed as the input to this stage. the face detector extracts and outputs all the faces detected in the image with their bounding box coordinates. the process of detecting faces accurately is very important for our architecture. training a highly accurate face detector needs a lot of labeled data, time, and compute resources. for these reasons, we selected a pre-trained model trained on a large dataset for easy generalization and stability in detection. three different pre-trained models were tested for this stage: dlib (sharma et al., ) -the dlib deep learning face detector offers significantly better performance than its precursor, the dlib hog based face detector. mtcnn (zhang, k. et al, ) -it uses a cascade architecture with three stages of cnn for detecting and localizing faces and facial keypoints. retinaface (deng et al., ) -it is a singlestage design with pixel-wise localization that uses a multi-task learning strategy to simultaneously predict face box, face score, and facial keypoints. the detection process is challenging for the model used in this stage, as it needs to detect human faces that could also be covered with masks. we selected retinaface as our stage model, based on our experimentation and comparative analysis, covered in section . . this block carries out the processing of the detected faces and batches them together for classification, which is carried out by stage . the detector from stage outputs the bounding boxes for the faces. stage requires the entire head of the person to accurately classify the faces as masked or unmasked. the first step involves expanding the bounding boxes in height and width by %, which covers the required region of interest (roi) with minimal overlap with other faces in most situations. the second step involves cropping out the expanded bounding boxes from the image to extract the roi for each detected face. the extracted faces are resized and normalized as required by stage . furthermore, all the faces are batched together for batch inference. the second stage of our system is a face mask classifier. this stage takes the processed roi from the intermediate processing block and classifies it as either mask or no mask. a cnn based classifier for this stage was trained, based on three different image classification models: mobilenetv (sandler et al., ) , densenet (huang et al., ) , nasnet (zoph et al., ) . these models have a lightweight architecture that offers high performance with low latency, which is suitable for video analysis. the output of this stage is an image (or video frame) with localized faces, classified as masked or unmasked. the three face mask classifier models were trained on our dataset. the dataset images for masked and unmasked faces were collected from image datasets available in the public domain, along with some data scraped from the internet. masked images were obtained from the real-world masked face recognition dataset (rmfrd) (wang, z. et al., ) and face mask detection dataset by larxel on kaggle (larxel, ) . rmfrd images were biased towards asian faces. thus, masked images from the larxel (kaggle) were added to the dataset to eliminate this bias. rmfrd contains images for unmasked faces as well. however, as mentioned before, they were heavily biased towards asian faces. hence, we decided not to use these images. the flickr-faces-hq (ffhq) dataset introduced by (karras et al., ) was used for unmasked images. our dataset also includes images of improperly worn face masks or hands covering the face, which get classified as nonmasked faces. the collected raw data was passed through stage (face detector) and the intermediate processing block of the architecture. this process was carried out to ensure that the distribution and nature of training data for stage match the expected input for stage during the final deployment. the final dataset has images, divided into two classes: we selected an initial learning rate of . . besides this, the training process included checkpointing the weights for best loss, reducing the learning rate on plateau, and early stopping. each model was trained for epochs and the weights from the epoch with the lowest validation loss were selected. based on a comparative analysis of performance, covered in sections . and . , the weights trained using the nasnetmobile architecture were chosen as our final trained weights. (all images used in section are either selfobtained or belong to the dataset by (larxel, ) ) table shows that densenet has the best f -score. however, the other models are not significantly behind. thus, there was a need to measure other aspects of performance comparison like inference speed and model size, to select the final face mask classifier model. we tested three pre-trained models for face detection in stage : dlib dnn, mtcnn, retinaface. the average inference times for each of the models were calculated, based on a set of masked and unmasked images. as observed in table , the retinaface model performs the best. it was observed that all three models show good results on images taken from a very short distance, having no more than two people in the image. however, it was noticed that as the number of people in the images increases, the performance of dlib becomes subpar. dlib also struggles to detect masked or covered faces. fig. (a) . dlib good detection on normal faces fig. (b) . dlib poor detection on faces covered by face masks mtcnn and retinaface perform better than dlib and can detect multiple faces in images. both of them can detect masked or covered faces as well. mtcnn has very high accuracy when detecting faces from the front view, but its accuracy heavily drops when detecting faces from the side view. fig. (a) . mtcnn good detection on covered faces on the other hand, retinaface can detect side view faces with good accuracy as well. compared to mtcnn, retinaface significantly decreases the failure rate from . % to . % (the nme threshold at %) (deng et al., , page ). fig. (a) . retinaface good detection on covered faces fig. (b) . therefore, we decided to use retinaface as our face detector for stage . nasnetmobile and densenet give better results than mobilenetv and are almost on par with each other. from the observations in table , it is evident that nasnet performs much faster than densenet . furthermore, the model size of nasnet is lighter than densenet (due to a lesser number of parameters). this leads to faster loading of the model during inference. due to these factors, nasnetmobile is much more suited for real-time applications as compared to densenet . therefore, nasnetmobile was selected as our final model for the face mask classifier. combining all the components of our architecture, we thus get a highly accurate and robust face mask detection system. retinaface was selected as our face detector in stage , while the nasnetmobile based model was selected as our face mask classifier in stage . the resultant system exhibits high performance and has the capability to detect face masks in images with multiple faces over a wide range of angles. until now, we have seen that our system shows high performance over images, overcoming most of the issues commonly faced in object detection in images. for realworld scenarios, it is beneficial to extend such a detection system to work over video feeds as well. videos have their own set of challenges like motion blur, dynamic focus, transitioning between frames, etc. in order to ensure that the detections remain stable and to avoid jitter between frames, we used the process of object tracking. we used a modified version of centroid tracking, inspired by (nascimento et al., ) , in order to track the detected faces between consecutive frames. this makes our detection algorithm robust to the noise and the motion blur in video streams, where the algorithm could fail to detect some objects. the detected face rois in a given frame are tracked over a predefined number of frames so that the roi coordinates for the faces are stored even if the detector fails to detect the object during the transition between frames. we selected five frames as the threshold in fps video streams for discarding the cached centroids, which gave good results with the least false positive face detections in video streams. after using this method, there was a significant improvement in face mask detection in video streams. the following results show the difference in detection with and without centroid tracking: tracking was added to our algorithm, which helped improve its performance on video streams. in times of the covid- pandemic, with the world looking to return to normalcy and people resuming in-person work, this system can be easily deployed for automated monitoring of the use of face masks at workplaces, which will help make them safer. there are a number of aspects we plan to work on shortly:  currently, the model gives fps inference speed on a cpu. in the future, we plan to improve this up to fps, making our solution deployable for cctv cameras, without the need of a gpu.  the use of machine learning in the field of mobile deployment is rising rapidly. hence, we plan to port our models to their respective tensorflow lite versions.  our architecture can be made compatible with tensorflow runtime (tfrt), which will increase the inference performance on edge devices and make our models efficient on multithreading cpus.  stage and stage models can be easily replaced with improved models in the future, that would give better accuracy and lower latency. chollet, f., & others, howard, j., huang, a., li, z., tufekci, z., zdimal, v., van der westhuizen, h., von delft, a., price, a., face masks against covid- : an evidence review densely connected convolutional networks a style-based generator architecture for generative adversarial networks gradient-based learning applied to document recognition feature pyramid networks for object detection focal loss for dense object detection ssd: single shot multibox detector, european conference on computer vision a hybrid deep transfer learning model with machine learning methods for face mask detection in the era of the covid- pandemic an algorithm for centroid-based tracking of moving objects system for medical mask detection in the operating room through facial attributes identifying facemask-wearing condition using image super-resolution with classification network to prevent covid- ( ), unpublished results you only look once: unified real-time object detection faster r-cnn: towards real-time object detection with region proposal networks, proceedings of the th international conference on neural information processing systems ieee/cvf conference on computer vision and pattern recognition farec -cnn based efficient face recognition technique using dlib visualizing the effectiveness of face masks in obstructing respiratory jets rapid object detection using a boosted cascade of simple features, computer vision and pattern recognition masked face recognition dataset and application britain faces an anxiety crisis as people return to work joint face detection and alignment using multitask cascaded convolutional networks learning transferable architectures for scalable image recognition key: cord- -ex zpud authors: isasti, guillermo; fernández, josé f. díaz title: comparison of telehealth and traditional face-to-face model during covid- pandemic() date: - - journal: med clin (engl ed) doi: . /j.medcle. . . sha: doc_id: cord_uid: ex zpud nan los autores no declaran ningún conflicto de interés. as early as , telehealth was being discussed as a link between hospitals and homes . there were few publications on the subject until , the turning point when publications on this model started to emerge. face-to-face interactions will always play a central role in our healthcare system. but a system based on high-quality remote care might work better for many patients and quite possibly for some doctors as well . since the advent of sars-cov- , telehealth has become a useful tool in certain healthcare systems . this disruptive experience has meant a sudden and total shift from face-to-face consultations to a virtual model, unprecedented in many health systems. our department implemented a comprehensive telecardiology model from th march until st may, time when we progressively returned to face-to-face activity. we do not yet have a specific tool, therefore, the model relied on two simple pillars, the electronic medical record and the telephone call as a means of communication with users and colleagues. a total of , teleconsultations were carried out, of which , came from general consultations, from the cardiac rehabilitation consultation and from the monographic consultation on advanced heart failure. for the analysis of the results we propose possibilities: ) follow-up (it is resolved by teleconsultation and requires a check-up/complementary test); ) resolved (it is resolved by teleconsultation without the need for further follow-up) and ) re-appointment (requires a face-to-face visit). of the total of patients contacted by teleconsultation, ( . %) were referred for a follow-up, ( . %) were resolved and only ( . %) required re-appointment we analysed general consultations due to their greater volume ( patients), differentiating two tasks: first visits ( patients) and follow-up visits ( patients). of the first-visit patients, . % were referred for a follow-up, . % were resolved and . % required a face-to-face visit. of the follow-up group, . % were doing a check-up, . % were resolved and only . % required a face-to-face visit. despite the technical limitations, the percentage of resolutions of first-visit patients was not negligible ( . %) but without a doubt, what was striking was the resolution capacity of almost % of the patients in the follow-up group. this data led us to perform a comparative analysis with the face-to-face model of review patients seen in the weeks prior to the start of the teleconsultation model. of these patients seen in person, ( . %) were resolved and ( . %) went for a follow-up visit (table table ) . we did not observe statistically significant differences in the outcomes of the follow-up group when the face-toface model was compared to teleconsultation (p░=░ . ). finally, we compared the number of patients who did not come to the face-to-face consultation ( , . %) versus the number of patients who did not respond to the phone call ( , . %), observing a statistically significant difference (p░<░ . ). although we are aware of the need for longer-term comparative studies evaluating the results of teleconsultation, telehealth interventions generally seem equivalent to face-to-face care . this healthcare modality is promising and has adequate resolution rates for a specific group of patients, such as those under follow-up for stable chronic diseases and those who come to the clinic to collect results. for this reason, it is vitally important to invest in and develop platforms that allow effective communication between healthcare levels and between healthcare providers-patients because, without a doubt, telehealth will be part of our daily healthcare work. telemedicine system: the missing link between homes and hospitals? mod nurs home in-person health care as option b virtually perfect? telemedicine for covid- the current state of telehealth evidence: a rapid review the authors declare no conflict of interest.j o u r n a l p r e -p r o o f key: cord- -xy f kon authors: armijo, priscila r.; markin, nicholas w.; nguyen, scott; ho, dao h.; horseman, timothy s.; lisco, steven j.; schiller, alicia m. title: d printing of face shields to meet the immediate need for ppe in an anesthesiology department during the covid- pandemic date: - - journal: am j infect control doi: . /j.ajic. . . sha: doc_id: cord_uid: xy f kon anesthesia providers are at risk for contracting covid- due close patient contact. proper personal protective equipment (ppe) use is critical to providing a safe environment and to minimize the risk of contagion. during the covid- pandemic, a series of supply chain issues, constant changes in ppe use policy, and higher demand for ppe led to shortages in ppe, specifically n masks and face shields. implementation of decontamination protocols successfully allowed n mask reuse but, required masks to be unsoiled. face shields not only act as a barrier against the soiling of n face masks, they also serve as more effective eye protection from respiratory droplets over standard eye shields. the university of nebraska medical center produced face shields using a combination of d printing and assembly with commonly available products. approximately face shields were constructed and made available for use in hours. importantly, we created and implemented a simple but effective decontamination protocol, which allowed reuse of the face shields. these methods were successfully implemented for in-house production of face shields used at tripler army medical center (tripler amc, hawaii). the effectiveness of the decontamination protocol was evaluated using the average log( ) reduction in colony counts for escherichia coli atcc and staphylococcus aureus atcc from the american type culture collection (atcc, manassas, va). in this manuscript, we present our detailed protocol and supplies needed for printing d face shields to enable the rapid production of this product by individuals with little to no d printing experience, in times of urgent need. (sars-cov- ) was first isolated in human airway epithelial cells from a cluster of patients with pneumonia of unknown etiology in december from wuhan, china [ ] . the novel virus has since spread to every continent, except for antarctica, infecting greater than . million people and causing greater than , deaths as of today. it is estimated that millions of americans will get infected by the sars-cov- virus that causes coronavirus disease and that % of the healthcare workforce will be infected and removed from the workforce due to exposure to the virus primarily through respiratory droplets emitted by patients [ , ] . anesthesia providers are at increased risk for exposure because of their primary role in airway instrumentation for symptomatic and asymptotic covid- patients during diagnostic, therapeutic, and surgical procedures. surgical masks, the standard personal protective equipment (ppe) before the covid- outbreak for anesthesia providers, do not offer satisfactory protection from covid- during close patient interaction, partly due to the risk for aerosol generation at the time of intubation. current literature indicate that surgical masks provide insufficient protection against inhalation of viral particles that exist in both respiratory droplets and aerosolized sub-micron particles generated by infected patients [ ] . to overcome this challenge, stringent policies and appropriate use of ppe, such as face shields, safety glasses, and n masks, are indicated for providers performing aerosol-generating procedures [ ] . n filtering face piece respirators (ffr) and powered air-purifying respirators (papr) are a more sophisticated ppe that provides full face and body coverage, respectively, enhancing the level of protection against aerosolized particles. however, there are several challenges associated with the continuous use of ppe, especially for papr and ffr, including the limited supply chain due to the high demand, communication barriers between provider and patient, and discomfort after long-hours of wear [ ] [ ] [ ] . therefore, extending the use of n masks, as recommended by the cdc, is an appropriate and suitable alternative in a resource-constrained environment, in which the use of papr and ffr is not practical [ ] . with the fast development of the covid- pandemic and the incredibly high transmission rates of sars-cov- , shortage of ppe has become one of the greatest and most concerning challenges among healthcare professionals. high cost, limited availability, low storage stocks to meet surge capacity, and limited capabilities for reuse of ppe all contribute to unavailability. additionally, changing recommendations of appropriate ppe use rapidly evolved in response to the pandemic, producing previously unused supply chain requests [ , [ ] [ ] [ ] . the cdc recommends the implementation of procedures that extend the use of n masks to combat the shortage of ppe. this sentiment is echoed by a joint position statement supported by the american society of anesthesiologists (asa), anesthesia patient safety foundation (apsf), american academy of anesthesiologist assistants (aaaa) and american association of nurse anesthetists (aana). one strategy to mitigate the soiling of n masks and extend their use is the addition of a face shield that is capable of withstanding decontamination. the physical barrier provided by the face shield provides an added layer of protection of the n mask and the face of the provider from respiratory droplets. it prevents the n from becoming soiled, allowing for prolonged use. in response to the covid- pandemic, the university of nebraska medical center (unmc), department of anesthesiology, mandated that anesthesia providers use face shields during patient care to extend the life of n masks and adequately protect providers from infection with sars-cov- . this mandate required the immediate procurement of face shields for approximately clinical providers working at any one time. our goal was to meet the immediate demand for an increased level of provider protection by providing face shields to reduce viral transmission to the provider. the face shields also prevent the soiling of n masks, allowing for reuse with a previously developed ultra-violet radiation sterilization protocol recently approved by cdc/niosh [ ] . due to the high demand and low supply of commercially produced face shields, unmc turned to in-house d printed face shields using publicly available resources. using this strategy, unmc was able to quickly and efficiently produce face shields in approximately hours using four relatively inexpensive and readily available d printers. the face shields were deployed for use by our clinical anesthesia providers the very next day, along with a sterilization protocol that allowed for the reuse of the face shields. the methods developed by unmc as described in this paper was also successfully replicated by the th maintenance squadron ( th wing airmen joint base pearl harbor-hickam) and the combat logistics battalion marines (marine corps base hawaii) to rapidly produce and supply face shields to healthcare providers (nurses, medics, physicians, intensivists) at tripler army medical center (tripler amc, hi). they were able to produce approximately face shields in hours with follow-up plans to equip greater than military and military associated healthcare providers and first responders on the island of oahu. all the information we used to make the face shields was readily available from various sources in the public domain. however, we had to overcome several significant, time-wasting challenges to produce a final, working product. first, we were limited in materials acquisition, to only using locally available materials and previously acquired equipment. secondly, we needed to understand and produce a product that had the appropriate dimensions not to impede our providers in clinical care. finally, we had a significant learning curve to overcome a significant learning curve to produce face shields without prior d printing experience. consequentially, we are providing a complete step-by-step instructional guide to producing d printed face shields rapidly. our protocol is specific to producing a face shield that is sized appropriately to not interfere with commonly performed procedures, such as endotracheal intubation, and are reusable after decontamination. however, the methods we provide can be used to produce and decontaminate face shields for general use at all treatment facilities. additive manufacturing, or what is commonly referred to as d printing, is a fabrication process in which layers of material are added successively to form the desired object. methods of additive manufacturing fall under several different categories, such as filament deposition manufacturing (fdm), also known as fused filament fabrication (fff), stereolithography (sla), digital light processing (dlp), selective laser sintering (sls), or multi-jet fusion (mjf). the key similarity among the methods is the process by which layer-by-layer an object is built through the addition of material. while the same object may be created using any of the methods mentioned above, each has its strengths and limitations [ ] . for all d printing platforms, the electronic file of the object to be printed (commonly a stereolithography or .stl file) can either be created by the user or downloaded from the shared sources on the internet. in order to print an object, the electronic file must first be loaded into the printer software, and potentially altered to be compatible with the specifications of the printer. a major consideration is the printing platform to use. printers used for fdm and dlp are commonly used desktop-sized printers. of these, fdm is the most frequently used d printing platform for non-industrial applications because it is relatively affordable in both the printer and the required thermoplastic filament. fdm printing platforms offer both low-cost filament use and often a more substantial build plate compared to a dlp platform, enabling fdm printers to produce larger or more objects in one run. thus, this was our platform of choice. a significant disadvantage of fdm is that it results in individual layers of a thermoplastic material that, while fused, may not be air-or watertight. dlp printing utilizes a digital projector screen to flash images of the object on to photosensitive resin in order to cure the resin layer by layer. this process results in objects with the potential for higher-layer resolution and are solid pieces that are air and watertight. the authors recognize that all fdm prints generated for the headband of the face shield are not watertight, allowing water and air to pass through them to some degree. this would make uv sterilization or a simple wipe down with anti-bacterial/viral wipes inappropriate and ineffective. given this information, we developed a decontamination protocol that utilized a dilute bleach solution that would allow penetration into any of the pores that are generated in the d printing process and permit the reuse of the face shields. the solid headband and chin piece of the face shield we created were d printed via fmd, while all other materials, including the transparent face guard, were purchased commercially, and then used to construct the face shield ( table ). the fdm fabrication process, even with a clear pet filament, does not allow for the type of uniformity and consistency that would permit the creation of a truly clear shield that allows good visual acuity for the wearer. fdm filament types include polylactic acid (pla), acrylonitrile butadiene styrene (abs), polyethylene terephthalate (pet). pla requires lower printing temperatures ( - ºc) and has less warping than abs or pet but is more brittle. abs has higher printing temperatures ( - ºc) and more durability, but is more prone to warping and can generate toxic gas fumes during printing. pet has a moderate printing temperature ( - ºc) with durability similar to abs with the ease of use similar to pla. however, it absorbs water and requires additional care when storing the filament. nylon is very durable and is a high-temperature ( - ºc) filament. while other thermoplastic filaments are available, the need for high-speed and low-cost prompted the use of pla in the current protocol. we chose pla as our printing material due to the fact that the material was readily available, we were very familiar with its use, and the material was low-cost. moreover, pla has excellent printing properties, allowing a fdm printer to print at very high speeds for the make and model ( mm/sec on a prusa mk and/or mk s printer). after careful consideration, we chose to use a prusa i mk s model printer for our d face shield printing needs. this model of printer is relatively low-cost (approximately $ ), handles pla filament well, and has sufficient printing surface area. additionally, many files are available in the public domain that are designed for use with this printer, thus lowering the barrier for production for individuals who may have little or no d printing experience. the specifications for the computer used for designing, modeling, processing, and printing of the .stl file depends on the d printing software used. for the face shields printed at unmc, we used a standard dell desktop (xps) computer running slic r software ( table ). the processed .stl file was then saved to an sd card, and the sd card inserted into the prusa d printer for printing. a wide array of software options is available, ranging from relatively simple such as google sketchup (free software) to highly complex such as autodesk autocad. mid-range software includes blender, autodesk maya, and solidworks. as complexity increases, the computer requirements also increase. for example, google sketchup requires a . +ghz cpu and gb ram, while autodesk autocad requires, at minimum, an intel pentium processor with gb ram. due to the need to transfer files from computer to d printer, downloading and installation of software, downloading of .stl files, there may be limitations/challenges to producing face shields at government and military installations, treatment facilities, or hospitals with secure networks that do not allow for easy transfer of files from computer to printer by an external drive. additionally, at these locations, there may be restrictions on acquiring or installing d printing software onto network computers. the successful production of a d printed face shield will require the following steps: a) creating or obtaining the electronic file for the d printed parts; b) printing the face shield parts ( figure ); and c) assembling the face shields with the additional required supplies. first, one must either make or find the file of the idealized model of the desired object. the .slt files used in this paper are located on the prusa face shield website (https://www.prusaprinters.org/prints/ -prusa-face-shield), under files. this file is optimized for use in the prusa printer and thus would require minimal, if any, modifications by the user to print a quality product. once the .stl file was obtained, it was loaded onto a computer capable of running the slicer software. the slicer software takes the d virtual model and determines the process required for the printer to produce the object layer by layer. the slicer printer software can assist in setting the appropriate speed, layer height, and generation of tool paths (the path that the printer extruder follows while printing) for the d printer being used. unlike traditional ink printers, where most settings are universal and ink pages would be printed the same regardless of the printer used, d printers will require unique modifications based on the model and brand of printer used. the headband print file was adjusted using slicer software to control speed, layer height, support material and the use of other supporting materials. using the prusa rc quattro file, a .gcode file was produced that would result in an optimized print speed. using and . mm layer height, outer layers and layers for top and bottom layers along with % infill, a stack of head and lower pieces could be printed in . hours. this print file also utilized a raft to provide optimum adhesion to the build plate give the small amount of contact area this design has with the build plate. no support material is used as the chamfered undersides of the headband allow the printer to successively print layers vertically without issue. prepare all components of the face shield for assembly. figure contains the terminology of the face shield components, whereas figure depicts a pictorial description for the initial face shield assembly. . remove the printed headbands and chins (item ) from the printing deck of the d printer. separate into individual components. . using the face guard template from the prusa website, item (www.prusa d.com), mark the location of the needed holes in the clear pvc binding cover (item ) that will be used for the face guard, using a permanent marker. . using a standard hole punch (item ), punch the holes marked in the face guard. our choice to utilize a high speed and low cost fdm printer with pla, had a known result of leaving small pores present in the final d printed product, making the use of uv light sterilization not possible. to circumvent this challenge, we created a liquid sterilization protocol that would allow reuse of our face shields. in brief, the face shields were dissembled, placed briefly in a dilute bleach solution, and allowed to be air dry. when dry, the clear face guard was wiped to remove any spots, and the face shield reassembled for use. our detailed decontamination protocol is included in appendix a. the surface of each face shield part was cleaned by wiping surfaces with caviwipes (metrex, orange, ca) followed by % ethanol prior to spiking. following drying, spots to be inoculated were marked with permanent marker. subsequently, µl of bacterial concentration was applied to each marked spot. as a positive control, organism suspensions were inoculated to each face shield part, allowed to dry, and swabbed without decontamination. pbs was inoculated to each part as a negative control. the droplets were left to air dry for hour. each face shield part was disinfected according to appendix a. after adequate drying, a cottontipped swab (puritan medical products company, guilford, me) was used to sample each marked spot. swabs were moistened in sterile pbs and the area was swabbed using a firm sweeping and rotating motion. organisms were enumerated using the spread-plate technique on ba plates. the plates were incubated at °c for - hours. experiments were repeated five times per face shield part (head band, head piece, face shield) and organism (e.coli, s. aureus) for a total of experiments not including positive and negative controls. decontamination effectiveness was evaluated using the average log reduction in colony counts. to assess the effectiveness of the appendix a decontamination protocol, we inoculated bacterial suspensions of e. coli atcc and s. aureus atcc directly onto each part of the face shield unit. all positive organism and pbs controls were as expected. the decontamination protocol effectiveness against e. coli was greater than s. aureus. two-spiked e. coli spots exhibited growth, one colony each, whereas five-spiked s. aureus spots had characteristic growth. e. coli was observed on the face guard piece, s. aureus was detected from the chin piece and face guard. no organisms were recovered from the head bands. overall, the decontamination protocol was highly effective against both e. coli and s. aureus, achieving a ≥ log ( . %) reduction in colony counts for every replicate. the masks we created are comparable and sometimes superior, to standard commercially available face shields, in terms of the protection area and coverage (figure ) . a known limitation of our face shield design is the gap between the clear shield and the forehead of the wearer. this space is usually occupied by a foam barrier present in several commercially available face shield models. while this foam provides comfort, it limits the ability to extend the use of the product. in order to reduce the possibility of provider contamination from droplets entering this top opening, a bouffant surgical cap can be pulled forward and attached to the four pins of the headband holding the face guard in place. another option to mitigate this concern is to print a cover piece for the headband, which is currently under development [ ] . however, for our purposes of rapidly producing enhanced ppe in the form of face shields, this design met the needs of our department. given the emergent circumstances and perceived time constraints, institutional infection control was notified, provided input, and was responsible for determining the sites for donning, doffing, and disinfection protocol. while the goal of the authors is to provide a detailed protocol and methodology that met the urgent needs of the unmc department of anesthesiology, modifications may be desired, or even necessary, depending on the availability of resources. to that end, we have included popular modifications and additional product resources. if a prusa brand printer is unavailable, or undesirable for other reasons, printer options with similar functionality are available. we recommend the creality cr- s pro v (https://www.creality dofficial.com/) or the creality ender series that was used to produce face shields in-house for tamc personnel. for this protocol, we recommend using pla due to its characteristics and compatibility with this project. other types of filaments could be used; however, they would require significant modifications of this protocol and additional steps. a " piece of foam is optional and can be attached to the headband. for the purchase, foam window seal can be found at any departmental store. make sure you have a / wide by / thick. to ensure that the foam holds in place, glue the foam into the headband. however, we do not recommend its use since it cannot be sterilized, nor detached from the headband. hence, if using the foam, the face shield will have to be disposed after a single use, and we therefore elected to not utilize a layer of foam inside the headband. there are several materials that can be used for the head strap. we tried three materials: rubber bands, elastic strips with buttonholes, and tourniquets. rubber bands have the advantage of being readily available, low-cost, ability to be sterilized in liquid and disposable. however, they were very difficult to adjust and tended to slip, making the security of the face shield a concern. however, they are easy to acquire and could be used if the urgency of the situation merited it. the elastic strip with buttonholes was also low-cost and somewhat easy to acquire, requiring a trip to a fabric or craft store. the buttonholes made adjustment and security of the face shield sufficient. however, the fabric-type and porosity of the material would not allow for reliable sterilization and reuse of the face shields. the material of choice for our design was a tourniquet used clinically for the placement of ivs or phlebotomy. this material was readily available, lowcost, able to be sterilized and did not get stuck in hair as easily as rubber bands we settled on an . x " clear mil polyvinyl chloride (pvc) binding cover as it was readily available and only created a small amount of distortion to the wearer's vision. the width permitted the holes to be punched to fit the rc headband. the edges were trimmed to prevent the lower corners from contacting the wearer's chest if they flexed their neck. the binding covers are offered in fixed width, to be used with standard-sized paper. nonetheless, if there is a need for adjusting the dimensions and size of the clear shield, one can replace the binding cover with laminating foil or plexiglas. however, there are limitations to using such materials, such as the need for additional equipment, such as a die cutter for the plexiglas or a laminating machine for the laminating foil. however, pvc poses no other benefits over these materials if this equipment and expertise in use are already available. due to the cleaning solution, the clear face guard became slightly blurred with time. additional clear face guards were available for providers who wanted to replace it. however, the number of times needed for the clear face guard to lose its transparency varied. we performed the swab method to recover organisms from the face shield surfaces, this method is commonly used in transfer studies [ , ] , although other methods exist such as direct elution which may be more efficient in organism recovery from porous surfaces [ , ] . the swab method was selected because it is simple and less labor-intensive than the direct elution method. it is acknowledged that swabs may retain some portion of organisms during plating. the rapid manufacturing capacity of commercially available desktop fdm printers paired with open source designed and readily available materials allowed for the creation of sufficient face shields to provide protection until other, more durable shields could be procured. at the time of this writing, these face shields have been in use in the unmc anesthesiology department for days, and at tamc for days. unmc is currently awaiting a locally-sourced injection molding type face shield that has a cover over the opening in the top. d printing can allow for not only rapid prototyping and iterative changes but can allow the user to manufacturer and augment key components of ppe when providers and first responders are faced with supply shortages. center for disease control and prevention. coronavirus disease (covid- ) a novel coronavirus from patients with pneumonia in china supporting the health care workforce during the covid- global epidemic covid- : protecting healthcare workers covid- faq's commentary: masks-for-all for covid- not based on sound data interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease (covid- ) in healthcare settings f -ncov% finfection-control% fcontrol-recommendations.html behavioral considerations and impact on personal protective equipment (ppe) use: early lessons from the coronavirus (covid- ) outbreak covid- : doctors still at "considerable risk" from lack of ppe, bma warns headaches associated with personal protective equipment -a cross-sectional study among frontline healthcare workers during covid- the efficacy of medical masks and respirators against respiratory infection in healthcare workers. influenza other respir viruses additive manufacturing ( d printing): a review of materials, methods, applications and challenges comparative surface-to-hand and fingertip-to-mouth transfer efficiency of gram-positive bacteria, gram-negative bacteria, and phage transfer efficiency of bacteria and viruses from porous and nonporous fomites to fingers under different relative humidity conditions transfer of bacteria from fabrics to hands and other fabrics: development and application of a quantitative method using staphylococcus aureus as a model assessment of surgical instrument bioburden after steam sterilization: a pilot study clear face protector portion of shield key: cord- -tuositq authors: kwok, yen lee angela; gralton, jan; mclaws, mary-louise title: face touching: a frequent habit that has implications for hand hygiene date: - - journal: am j infect control doi: . /j.ajic. . . sha: doc_id: cord_uid: tuositq background: there is limited literature on the frequency of face-touching behavior as a potential vector for the self-inoculation and transmission of staphylococcus aureus and other common respiratory infections. methods: a behavioral observation study was undertaken involving medical students at the university of new south wales. their face-touching behavior was observed via videotape recording. using standardized scoring sheets, the frequency of hand-to-face contacts with mucosal or nonmucosal areas was tallied and analyzed. results: on average, each of the observed students touched their face times per hour. of all face touches, % ( , / , ) involved contact with a mucous membrane, whereas % ( , / , ) of contacts involved nonmucosal areas. of mucous membrane touches observed, % ( ) involved the mouth, % ( ) involved the nose, % ( ) involved the eyes, and % ( ) were a combination of these regions. conclusion: increasing medical students' awareness of their habituated face-touching behavior and improving their understanding of self-inoculation as a route of transmission may help to improve hand hygiene compliance. hand hygiene programs aiming to improve compliance with before and after patient contact should include a message that mouth and nose touching is a common practice. hand hygiene is therefore an essential and inexpensive preventive method to break the colonization and transmission cycle associated with self-inoculation. infections may be transmitted by self-inoculation. self-inoculation is a type of contact transmission where a person's contaminated hands makes subsequent contact with other body sites on oneself and introduces contaminated material to those sites. , although the literature on the mechanisms of self-inoculation of common respiratory infections (eg, influenza, coronavirus) is limited, [ ] [ ] [ ] contaminated hands have been reported as having potential to disseminate respiratory infections. staphylococcus aureus is carried in the nasal mucosa in approximately % of the community , and, may be self-inoculated, via face touching, by individuals who are frequently exposed to potential carriers in both the community and health care settings. , during the influenza a (h n ) pandemic, face-touching behavior in the community was commonly observed with individuals touching their faces on average . times per hour. in the health care setting, frequent face touching, particularly during periods of seasonal endemicity or outbreak, has the theoretical potential to be a mechanism of acquisition and transmission. however, quantifying the role of face touching in the spread of respiratory infections or s aureus colonization is difficult for several reasons. first, such a study would require enrollment, screening, and prospective follow-up of a large population to identify a significant causal link. second, the study would need to observe transmission occurring in community settings, rather than in isolation or under laboratory conditions, which would be ethically challenging. finally, there are likely to be confounding factors, such as virulence of pathogens, varying susceptibility of the study population, and effects of modes of transmission other than hand to face contamination, that cannot easily be controlled. a self-inoculation event may occur if a health care worker (hcw) fails to comply with hand hygiene after patient contact (moment ) or after contact with the contaminated environment of the patient's zone (moment ) (fig ) and makes subsequent physical contact with susceptible sites on their own bodies. to better understand the dynamic between face touching and the implications for hand hygiene among clinicians, we explored the prevalence of face-touching behavior in medical students. in may , a behavioral observation study was undertaken involving phase medical students at the university of new south wales (unsw). ethical approval was obtained from the unsw human research ethics committee prior to the commencement of the study. the student cohort had completed a one -hour infection control course in the previous months. the infection control course included education on hand hygiene, aseptic technique, standard precautions, and transmission-based precautions. the same student cohort attended two -hour lectures unrelated to infection control, on separate occasions. one week before the -hour lecture commenced, students were informed that a behavioral observation study was being conducted during the lecture and required the students to be videotaped while they listened to the lecture. students were not informed about which behaviors were under observation to blind them from the aims of the study; this was necessary to minimize the potential for a change in behavior as a result of being observed. to participate in the study, students were instructed to move to a marked area on the left side of the lecture theatre and complete a participant consent form. to opt out of the study, students were instructed to move to the right side of the lecture theatre outside of the videotape recording range. students were also informed that they could withdraw from the study once recording commenced by simply moving to the other side of the theatre. all participants consented prior to videotape recording. a digital videotape recording was made of the consenting participants and was viewed by investigators to record the facetouching behavior of every participant. for the purposes of precision, the digital recording was viewed multiple times after the lectures had taken place by researcher (y.l.a.k.). a standardized scoring sheet was used to tally the frequency of hand-to-face contacts, the area of the face that was touched, whether a mucosal area (eyes, nose, mouth) or nonmucosal area (ears, cheeks, chin, forehead, hair) was touched, and the time in seconds of each contact. descriptive statistics were performed to determine the frequency and duration of touches per hour using spss version for windows (spss inc, chicago, il). a total of students were observed making , touches to the face over minutes. of the face touches, % ( , / , ) involved nonmucosal regions, whereas % ( , / , ) involved contact with mucosal membranes. of the , nonmucosal membrane touches, most involved the chin ( %; / , ), followed by the cheek ( %; / , ), hair ( %; / , ), neck ( %; / , ), and ear ( %; / , ). of the , touches involving a mucosal membrane region, % ( / , ) involved the mouth, % ( / , ) involved the nose, % ( / , ) involved the eyes, and % ( / , ) involved a combination of the mucosal membranes. during an average hour participants touched their face times (median, . times; lq (lower quartile), . ; uq, . ; range, - ). the average duration of mouth touching was seconds (median, second; lq, . ; uq (upper quartile), . ; range, - seconds), the average nose touching duration was second (median, < second; lq, . ; uq, . ; range, - seconds), and the average eye touching duration was second (median, < second; lq, . ; uq, . ; range, - seconds). hands are considered a common vector for the transmission of health careeassociated infections , , and have been implicated in the transmission of respiratory infections. , good hand hygiene before and after patient contact is imperative to prevent transmission of infection. this is particularly so during the symptomatic or asymptomatic prodromal stages of infections when patients shed infectious material. in particular, clinicians caring for infectious pediatric patients with high shedding concentrations , may be at risk of acquiring an infection if they have a high level of facetouching behavior. s aureus is a common pathogen prevalent in both community and health care settings. colonization of the nasal mucous membranes with s aureus is common and ranges from %- % in health care and community settings. nose touching was common among our participants. this finding supports the importance of hand hygiene as a means of preventing occupationally acquired colonization with s aureus from patients or the contaminated environment. , , , s aureus can survive for up to years on hard surfaces, and no obvious role has yet been attributed to colonized staff. when mixed with hospital dust, s aureus can still survive for > year until it is picked up from the environment. , contaminated hands may act as a vector, transmitting the bacteria from a contaminated surface to the hcw's nasopharynx via face touching. high hand hygiene compliance before and after patient contact should reduce the likelihood of transferring pathogens through self-inoculation and in turn prevent inoculation of patients. , , pathogens found on stethoscopes have also been recovered from physician's hands. given the habitual face-touching behavior observed in our study, it is possible that the inoculation of stethoscopes and other contaminated medical equipment may have been the result of inoculation from nose touching to hands and subsequently to the stethoscope. given the frequency of facetouching behavior observed in this study, clinicians must practice hand hygiene before and after using such equipment to ensure that patient equipment is kept clean prior to use. given the high frequency of mouth and nose touching observed, times per hour on average for mouth touching and times per hour on average for nose touching, performing hand hygiene is an essential and inexpensive preventive method for breaking the colonization and transmission cycle. models of infection transmission and comparison of transmission efficiency of self-inoculation against other transmission routes are required to further expand our knowledge on the role of face touching for self-inoculation. meanwhile, raising awareness that face-touching behavior is common and is a possible vector in self-inoculation could result in hcws accepting the message that hand hygiene before and after patient contact is an effective method of reducing colonization and infection transmission for themselves and their patients. a study quantifying the hand-to-face contact rate and its potential application to predicting respiratory tract 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the novel a (h n ) influenza virus: don't touch your face! my five moments for hand hygiene': a user-centered design approach to understand, train, monitor and report hand hygiene a dictionary of epidemiology evidenceebased model for hand transmission during patient care and the role of improved particles nasal and hand carriage rate of methicillin resistant staphylococcus aureus (mrsa) among healthcare workers in mekelle hospital, north ethiopia clinical signs and symptoms of influenza: influenza prevention & control recommendations rhinovirus transmission within families with children: incidence of symptomatic and asymptomatic infections clinical effects of rhinovirus infections survival of influenza virus on human fingers methicillin resistant staphylococcus aureus: carriage rates and characterization of students in a texas university studies of the community and family: acute respiratory illness and infection the staphylococci in human disease tackling contamination of the hospital environment by methicillin-resistant staphylococcus aureus (mrsa): a comparison between conventional terminal cleaning and hydrogen peroxide vapor decontamination the public hand hygiene practices of new zealanders: a national survey hand hygiene and face touching in family medicine offices: a cincinnati area research and improvement group (caring) network study contamination of stethoscopes and physicians' hands after a physical examination we thank professor gary velan for providing us access to the unsw medical students prior to his lecture and to professor william rawlinson for providing recording equipment. key: cord- - xxevp authors: patel, piyush; gohil, piyush title: role of additive manufacturing in medical application covid- scenario: india case study date: - - journal: j manuf syst doi: . /j.jmsy. . . sha: doc_id: cord_uid: xxevp this paper reviews how the additive manufacturing (am) industry played a key role in stopping the spread of the coronavirus by providing customized parts on-demand quickly and locally, reducing waste and eliminating the need for an extensive manufacturer. the am technology uses digital files for the production of crucial medical parts, which has been proven essential during the covid- crisis. going ahead, the d printable clinical model resources described here will probably be extended in various centralized model storehouses with new inventive open-source models. government agencies, individuals, corporations and universities are working together to quickly development of various d-printed products especially when established supply chains are under distress, and supply cannot keep up with demand. mankind has seen different pandemics since the starting where a portion of them were more horrendous than the others to the people. the worldwide emergency of novel coronavirus also referred to as covid- initially detected in the wuhan region of china. as of august , there is no proven vaccine for covid- , but numerous continuous clinical preliminaries are assessing expected medicines [ ] [ ] [ ] . d printing [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] is an essentially unique method of creating parts contrasted with conventional subtractive or formative manufacturing technologies. in d printing the part is made directly onto the built stage layer-wise, which prompts a novel arrangement of advantages and confinements -more on this beneath. the d printing technique needs to think outside the standard for changing human services. in a few words, d printing consists of empowering specialists to treat more patients, without sacrificing results. hence, similar to any innovation, d printing has presented numerous favorable circumstances and conceivable outcomes in the clinical field [ - ]. manufacturing industries and investors are continually trying to improve procedures to bring down cost, vitality and grow their ability (table ). at this stage, exploration and industry intrigue lie in figuring out where am can supplant or make new assembling frameworks [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . am might have the option to assume a job in assisting with supporting modern gracefully chains that are influenced by constraints on conventional creation and imports. co-ordinations of the supply chain are likely j o u r n a l p r e -p r o o f the primary enormous scope business that might be influenced by d printing innovation. as shown in fig. (a) traditional method involves prolonged process starting from taking raw materials, acquiring materials, manufacturing, distributing and selling to end-user. fig. (b) represents changes in the supply chain that quick part production possible through the use of d printing [ ] [ ] [ ] [ ] . (a) traditional supply chain (b) d printing supply chain fig. traditional versus d printing supply chain [ ] makers are on the whole being compelled to develop and actualize new and coordinated ways to deal with item observing and quality control. one of their greatest calculated difficulties includes guaranteeing their creation lines are running, despite the absence of accessible staff because of social distancing rules [ ] . this is the place computerized developments in smart manufacturing [ ] [ ] [ ] can offer numerous advantages. the decision of the most appropriate procedure for each kind of model depends on the meaning of the target behind the creation of the model and different factors: innovation, creation time, weight, materials, cost, aesthetic, functional, investigational, surface completion, post processing requirements, assurance, spares and consumables things. consider the ideal characteristics for your specific application and contrast them with the available choices in a given manufacturing processes. (fig. ) the present advanced cloud-based innovation services [ - ] and arrangements offer an uncommon degree of adaptability, with factory managers ready to remotely monitor and deal with their creation lines from any area with a web association [ ] [ ] [ ] . the designer must realize the deciding components of the finished result so as to have the option to choose the most appropriate assembling strategy, make the essential changes to the geometrical data file (stl or amf), and survey the nc code. the designer must, therefore, have a full outline of the times of the cycle as appeared in fig. . this highlights the impact of design for additive manufacturing (dfam), when an item has been intended for a particular machine or cycle [ ] , just as the significance of print settings to optimize production [ ] [ ] [ ] [ ] . key advantages of d printing over traditional manufacturing are digital storage, quicker creation, detectability of part files, reduction in delivery time and the capacity to deliver segments regardless of the complexity of part geometry. three iso/astm d printing measures, in particular material extrusion (me), powder bed fusion (pbf) and vat photo-polymerization (vp) are most usually used to create medical parts in the current covid- pandemic [ , ] . the current government has made some excellent strides in pushing for assembling with ventures, for example, prime minister narendra modi's domestic task 'make in india', and the nation has seen critical enhancements in its 'ease of doing business' rankings [ ] . there still is sufficient time for india to get up to speed, yet lead the world by concentrating on building the next generation of pioneers [ ] [ ] [ ] [ ] . according to the th edition of the world bank's (wb) report on october , , "doing business -comparing business regulation in economies", india has ranked rd in the list with the score of . . it has improved by places among nations as against th position in the - list. industry . [ - ] has likewise brought the capacity of consistent advanced physical change through robotics and am innovations like d printing. am advancements are reshaping worldwide worth chains and hold the guarantee of new creation capacities [ ] . india right now represents just around percent of the am introduced base across asia and oceania consolidated, however, organizations such as ge, wipro and intech are driving d printing appropriation in the nation. while the current market size might be little, the future has conceivably numerous situations and the state of the industry relies upon imaginative new use instances of receptions. ( fig. ) in the indian market, there are some limitations in terms of diagnostic kits and a sufficient standard quantity of personal protection equipment (ppe). presently to change india into a worldwide design and manufacturing hub, it is a powerful call to action to citizens and business pioneers to discover gaps and satisfy the necessity of the customer by make in india initiative. the utilization and selection of d printing services are expanding step by step. there will be a more noteworthy requirement for training and capability building inside the associations with expanded infiltration of am. there is additionally a growing concern that am items can't be copyrighted yet should be patented dependent on obvious differentiation. an industry wide joint effort is required to create clarity on what meets all requirements for patent security to control the multiplication of replica parts. [ ] covid- pandemic is the most noticeably terrible unnerving episode of humanity's rule on earth to date. not just it has asserted over a hundred thousand lives afterward, however, it has likewise given many restless evenings to clinical and investigates experts over the globe give concrete solutions for healthcare workers and all those exposed in this time of crisis of lack of medical equipment shortages [ ] [ ] [ ] . hospitals around the globe confronted disturbing deficiencies of clinical apparatus basics like face shields and covers, testing swabs, ventilators, and more. while traditional supply chains [ , ] diverse to respond, d printing outfits have begun dealing with transient curiosity [ ] . most d printers can't produce stock as fast as other assembling techniques like injection molding, however, they can create a wide variety of designs without the need for new molds. by sharing design files and pooling assets, individuals from the d printing network have joined together to become something of an assembling hive mind during this pandemic [ , ] . the world health organization has published a list of covid- critical items facing a global shortage, grouped into three categories like personal protective equipment (ppe), diagnostic equipment and critical care equipment. governments around the globe are approaching makers to briefly repurpose their assembling lines to meet this deficit. normally, various degrees of repurposing are required to produce covid- basic things, depending on the items' level of complexity. covid- is setting off the assembling segment to re-evaluate its conventional creation forms, driving digital transformation and smart manufacturing over the creation lines [ ] [ ] [ ] [ ] . ppe refers to protective clothing, helmets, gloves, face shields, goggles, surgical masks, respirators, and other equipment designed to prevent wearer exposure to infection or illness in this covid- pandemic. some of the equipment required for the general public are covered in this article for the benefit of society. a large number of the ppe designs featured here are works in progress, and the viability of privately fabricated subordinates of these gadgets ought to be carefully evaluated locally [ ] [ ] . face shields are personal protective equipment devices that are utilized by numerous specialists for protection of the facial zone and related mucous membranes (eyes, nose, mouth) from sprinkles, splashes, and scatter of body liquids. in common surgical masks and n masks, the assurance is only for nose and mouth, yet eyes are uncovered. these face shields will assist them with protecting their general face for a more extended time without much discomfort [ ] . indian institute of technology madras-bolstered new businesses has created ppe, such as face shields (fig. )from d printers just as generally accessible materials besides to protect healthcare professionals fighting covid- [ , ] . weighing under gm, the d-printed face shields utilize an adaptable plastic casing to fit people without the requirement of elastic bands and can be worn for long hours. it utilizes a replaceable transparent sheet, which is cheap and can be handily taken off [ ] . the stopgap face mask (fig. ) is created as an emergency action to protect frontline workers and secondary support service health care professionals. it consists of two main parts mask body and filter cover [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the mask and filter cover is printed from a biocompatible nylon material using selective laser sintering technology. the others feature for the attachments are flexible straps and rectangular filter patch are disposed of after every use of this device [ ] . mask adjuster (fig. ) plays an important role for hospital staff who need to wear a face mask for an extended period [ , ] . a designer is fabricating thousands of d printed buckles to improve comfort and alleviate associated ear pain for medical workers treating coronavirus patients. another critical factor in the battle against coronavirus is widespread diagnostic testing. the common processes consist of inserting a five-inchlong nasal swab along the nasal septum until the nasopharynx is reached. the swab must then be rotated for up to seconds to collect secretions before being removed and placed in a sterile container for lab testing [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the d-printed swab (fig. ) design is thin at the top and gets gradually thicker throughout the neck and handle. it has a well-designed tip for efficacy in sample collection for a medical professional, and also for patient comfort and safety [ ] . but for large-scale testing ( fig. ), medicinal services experts get tired and exhausted of tedious work. the robot has extraordinary potential for mass screening for covid- in the healthcare sector. so to fulfill these gap robotics researchers from the university of southern denmark have built up the world's first completely programmed robot to do throat swabs for covid- [ ] [ ] [ ] . the d printed robot swabs the patients with the goal that human services experts are not presented to the danger of contamination. e) ventilator parts hp has declared achievement in empowering frontline workers and communities to react to the difficulties of covid- through d printing. hp has collaborated with redington d in india, to effectively create , ventilator parts for agva healthcare (fig. ) . as a major aspect of this activity, classes of parts have been d printed, to make , ventilators [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . these ventilators are being sent across india for the treatment of covid- patients. the parts incorporate breathe in and breathe out connectors, valve holders, oxygen nozzles and solenoid mounts among others. by using the conventional process to prepare such types of complex parts it requires - months to manufacture theses quantities but with hp d printing innovation, these parts were printed in only days [ ] [ ] [ ] [ ] [ ] [ ] . the infection that causes covid- can live on surfaces for a long time which implies it may infect yourself by reaching a contaminated surface. people often have to enter and exit rooms so it may be possible to infect yourself by touching the door handle [ ] . to shield from such kind of polluted surface a d printable door opener (fig. ) can be fitted onto entryways in clinics and organizations, permitting individuals to open entryways without hands. there has been an increased need for facilities to quarantine oneself in this critical situation of covid- . in this demand, winsun, a d printing firm has found an ingenious solution [ ] . by using d-printing powers on an architectural scale firm is preparing coronavirus isolation wards (fig. ) in a single day. the isolation wards are also furnished with electricity and water supplies. this will help overcome the shortage of hospital rooms at a time when the country and the world are facing the covid- crisis. the ficci drone committee comprehend that drones (fig. ) are playing a huge job in a battle against the coronavirus in help to the accompanying activities undertaken by police, healthcare and municipal authorities like surveillance and lockdown enforcement, public broadcast, checking monitoring body temperatures, medical & emergency food supplies delivery, surveying & mapping, spraying disinfectants, etc [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . drone for covid- [ ] "corona killer", as now popularly known, the quick sanitization drones possess the capacity to cover almost km/day and it is times more efficient than manual sprayers and cost-effective, and got its recognition from the government of india. d printing shortens lead times during product development, brings down creation expenses, and engages designers and manufacturers to face more challenges with new d printed drone structures that give new expected applications to the innovation [ ] . digital aerolus, a worldwide innovator in autonomous advancement has developed the essential indoor drone (fig. ) to fight the spread of the covid- contamination with a % cleansing rate. the battel against coronavirus elimination requires a multi-sectoral approach by focusing on treatment, supportive care, prevention and quickly initiate research projects on medical equipment and vaccine development. as per the world bank data shown in the below fig. & fig. point to the strong possibility that the strength of the healthcare system and the base level of health in the general population are two other important factors that matter crucially. numerous articles have been written in the clinical field identified with the covid- flare-up that has encircled the world and killed numerous individuals. around the world, the episode brought about by covid- makes individuals have restricted social opportunity. general wellbeing activities, for example, social distancing, can cause individuals to feel confined and desolate and can build pressure and nervousness. however, these activities are important to decrease the spread of covid- [ , ] . then again, reductions in greenhouse gas emissions are seen because of altogether reduced street transport, reduced industrial, educational and other activities. with restrictions on up close and personal clinical meetings in the covid- pandemic and the difficulties looked by medical care frameworks in conveying patient care, innovations like telemedicine and smartphone are playing a key role [ ] [ ] [ ] . to avoid a potential pandemic-level outbreak of coronavirus, recommendations to utilize advanced manufacturing resources to provide hospital services in a short duration of time. medical parts are available but because of logistical and supply issues, they may not reach at requiring place in time. d printing has gotten an opportunity to prove itself as an answer for the quick creation of basic segments for life-saving machines in the tragedy of covid- . the government of india (goi) launch different schemes/services (fig. ) to raise funds and adopt new technologies in manufacturing and another sector. india is an important player and tremendous potential for diffusing new technology in the indian market and get economic benefits with affordable additive technology price, and future possibilities continue to rise. government of india schemes / services [ ] [ ] [ ] in this context, the objective of the study is to scrutinize the motivational factors of entrepreneurs that encouraged to adopt additive technology and how its function as responsible innovation. additive manufacturing society of india's vision for aims to put a d printer in every educational institute in india, so its help to education is a practical based. in this regard, they organize a business summit such as gujarat vibrant, the plastic summit, etc. moreover, the examination additionally looks at specific chances and difficulties that impact the adjustment procedure; and describe explicit plans of action contributes towards reliable development. portuguese specialists are working with lisbon university, fan d and others to create formats and legitimate systems to bring resident drove d printing into clinical arrangement. elsewhere in europe, the european commission is working with the european association for am on [ , ] . am has the upside of facilitating the production of complex building structures, for example, clinical gadgets including ppe that can't be easily produced using traditional methods. customization is tedious and costly when by conventional manufacturing techniques. this is the place am makes well and aides in the plan of customized product. metal cutting pioneer, sandvik coromant [ ] , has built up another d demonstrating procedure that can d print up to plastic face shields in the time conventional methods require to print one. this innovation makes ideal fit of the customized product, saves time as well as cost [ ] . a short review identified with the most recent d printing endeavors against covid- is represented in table . overall information from this examination shows that face shields are essentially faster to d print than face masks, requiring less material, less d printed parts, and along these lines costing less to d print, which might be contributing variables to the prominence of face shields among producers compared to face masks. subsequently the determined d printing potential on the globe is in truth moderately assessed to be in any event - times bigger, and along these lines can huge affect the lack of clinical flexibly in the current circumstance. moreover, it ought to be noticed that specific d printing advances are better for assembling explicit kinds of items than others. based on the discoveries, our investigation gives measurable proof that the most potential medical services items that can be fabricated utilizing d printing are those that have a high profitability with a single set of equipment and with boundless accessibility of hardware in the market. in any case, this new unregulated flexibly chain has additionally opened new inquiries concerning product certification and ip. there is a squeezing need to create d printing clinical norms for current and future pandemics. indian governments are likewise observing all the points and effectively reassuring advancement in this space. the first impact is to improve as-is forms by quickening the structure period of new item advancement, upgrading quality by different rounds of testing of models well in time and modifying the manufacture of tooling to improve profitability. the subsequent effect is on item development by decreasing driving weight, production cost and assembly process through part simplification and empowering quick customization of parts. the third effect is to investigate the reduction of after-market part inventory through disseminated producing and improving business sector responsiveness and reducing lead time for customization of embellishments or elite parts. at long last, overall disruptions in the plan of action are normal as am can help the worth creation portion of original equipment manufacturer (oems) and investigate choices for on location manufacture to quicken support and fix for costly segments. in such manner, a forward-thinking survey has been led to decide the capacity of am for giving elite advantages to mankind inside the clinical medical services supplies division. notwithstanding the numerous advantages identified with utilizing am in medical care applications, there are some significant limitations, and consequently the focal points and impediments of this innovation have been introduced. the findings show that experts and investigators who used to with am can focus on the current situation of am from their perspective. it brings another change in perspective in shaping and performing creative thoughts for designers and innovators. additive manufacturing 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prevention and imaging features of covid- agnishwar jayaprakash garuda aerospace pvt ltd world's first indoor disinfection drone ready to fight covid- covid- pandemic in europe countries in the world by population factors related to preventive covid- infection behaviors among people with mental illness fake news and covid- : modelling the predictors of fake news sharing among social media users have traffic restrictions improved air quality? a shock from covid- effects of covid- outbreak on environment and renewable energy sector covid- and applications of smartphone technology in the current pandemic list of union government schemes in india available at young india-vibrant india. pib headquarters d printing and coronavirus: u.s. additive manufacturers share their experiences. additive manufacturing (newsletter) covid- outbreak in malaysia: actions taken by the malaysian government fast-tracking face shield production with d modeling technique fast mass-production of medical safety shields under covid- quarantine: optimizing the use of university fabrication facilities and volunteer labor d printing to support the shortage in personal protective equipment caused by covid- pandemic examplatory use of d printing to provide medical supplies during coronavirus (covid- ) pandemic in mumbai-based startup d prints protective face shields for doctors. boson machines, a mumbai-based d printing firm iit-madras startups develop ppes from d printers and regular stationery materials hyderabad start-up is d printing face shields, hands-free door openers to stave off covid's spread china pushes all-out production of face masks in virus fight iit kanpur to produce , masks per day available at govt panels flag issues with agva ventilators bought by pmcares fund d printed multipurpose door opener tool for covid . defence research and development laboratory (drdl), drdo ministry of defence, kanchanbagh, hyderabad. . d printing centre(poland) the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. key: cord- - javg m authors: kumar, jagdesh; katto, muhammad soughat; siddiqui, adeel a; sahito, badaruddin; jamil, muhammad; rasheed, nusrat; ali, maratib title: knowledge, attitude, and practices of healthcare workers regarding the use of face mask to limit the spread of the new coronavirus disease (covid- ) date: - - journal: cureus doi: . /cureus. sha: doc_id: cord_uid: javg m introduction many countries including pakistan are currently using face masks in their pandemic control plans. being highly prevalent, the correct use of these masks is particularly important, as an incorrect use and disposal may actually increase the rate of transmission. the purpose of this study was to investigate the knowledge, attitude, and practices of healthcare workers (hcws) in wearing a surgical face mask to limit the spread of the new coronavirus disease (covid- ). materials and methods this survey was conducted by interviewing hcws using a questionnaire consisting of the basic demographic characteristics, and the knowledge, attitude, and practices regarding the use of surgical face mask to limit the new covid- exposure. each correct answer was scored and each incorrect answer scored . the total number of questions was , and the final score was calculated and then labeled according to the percentage (out of ) of correct responses as good (> %), moderate ( - %), and poor (< %). results a total of participants with a mean age of . ± . years ( males and females) were included in the study. the overall final results were good in ( . %), moderate in ( . %), and poor in ( . %). around . % of participants knew about the correct method of wearing the masks, . % knew that there are three layers, % stated that the middle layer act as a filter media barrier, and . % knew the recommended maximum duration of wearing it. the majority ( . %) of participants knew that a cloth face mask is not much effective, around . % knew that used face mask cannot be re-used, and . % knew about the yellow-coded bag for disposal. conclusions knowledge, attitude, and practice of hcws regarding the use of face masks were found to be inadequate. studied hcws had a positive attitude but moderate-to-poor level of knowledge and practice regarding the use of face mask. hcws and general public awareness campaigns regarding the proper use of face mask by utilizing all social media available resources would be helpful during this pandemic. coronavirus disease (covid- ) is a respiratory illness caused by severe acute respiratory syndrome coronavirus (sars-cov- ), which first emerged in china in december , and has since spread to most countries around the world, resulting in the - coronavirus pandemic [ ] [ ] [ ] . the virus primarily spreads between people through respiratory droplets, which are produced when an infected person coughs or sneezes, or by touching contaminated surfaces or objects and then touching their own mouth, nose, or possibly their eyes. the risk of getting severe covid- is higher in health care workers (hcws) who are in close contact with confirmed covid- cases. the latest figures show thousands of hcws getting infected with a large percentage of them dying [ ] . in order to minimize risk, hcws are required to follow accepted infection control practices. aside from hand hygiene, one of the infection control measures is the routine use of a face mask. many countries including pakistan are currently using face masks in their pandemic plans. face mask works by providing a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment [ ] . in resource-limited settings, where the incidence of infectious disease is high and the environmental conditions of hospitals are often poor, hospitals may rely heavily on a face mask to protect medical staff against covid- and to prevent cross-contamination among patients and hcws. the use of a face mask among hcws is strongly recommended by the world health organization (who) and the centers for disease control and prevention (cdc) as a standard for transmission-based precaution [ , ] . moreover, the correct use of these masks is particularly important especially during this time when its use is becoming highly prevalent [ ] . the who states that incorrect use and disposal of this mask may actually increase the rate of transmission. if you wear a mask, then you must know how to use it and discard it properly [ ] . there is evidence that the hcws have inadequate knowledge and poor practice regarding the use of surgical mask [ ] . the purpose of this study was to investigate the knowledge, attitude, and practices of hcws in wearing a face mask particularly a standard surgical face mask to limit the spread of covid- . this cross-sectional community-based survey was conducted at the department of orthopedic surgery, dr. ruth k. m. pfau civil hospital, affiliated to dow university of health sciences, karachi, pakistan, in march (one month). the study participants were hcws, that is, consultant, medical officer, postgraduate trainee, house officer, and paramedical staff. a convenient sampling method was used and a sample size of was calculated, considering % precision, % confidence interval, and % as the correct practice of using face masks [ ] . keeping a minimum sample size of in mind, a total of patients were registered in the study duration. the study was conducted by interview using a semi-structured questionnaire. the questionnaire was developed with the help of previous literature on the proper use of surgical face mask and the guidelines of the centre for health protection and the cdc and consisted of two parts:( ) basic demographic characteristics (age, gender, job designation), and ( ) knowledge, attitude, and practices regarding the use of a face mask to limit covid- exposure [ , , ] . prior to the inception of the study, the nature and purpose of the study were explained to each respondent, and informed consent was obtained. for the convenience of analyses, each correct response in the knowledge category, good practice, or positive attitude was scored , and each incorrect response, bad practice, or negative attitude was scored . the total number of questions was , and the final score was calculated and then labeled according to the percentage (out of ) of correct responses as good (> %), moderate ( - %), and poor (< %). the information obtained from the participants was entered and analyzed using statistical package for the social sciences (sdss) statistics for windows, version . (ibm corp., armonk, ny, usa). mean with standard deviations were calculated for age and frequency with percentages for categorical variables. face masks are used as a protective barrier to reduce the risk of transmission of microorganisms between patients, hcws, and the environment [ ] . however, in order for face masks to provide effective protection, the hcws must have an intimate knowledge of wearing and disposing of those. in this study, . % of participants thought that they knew the proper steps of wearing a surgical face mask; however, only % obtained a good score by answering the procedural questions correctly. these results may be because of its simplest design, which leads many participants to mistakenly assume that they know the proper steps of wearing it. there was higher male participation in our study ( . %) compared with female participation ( %). this finding can be attributed to the higher male enrolment in our institution. in this study, . % of participants obtained an overall moderate-to-poor score regarding the correct usage of a surgical face mask. this low knowledge and practice may be because of recently circulating messages on social media claiming the proper way to wear the threelayered surgical mask, like "colored side facing out if you are sick, and the white side facing out if you want to 'stop the germs from getting in'". this is, however, false and misleading, according to nawhen, a columnist for medical mythbusters malaysia, a non-governmental organization that works to counter myths and inaccurate facts on medical matters; the correct way to wear a surgical mask is by wearing the colored side facing out independent of your health status. the outer colored layer is hydrophobic or is a fluid-repelling layer and its main function is to prevent germs from sticking to it, whereas the inner one is a hydrophilic layer that absorbs moisture from the air we breathe out. if you wear it the other way round, the moisture from the air will stick onto it, thus making it easier for germs to stay there. there is a middle layer that actually filters the microorganism [ ] . cloth mask, re-use of a surgical mask, and its extended use are commonly seen in pakistan during the extended outbreak of the covid- pandemic. it is highly unlikely for low-income countries that they will be able to provide disposable face masks for that extended period of time and may have to ration the use of these products. in this study, around . % hcws agreed that cloth mask is not as effective as a regular surgical mask and about . % knew that used surgical face mask cannot be re-used. around . % knew the correct maximum duration of using it. other studies also highlighted similar findings concluding that cloth mask, re-use, and extended use of mask makes it ineffective, still hcws are sometimes forced to do it due to the increasing shortage of these masks. we observed that wearing the same mask without removing it between patient encounters and disposing it properly at the end of the day is better than re-using it. still if re-using it due to shortage, it is better to fold the mask in such a way that the outer contaminated surface is held inward followed by storing it in a clean sealable paper bag or container [ ] [ ] [ ] . there is not enough evidence to prove that wearing a surgical mask protects every person from covid- . the who currently recommended that only hcws and people who are ill and those who are caring for the ill need to wear a mask to protect themselves from covid- . however, in low-income countries like pakistan, where the incidence of infectious disease is high and the hospital environmental conditions are often poor, our hcws rely almost entirely on a face mask to limit the spread of covid- [ ] . the who established a color-coded bin system for proper disposal of biomedical waste in hospitals [ ] . however, when it was asked from our participants, . % disposed it in the yellow-coded bag for disposal of face mask; this shows poor knowledge of hcws regarding the safe disposal of biomedical waste. some of the limitations of this study include the cross-sectional nature of study design limited to a single governmental hospital. further longitudinal studies should be carried out on a larger sample size, and both private and government hospitals should be included before the results could be generalized. moreover, different types of masks can be compared. knowledge, attitude, and practice of hcws regarding the use of surgical face masks were found to be inadequate. studied hcws had a positive attitude but moderate-to-poor level of knowledge and practice regarding the use of surgical face mask. hcws and general public awareness campaigns regarding the proper use of face mask by utilizing all social media available resources would be helpful during this pandemic. rd: features, evaluation and treatment coronavirus (covid- ). statpearls. statpearls publishing epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid- ) during the early outbreak period: a scoping review world health organization declares global emergency: a review of the novel coronavirus (covid- ) clinical course and risk factors for mortality of adult inpatients with covid- in wuhan, china: a retrospective cohort study use of face masks in a primary care outpatient setting in hong kong: knowledge, attitudes and practices. public health guideline for isolation precautions: preventing transmission of infectious agents in health care settings advice on the use of masks in the community, during home care and in healthcare settings in the context of the novel coronavirus ( -ncov) outbreak: interim guidance wearing face masks in public during the influenza season may reflect other positive hygiene practices in japan how effective are face masks in operation theatre? a time frame analysis and recommendations use mask properly knowledge, perceptions and practices of healthcare workers regarding the use of respiratory protection equipment at iran hospitals show your colours: only one way to wear surgical masks correctly, with the coloured side out use of cloth masks in the practice of infection controlevidence and policy gaps a cluster randomised trial of cloth masks compared kumar et al. cureus ( ): e . doi healthcare workers contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers covid- ) advice for the public: when and how to use masks safe management of wastes from health-care activities human subjects: consent was obtained by all participants in this study. dow university of health sciences and dr. ruth k. m. pfau civil hospital issued approval ortho/duhs/ / . animal subjects: all authors have confirmed that this study did not involve animal subjects or tissue. conflicts of interest: in compliance with the icmje uniform disclosure form, all authors declare the following: payment/services info: all authors have declared that no financial support was received from any organization for the submitted work. financial relationships: all authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. other relationships: all authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. key: cord- - a eb mr authors: eckl, l.; hansch, s. title: gender- and age-related differences in misuse of face masks in covid- prevention in central european cities date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: a eb mr abstract objective correct use of face masks is required for their efficacy in preventing possible droplet infections with sars-cov- . we tried to provide information about differences in the distribution of gender and age groups wearing face masks incorrectly. design pilot field study methods visual observation of mask use in public, not age- and gender-related places in central european large cities regarding incorrect mask-wearing (n= ); statistical analysis (nominal scale) in terms of gender and estimated age group using the total numbers, binomial test and chi-square test. results there is no significant difference (binomial test: p-value = . ) in mask misuse between the genders (female: ( . %), male: ( . %) and non-binary individuals ( %)). there is a significant difference (chi-square test: p-value < . e- ) in age group distribution ( young - years ( . %), middle-aged - years ( . %), older adults [≥] years ( . %)). in total numbers, the highest counts were observed in middle-aged persons with counts ( . %). conclusion our study shows an uneven age-distribution of people wearing the face mask in public improperly. keywords coronavirus, sars-cov- , covid- , community, face mask, prevention in the spread of the global pandemic of corona virus disease (covid- ) caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), the necessity of protective countermeasures emerges. dependent upon geographical area, professional or community setting, the use of face masks is controversially discussed or often mandatory. a recent overview by feng et al. [ ] shows how different healthcare authorities handle the current evidence by providing different recommendations on the use of face masks. despite initial discouragement or at least insufficient evidence of risk reduction to get infected, the wearing of face masks in defined situations was recommended by the german federal ministry of health [ ] . public guidelines for the use of face masks were provided by the german federal institute for drugs and medical devices [ ] , inter alia regarding the placement of a closely fitting mask covering mouth and nose. besides other measures like distance and hand hygiene, the optimal use of face masks is needed to provide a sufficient efficacy of the physical barrier's aspired protective effect [ ] . a recent study by leung et al. [ ] on expiratory virus shedding found higher virus loads in nasal swabs than in throat swabs, so an incorrectly worn mask without covering the nose could drastically facilitate disease spread. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint the prevalence of masking after the post-lockdown reopening of businesses has currently been examined in other studies [ , ] , and significant differences in regional, age and gender groups have been found. we address the question: who are the people in public that are not wearing the face mask properly and therefore risk to spread sars-cov- ? this could contribute to improve health behavior education campaigns and / or advertisements, under the assumption, although not proven by this study, that people, who are wearing a mask, and therefore already show compliance with the latest regulations, are generally approachable for the correct use of a mask and prevention measurements. three factors influenced the observations: i) the general age-and gender-distribution in public, ii) the probability that a certain age-and gender-group does not properly use the mask and iii) the distribution seen by the observers. for efficiency reasons with focus on the spreading of sars-cov- in public space, we combined the numbers of the general age-and gender-distribution in public (i) and the probability, a certain ageand gender-group does not properly use the mask (ii) as there is lack of consequences in the first line, if surveyed separately. combining these two factors leads to a distribution of people improperly using the face masks in the public, which itself could risk a higher spread of the infections. factor iii was tried to be minimized, as to be seen in the methods part of this manuscript. we therefore measured the total counts of different age-and gender-groups in public (i and ii combined), that are using the mask incorrectly. between june and september , we performed observations at different times and weekdays in three german (regensburg, augsburg and berlin), one austrian (vienna), and one polish city (szczecin). these observations were conducted by a team of one female and one male researcher and took place in public places and transportation (buses, streetcars, subways, trains, stations, shopping malls, bakeries and supermarkets). each of these places had an official recommendation to wear a face mask. we excluded gender-and age-specific locations, like woman clothing-shops, schools or retirement homes. the male and the female researcher both were medically experienced in signs of pre-aging and physical signs of age. both researchers had to see the person, otherwise the person was excluded. furthermore, both had to confirm the age-group and gender. without confirmation of both scientists, physical signs, like specific clothing, physical signs or family-status were used to determine an age group. as an incorrect fit of face mask, we defined any deviant kinds of mask use, i.e., covering only the mouth or the nose but not both or neither of them, a very loose fit with forming gaps between the mask and the face and taking the mask off for coughing or sneezing. as correct use of the face mask served the who recommendation, as to be seen in the "advice on the use of masks in the context of covid- " [ ] . we considered all people in the mentioned public places as eligible, with the exclusion criteria of ( ) children under the estimated age of years and ( ) individuals with visible physical disabilities like people in wheelchairs, with walking aid or oxygen device. age groups were divided into young ( - years), middle-( - years), and advanced age (≥ years), independently estimated by the two researchers. gender groups included phenotypically female, male, and non-binary gender. observations were taken from a distance without interaction between researchers and subjects. notes were taken digitally by a tally list in the above-mentioned categories. we conducted statistical analysis (nominal scale) in terms of gender and age, total numbers, binomial test, and chi-square test using the r-functions chisq.test() and binom.test(). is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint we tried to further minimize the above-mentioned distribution seen by the observers (iii) by different approaches. one of these approaches concerns the time of the day. we performed separate measurements, either between morning and noon ( am - pm, three measurements) or in the afternoon ( pm - pm, three measurements), for an average duration of . hours for each observation. another approach was made by watching different cities. both are analyzed as part of the whole statistical analyses and separately. there was no acquiring of personal data, so no conclusions on individuals can be drawn. therefore, the university of regensburg ethics committee saw a board review of our study as not obligatory. we observed samples of incorrect mask use, shown in table and figure . the first question was if there is a difference in misuse of the face mask between the genders. as we observed no cases in the non-binary gender group, only male and female genders are mentioned in the following. our hypothesis was, that there is no difference between man and woman in misuse. therefore, we compared the total numbers of each gender ( (female) vs. (male)) using the binomial test and received a p-value = . . this p-value is above our significance level of p< . . furthermore, we applied the chi-square test on our data, which showed x-squared = . , df = , p-value = . , which also indicates no difference. another question was if there is a difference between the age-groups (young with , middle-aged with and older adults with persons). we also applied a chi-square test and received x-squared = . , df = , p-value < . e- . this p-value is below p< . and shows, that misuse of face masks is significantly age-related. in total numbers, the highest counts were observed in middle-aged persons with counts ( . %). further analyses, which are especially addressing different cities and different daytimes are shown in table and table . all these analyses are statistically significant. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint figure total numbers of observed subjects is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint our study aims to determine if there is a relevant difference in the misuse of face masks between subgroups in terms of gender and age. this study is the first one to assess the misuse of face masks during the current global pandemic. this topic is especially of interest, to evaluate the application of protective countermeasures in public, and it can contribute to further modelling and prognosis of pandemic spread. another strength is the relative high case number, which allows a representative statement about our study question, and makes it comparable to other works. we performed our observations in cities in the south (regensburg, augsburg) and the northeast of germany (berlin), in a large polish city (szczecin), and the capital city of austria (vienna) to improve the study design by decreasing regional effects. here must be said that the highest number of observations was taken in regensburg, but a cross-analysis (see tables and ) between regensburg and the other cities shows a significantly uneven distribution of age groups with p-values below our level of significance of < . . also, some limitations must be noted. one is the time window of our observations in terms of the whole timespan. there may be an effect of in-or decrease of mask misuse over time in the assessed places, influenced by the current climate of public opinion or the continuously updated state of knowledge. another limitation lies within the location of our observations. these were taken mainly in centrally located malls, shops, supermarkets and stations of large cities as described in methods. rural areas, senior homes, universities, and suburban regions are not included in our study. further and more widespread investigation can contribute to exploring the topic of mask misuse in these areas. our pilot-study shows a significant, gender-independent difference between age groups in the correct use of face masks in public. this serves as a reference point for our further investigation concerning subgroup-analyses and prevalence studies, which are already in preparation. the results may be useful in health education and advertising, like promoting to avoid public places or the correct mask use, addressing especially subgroups with highest misuse rates. . cc-by-nc-nd . international license it is made available under a perpetuity. is the author/funder, who has granted medrxiv a license to display the preprint in (which was not certified by peer review) preprint the copyright holder for this this version posted november , . ; https://doi.org/ . / . . . doi: medrxiv preprint rational use of face masks in the covid- pandemic coronavirus sars-cov- : chronik der bisherigen maßnahmen hinweise des bfarm zur verwendung von mund-nasen-bedeckungen (z.b. selbst hergestellten masken physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and metaanalysis respiratory virus shedding in exhaled breath and efficacy of face masks who is wearing a mask? gender-, age-, and locationrelated differences during the covid- pandemic prevalence of mask wearing in northern vermont in response to sars-cov- advice on the use of masks in the context of covid- : interim guidance all authors of this article certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript. we thank florian schlieckau, simon stelzl, karl-peter ittner, gerhard hansch, and fro wirtz for helpful discussions key: cord- -otpwb vs authors: pagliazzi, angelica; mancano, giorgia; forzano, giulia; di giovanni, fabiana; gori, giulia; traficante, giovanna; iolascon, achille; giglio, sabrina title: genetic counseling during covid‐ pandemic: tuscany experience date: - - journal: mol genet genomic med doi: . /mgg . sha: doc_id: cord_uid: otpwb vs background: covid‐ outbreak prompted health centres to reorganize their clinical and surgical activity. in this paper, we show how medical genetics department's activity, in our tertiary pediatric hospital, has changed due to pandemic. methods: we stratified all our scheduled visits, from march th through april th, and assessed case‐by‐case which genetic consultations should be maintained as face‐to‐face visit, or postponed/switched to telemedicine. results: out of scheduled appointments, were prenatal consultations and were postnatal visits. we performed most of prenatal consultations as face‐to‐face visits, as women would have been present in the hospital to perform other procedures in addition to our consult. as for postnatal care, we suspended all outpatient first visits and opted for telemedicine for selected follow‐up consultations: interestingly, % of our patients’ parents revealed that they would have cancelled the appointment themselves for the fear to contract an infection. conclusions: spread of covid‐ in italy forced us to change our working habits. given the necessity to optimize healthcare resources and minimize the risk of in‐hospital infections, we experienced the benefits of telegenetics. current pandemic made us familiar with telemedicine, laying the foundations for its application to deal with the increasing number of requests in clinical genetics. sharing for other members of the family. the relationship between patient and physician is, therefore, more demanding for both parties and must be based on mutual trust. as of april th , sars-cov- virus was accounted for infections and deaths in italy (world health organization, https://www.who.int/emerg encie s/disea ses/novel -coron aviru s- /situa tion-reports), making our country one of the worst affected. covid- outbreak has proven to be a rapidly evolving and complex situation: the fast spread of sars-cov- infection in italy at the end of february led italian government to set a nationwide lockdown starting on march th. given the state of emergency, health centres were asked to reorganize clinical and surgical activities in order to reduce the risk of contamination within the hospital as well as to get prepared to admit the prospectively growing number of affected patients. in this unexpected scenario, national and regional authorities suggested to identify and perform only urgent and non-deferrable procedures, suspending elective and postponable activity. in absence of standardized guidelines, each surgical (cini et al., ) and clinical (danese et al., ) department had to individually face their activities' reorganization, in order to maintain as good as possible standard of care, to optimize healthcare resources and to reduce the risk of hospital-acquired infection to lowest term. aim of this present paper is to show how, in a tertiary pediatric hospital, our medical genetics department's activity has changed due to covid- outbreak. we queried our prospectively maintained outpatient clinic database from march th through april th. we recorded patients' personal data, type of consultation and clinical indication: in detail, we stratified our visits considering type of counseling (prenatal and postnatal), type of appointment (first or follow-up visit), and, finally, type of setting (outpatient clinic or inpatient consultation). we, therefore, took note of how many and, more interesting, which type of consultations we decided to ( ) maintain as face-to-face visit, ( ) reschedule later in time or ( ) switch to telemedicine consultation, trying to draw up as standardized as possible criteria. to test the appreciation of telemedicine, we sent an email survey to the families' address, after the consultation. during that period, every member of our hospital's medical staff was tested for sars-cov- virus, through both rapid serologic test and nasopharyngeal swab simultaneously, in order to reduce hospital-acquired sars-cov- infections. similarly, all patients, who had to be hospitalized for scheduled or emergency procedures, were tested just before admission, in order to exclude a sars-cov- contamination. outpatients and their caregivers were not routinely tested for covid- but they underwent temperature screening with a thermal scanner at hospital entrance. for each child, only another person (parent/caregiver) was allowed to enter the hospital. in exceptional cases and after physician's specific request, both parents could be admitted to the hospital, for example, to sign informed consent. lastly, all patients and all members of hospital staff were provided with surgical masks. out of scheduled appointments, were prenatal consultations and were postnatal visits ( figure ). in our hospital, prenatal genetic consultation is generally programmed so to be performed along with other prenatal either invasive or non-invasive procedures, providing women with a thorough and well-scheduled prenatal diagnosis program. given the non-postponable nature of most of our prenatal consultations and considering that women would be admitted to the hospital on the same day to undergo other procedures, we performed all the scheduled consultations as face-to-face visits. as for post-test counseling, we decided upon a face-to-face consultation in case of pathological results, opting for a telemedicine meeting to return normal results, subject to patient's agreement. in our department, postnatal genetic activity is divided into outpatient clinic, for both first and follow-up visits, and inpatient consultations, generally prompted by other specialists' requests. given the rapid spread of sars-cov- virus infection in tuscany, all outpatient first visits were suspended from march th. the subsequent need to reschedule so many appointments has meant a significant organizational issue, which will probably require us to establish criteria in order to stratify consultations, based on their urgency and on the possibility to perform them as telemedicine visits. concerning already scheduled outpatient follow-up appointments, in these last two months we had to go through our working plan case-by-case, so to decide which ones could be performed as telemedicine consultations and which ones actually required an in-person visit, rescheduling these last ones. interestingly, once called by our medical staff, most of our patients' parents ( %) told us that they would have cancelled the appointment themselves, fearing to contract covid- inside the hospital. we also opted for telemedicine consultations to return genetic tests results: following every remote consultation, we drafted a detailed report and sent it by e-mail protected by a password communicated exclusively to the patient's family/caregiver. out of telemedicine consultations performed ( postnatal follow-up visits and prenatal consultations to return negative results), ( %) families responded to the survey, reporting a satisfying level of communication. with regard to inpatients' genetic consultations, we observed a reduction in the number of requests received by our department in this period; we usually perform a minimum of inpatient visits a month, but only consultations have been requested from march th to april th. this noticeable decrease in the number of inpatient consultations reflects the reduction of routinely elective clinical and surgical activity in our hospital in this period. as reported in figure , we performed all the inpatients consultations as face-to-face ones. fast spread of sars-cov- virus infection in italy prompted our hospital to rapidly reorganize clinical and surgical activities, in order to optimize healthcare resources and minimize the risk of in-hospital infections (cini et al., ) . therefore, each department in our hospital was asked to temporarily suspend non-urgent clinical and surgical procedures, to avoid unnecessary hospitalizations and outpatient admissions. to the best of our knowledge, this is the first report on changes in daily clinical practice at a medical genetic department of a tertiary pediatric hospital, during actual pandemic. concerning the medical genetics department activity, we continued to perform prenatal first appointments and inpatient consultations as face-to-face visits, as patients would have been present in the hospital to perform other procedures in addition to our consult. regarding prenatal care, technological advances in the field of prenatal genetic diagnosis have made it essential to provide detailed pre-and post-test counseling to women and their families; current advanced molecular and cytogenetics technologies like snp-array and exome sequencing, which should be offered in a tertiary care centre, can reveal even unknown or of uncertain significance results which must be explained in detail by a medical geneticist (hui, szepe, halliday, & lewis, ) . therefore, in addition to an extensive illustration of possible results and clinical implications of a given genetic test, it is important to provide support to patients and to reassure them (harding, hammond, chitty, hill, & lewis, ) . even in such critical period, thanks to a wellestablished prenatal diagnostic program that gives us the chance to concentrate multiple visits in a single day, our patients could benefit from face-to-face genetic consultations, receiving adequate support and gaining proper understanding of given information. regarding the postnatal setting, we maintained very few of the scheduled follow-up appointments, choosing to either postpone or convert to telemedicine consultations most of them. we opted for telecommunication in selected cases, thus finding an efficient alternative to the classic face-toface visit for ensuring continuity of care. telemedicine consultation proved to be an effective method to provide genetic counseling, receiving positive feedback from both patients and genetics specialists: in a systematic review (hilgart, hayward, coles, & iredale, ) , authors concluded that telegenetics, through the use of videoconferencing tools, is an acceptable method of performing any type of genetic consultation, both in the prenatal setting and to evaluate pediatric patients with suspected genetic conditions. previously, some experiences about the use of telegenetics across united states and europe have been reported; however, application of telemedicine appeared to be different among the various hospitals (otten, birnie, lucassen, ranchor, & van langen, ; terry et al., ) . so far, in italian healthcare, patients have never been inclined to accept telemedicine as a clinical procedure equivalent to in-person visit: this uncertainty regarding the clinical value of telemedicine was probably related to the stereotype for which the development of a relationship between patient and physician could not occur without a face-to-face method. despite this reluctance to employ a method already in use in other european countries and so sporadically in our territory, the provision of support through a telehealth approach has been really useful to maintain the psychological wellbeing of our patients. according to our recent experience, telemedicine made it possible to remain in contact with patients, to follow and to answer questions about the clinical course of a given condition and to communicate genetic tests' results providing an exhaustive explanation. so far, we opted for telemedicine only in selected post-test consultations in the prenatal setting, and in case of follow-up consultations in the postnatal setting, suspending all the first outpatient appointments for these two last months. given the uncertainty of the current pandemic situation, it is now mandatory for us to think about how to deal with to the increasing demand for genetic counseling, also taking benefit from telemedicine. since there is currently no standardized approach or guidelines on telegenetics, we need to establish specific criteria to make an a priori assessment of the first visits in terms of urgency, also trying to discern whether they can be performed as telemedicine consultation or must be done as in-person visit. being a tertiary referral centre, our hospital mostly attracts pediatric patients who need a multidisciplinary diagnostic approach, within which geneticist has the role to coordinate various investigations: in this specific setting, the experience of the clinical geneticist is essential and, usually, a detailed face-to-face evaluation is pivotal to guide the diagnostic path in order to reach the diagnosis (malinowski et al., ) . since genetic consultations in pediatric patients are mainly required by pediatricians or other specialists, setting up a network for sharing patients' clinical information might be extremely useful in order to stratify requests for first consultations. by adopting this approach, it would be possible to refer complex patients to a tertiary hospital, providing them with a well-structured diagnostic path that includes a first face-to-face genetic consultation ( figure ) ; instead, firstline tests might be offered to patients with less complex and heterogeneous phenotypes in smaller hospitals. in conclusion, spread of sars-cov- virus infection in italy forced us to change our working habits. with regard to prenatal care, we opted for in-person consultations, for they are scheduled on the same day of other procedures and also because we prefer to maintain a face-to-face approach in this delicate setting. as for postnatal care, we experienced satisfactory communication through telemedicine, for both returning genetic test results and receiving updates about our patients. although we have always been used to a face-to-face counseling, the current pandemic situation made us get acquainted with the benefits of telemedicine in such a complex situation, also in terms of reducing waiting times. furthermore, given the limited number of clinical geneticists in our country, telegenetics services, which make genetic counseling feasible through the internet, can provide consultations faster and with a reduction of waiting lists. we experienced that genetic consultations performed with telemedicine revealed to be equal to face-to face visits. both patients and f i g u r e reorganization of medical genetics department in the light of covid- pandemic | of pagliazzi et al. providers reported a greater appreciation of real-time videoconferencing over telephone call to perform the consultation. it is interesting to note that, in addition to the fear of contracting an infection in the hospital, most families appreciated the proposal for telemedicine consultation because they could carry out the visit without travelling long distances. given the uncertainty of covid- outbreak's course, we must define a new plan to manage postnatal first consultations: developing a network to share clinical information among geneticists, pediatricians and other pediatric specialists might represent an essential step to prioritize the increasing number of requests, in order to choose wisely which cases should be approached with an in-person genetic consultation in a multidisciplinary setting. improvement of real-time videoconferencing with high-speed technologies will hopefully help us integrate telegenetics consultations in our clinical routine and will allow us to tele-communicate even more complex and clinically significant results, providing a satisfying connection between patient and physicians. paediatric urology practice during covid- pandemic gastroenterology department operational reorganisation at the time of covid- outbreak: an italian and chinese experience couples experiences of receiving uncertain results following prenatal microarray or exome sequencing: a mixed-methods systematic review telegenetics: a systematic review of telemedicine in genetics services maternity health care professionals' views and experiences of fetal genomic uncertainty: a review systematic evidence-based review: outcomes from exome and genome sequencing for pediatric patients with congenital anomalies or intellectual disability telemedicine uptake among genetics professionals in europe: room for expansion clinical models of telehealth in genetics: a regional telegenetics landscape emerg encie s/disea ses/novel -coron aviru s- /situa tion-reports how to cite this article we acknowledge dr. riccardo tellini (department of urology, careggi hospital, florence, tuscany, italy) for his support in the conceptualization of this idea. we acknowledge all the members of the medical genetics unit of the meyer university hospital for children in florence for their contribution to the realization of the project and we thank our patients and their families for participating in the survey. nothing to disclose. pa, gs designed and conceived the project. pa, fg, dgf, gg, tg collected and analyzed data and survey results; pa, gs wrote the manuscript; ia, mg revised the manuscript; and gs supervised the project. https://orcid. org/ - - - giorgia mancano https://orcid. org/ - - - achille iolascon https://orcid.org/ - - - sabrina giglio https://orcid.org/ - - - x key: cord- -r rsbfs authors: chowdhury, mohammad asaduzzaman; ahmed shuvho, md bengir; shahid, md abdus; haque, a.k.m. monjurul; kashem, mohammod abul; lam, su shiung; ong, hwai chyuan; uddin, md. alhaz; mofijur, m. title: prospect of biobased antiviral face mask to limit the coronavirus outbreak date: - - journal: environ res doi: . /j.envres. . sha: doc_id: cord_uid: r rsbfs the rapid spread of covid- has led to nationwide lockdowns in many countries. the covid- pandemic has played serious havoc on economic activities throughout the world. researchers are immensely curious about how to give the best protection to people before a vaccine becomes available. the coronavirus spreads principally through saliva droplets. thus, it would be a great opportunity if the virus spread could be controlled at an early stage. the face mask can limit virus spread from both inside and outside the mask. this is the first study that has endeavoured to explore the design and fabrication of an antiviral face mask using licorice root extract, which has antimicrobial properties due to glycyrrhetinic acid (ga) and glycyrrhizin (gl). an electrospinning process was utilized to fabricate nanofibrous membrane and virus deactivation mechanisms discussed. the nanofiber mask material was characterized by sem and airflow rate testing. sem results indicated that the nanofibers from electrospinning are about - μm in diameter with random porosity and orientation which have the potential to capture and kill the virus. theoretical estimation signifies that an l/min rate of airflow through the face mask is possible which ensures good breathability over an extensive range of pressure drops and pore sizes. finally, it can be concluded that licorice root membrane may be used to produce a biobased face mask to control covid- spread. the emergence of coronavirus and its rapid spread across the globe has led to a large epidemic and pandemic. in response, many countries have initiated prodigious non-pharmaceutical activities like lockdowns, social distancing, and closure of educational institutions. it will be beneficial for people if an appropriate face mask can be designed that can inactivate the virus itself. during coronavirus (sars-cov- ) infections, the face mask is crucial in preventing transmission [ ] . it has been reported that face masks are effective in lowering the spread of the virus. [ ] [ ] [ ] [ ] . sars-cov- is spread through airborne droplets and, in some cases, aerosols containing the virus. respiratory droplets transmission is a serious concern due to the rapid spread and circulation of sars-cov- in humans [ ] . face masks can filter droplets containing the virus. many countries are not yet fully prepared for disease control at this magnitude and may not be able to prevent transmission efficiently. in this regard, a vaccine can comprehensively reduce mortality. however, potential vaccines are still in the trial stage. in this situation, masks can significantly prevent any microbes. thus, the use of personal respiratory masks may be an effective way to reduce transmission of covid- however, face masks that are currently available in the market may not reduce the transmission of the virus in the community because they are not used correctly. it would be better and advantageous to reduce the transmission of the virus if the face mask itself could damage the virus. in addition, most current face masks have a pore size which is larger than the virus. it is a major challenge for researchers to inactivate the virus, thus, they are trying to develop a universal virus capturing system. nevertheless, face masks become an important global healthcare measure amid the coronavirus pandemic. it is a challenging task during the pandemic to balance the supply of and demand for masks during disease outbreaks. currently available masks, which are made of non-renewables, are environmentally hazardous and non-biodegradable. the processing of single-use masks made of synthetic polymers produces environmentally damaging microplastics. therefore, the efficacy of mask disposal must be improved urgently by integrating raw materials that are intrinsically j o u r n a l p r e -p r o o f environmentally friendly, lightweight, and disposable and provide a high standard of efficiency at a low cost. in this circumstance, plants with antimicrobials properties such as oregano, sage, basil, fennel, garlic, and licorice can significantly reduce the spread of coronavirus [ ] . among these plants, licorice has potentially very powerful antiviral properties [ ] . it is a common herb traditionally used in the asia-pacific region. researchers have demonstrated that licorice is effective against rsv, hiv, and sars-cov, all of which causes serious pneumonia [ ] [ ] [ ] . researchers have found that different elements of licorice are responsible for antimicrobial and antiviral activities through various mechanisms. licorice contains around flavonoids and more than triterpenoids. among them, two triterpenes, -β glycyrrhetinic acid (ga) and glycyrrhizin (gl) have been shown to have antiviral properties and the potential to weaken virus activities [ ] . the recent study discloses that the polymeric form of glycyrrhetinic acid leads to excellent antiviral effects [ ] . therefore, this study aims to develop and assess the porosity of a fibrous threelayered filtration mask made from licorice root membrane. no study on the development of biobased face masks using licorice root membrane was found in the literature. therefore, it is expected that the outcome of this research will guide researchers, scientists and policymakers to develop biobased antiviral face masks to reduce the spread of covid- . in this study, licorice root was used to fabricate the nanofibers due to its viral inactivation compounds including gl and ga, which possess an antimicrobial capacity. nanofibers destroy the virus by releasing gl and ga via contact inhibition or immobilization. plants have been utilized for drug development, thus, it would be expedient to investigate and characterize the possible fusion of the active elements of these plants for anti-viral applications. licorice nanofibers can be assembled for increased protection against covid- . polyvinyl alcohol (pva) is a biocompatible nontoxic, highly hydrophilic semi-crystalline polymer with remarkable properties such as water solubility, strength, gas permeability, and thermal characteristics [ ] . pva solution has been used broadly in the electrospinning process because of its ability to produce biodegradable mats and ultrafine separation filters. pva solution helps the formation of excellent quality nanofibers in electrospinning. j o u r n a l p r e -p r o o f licorice roots were washed thoroughly with mineral water, ground and then immersed into methanol from sigma-aldrich (ns: m= : ) for hours for extraction. the extracts were filtered twice through a quadruple layer of nylon mesh fabric and then evaporated at ℃ while being magnetically stirred until a jelly of ns polymer formed. in addition, g polyvinyl alcohol (pva) with a molecular weight (mw) of , dp of - , viscosity: - cps, % hydrolyzed granules were sourced from loba chemical (india). pva was mixed with ml deionized water to obtain wt % (w/v) solution. this mixture was stirred and heated to °c to attain a clear, highly soluble and transparent solution. next, g of licorice extract was mixed with ml pva solution to prepare the final solution for electrospinning. an electrospinning machine (model tl- , tong li tech) produced the nanofibrous membrane using pva and licorice root extract under optimized processing parameters. figure depicts the process from licorice root extract to mask design. the prepared solution was transferred to a plastic syringe attached to a capillary tip with an inner diameter of gauge ( . mm). the plastic syringe was placed at a ° angle and the distance between the collector and capillary tip was maintained at cm. the copper wire attached to a positive electrode at kv was inserted into the solution and a negative electrode at kv was connected to a metallic collector. the solution pumping rate was fixed at mm/h. the measurement of airflow through the pores of the mask is important to determine the functionality of the mask. the airflow rate q (m /s) has been calculated using equation while the air mean velocity ܷ (m/s) has been determined using equation [ ] . where, ∆ܲ is the pressure drop across the face mask, ݀ is the diameter of the mask pore, η is the air dynamic viscosity (pa.s), h is the pore length (m), a is the mask area (m ), and m is the number of the pores. the air dynamic viscosity was taken at °c. the ∆ܲ is maintained at pa and the thickness of the face mask is maintained at µm. to simplify the estimation, the shape of the pore is considered circular due to the nanoscale range. additionally, it has been assumed that the airflow is laminar and the effects of friction is negligible. the mechanism of virus deactivation is shown in figure . the topography of fabricated nanofibrous membrane shows that sneezed microdroplets can be easily captured and inhibited. cinatl et al. [ ] report that the most active compound of licorice root in inhibiting the sars related virus is glycyrrhizin. glycyrrhizinic acid (glr), a triterpenoid saponin, is mainly isolated from licorice root, which is effective against a variety of human viruses [ ] . the study by the researcher [ ] shows clear evidence that glycyrrhizinic acid isolated from licorice has antiviral properties that can deactivate the virus and stop replication. droplet microbes are locked on the agent and infectious droplets are rapidly opened by hydrophilic action leading to exposure of viruses. the trapping and inhibiting properties of the licorice root inactivates the virus quickly. gl and ga are capable of damaging biomolecules such as portions, lipids and dna [ ] . j o u r n a l p r e -p r o o f shows that a licorice root particle density of about . particles/mm was detected, which signifies that a maximum amount of the licorice roots was formed to nanofibers. figure (a) shows that the airflow rate is increased with an increasing pore size, which signifies that the breathability of the mask membrane is improved because of the improved porosity of the mask membrane. it is also worth mentioning that the pore size of nm, which is smaller than the size of covid- , is needed to maintain a good breathability of l/min [ ] . moreover, the fabricated membrane allows good breathability across an extensive range of pressure drops as shown in figure (b). a higher airflow resistance signifies a higher pressure drop that reduces the breathability of the face mask [ ] . in this situation, an increasing airflow rate would not influence the filtration efficiency if the pore size of the mask membrane were maintained at a size smaller than the size of covid- as a consequence of the straining mechanism [ ] . increasing the airflow rate affects the filtration efficiency if the pore size is larger than the particle size as for an n face mask with a pore size of nm. most countries in the world have taken many precautionary measures against covid- . government officials have been continuing to make efforts to reduce crowds in public places and many steps have been taken to ensure people's safety such as social distancing, reducing public transport, and the shutdown of offices and factories. this may reduce covid- cases, but the economic crisis is still going to worsen. to avoid the spread of covid- and ensure a sense of protection and wellbeing for all, personal hygiene must be preserved until an effective vaccine is produced. the face mask is one safety measure and there is a significant rise in the use of face masks every day, numbering in the millions, resulting in a high demand for materials. in this paper, we have proposed the potential of the licorice root membrane as a nanofiber that can be used in the production of a face mask. the porosity of the proposed mask is less than the size of covid , thus, it is believed that this mask can help to prevent the spread of the virus. despite significant findings on the potential of licorice root membrane as a raw material for face masks, some limitations remain. for example, the performance of a mask depends on the fluidresistant, bacterial filtration and particulate filtration capacities. therefore, further comprehensive research is still necessary to explore these variables and give a clearer picture of their virus-resistant capacity. a quantitative assessment of the efficacy of surgical and n masks to filter the influenza virus in patients with acute influenza infection wearing face masks-the simple and effective way to block the infection source of covid- covid- : face masks and human-to-human transmission efficacy of face mask in preventing respiratory virus transmission: a systematic review and meta-analysis airborne sars-cov- and the use of masks for protection against its spread in wuhan influenza viruses are transmitted via the air from the nasal respiratory epithelium of ferrets traditional chinese medicine treatment of covid- commentary: the antiviral and antimicrobial activities of licorice, a widely-used chinese herb glycyrrhizin, an active component of liquorice roots, and replication of sars-associated coronavirus water extract of licorice had anti-viral activity against the human respiratory syncytial virus in human respiratory tract cell lines antiviral and antitumor activity of licorice root extracts glycyrrhizic-acid-based carbon dots with high antiviral activity by multisite inhibition mechanisms electrospun poly (vinyl alcohol) nanofibers: effects of degree of hydrolysis and enhanced water stability glycyrrhizin as an antiviral agent against hepatitis c virus glycyrrhizin: an alternative drug for the treatment of covid- infection and the associated respiratory syndrome scope of natural plant extract to deactivate covid- pressure drop of filtering facepiece respirators: how low should we go a flexible nanoporous template for the design and development of reusable anti-covid- hydrophobic face masks testing of air permeability of distant knitted fabrics in the direction of their plane efficient and reusable polyamide- nanofiber/nets membrane with bimodal structures for air filtration key: cord- -qr xynn authors: uzzaman, md. nazim; jackson, tracy; uddin, aftab; rowa-dewar, neneh; chisti, mohammod jobayer; habib, g m monsur; pinnock, hilary title: continuing professional education for general practitioners on chronic obstructive pulmonary disease: feasibility of a blended learning approach in bangladesh date: - - journal: bmc fam pract doi: . /s - - - sha: doc_id: cord_uid: qr xynn background: continuing medical education (cme) is essential to developing and maintaining high quality primary care. traditionally, cme is delivered face-to-face, but due to geographical distances, and pressure of work in bangladesh, general practitioners (gps) are unable to relocate for several days to attend training. using chronic obstructive pulmonary disease (copd) as an exemplar, we aimed to assess the feasibility of blended learning (combination of face-to-face and online) for gps, and explore trainees’ and trainers’ perspectives towards the blended learning approach. methods: we used a mixed-methods design. we trained gps in two groups via blended (n = ) and traditional face-to-face approach (n = ) and assessed their post-course knowledge and skills. the copd physician practice assessment questionnaire (copd-ppaq) was administered before and one-month post-course. verbatim transcriptions of focus group discussions with course attendees and interviews with three course trainers were translated into english and analysed thematically. results: forty gps completed the course (blended: ; traditional: ). the knowledge and skills post course, and the improvement in self-reported adherence to copd guidelines was similar in both groups. most participants preferred blended learning as it was more convenient than taking time out of their busy work life, and for many the online learning optimised the benefits of the subsequent face-to-face sessions. suggested improvements included online interactivity with tutors, improved user friendliness of the e-learning platform, and timing face-to-face classes over weekends to avoid time-out of practice. conclusions: quality improvement requires a multifaceted approach, but adequate knowledge and skills are core components. blended learning is feasible and, with a few caveats, is an acceptable option to gps in bangladesh. this is timely, given that online learning with limited face-to-face contact is likely to become the norm in the on-going covid- pandemic. provision of postgraduate training in family medicine is increasing in asia pacific, but rarely uses innovative online learning [ ] that could enhance access to continuing medical education (cme) essential for building and maintaining a high-quality primary care workforce [ ] . traditionally in bangladesh, post-graduate training involves face-to-face study, but shortage of physicians in many rural and semi-urban areas [ ] , mean that physicians often cannot leave their practices to attend several days of training. blended learning is a combination of face-to-face and online learning [ ] , which has become possible in bangladesh with recent substantial improvements in internet coverage, and may be a useful way to achieve cme [ ] . chronic obstructive pulmonary disease (copd) is an exemplar of a condition in which there are concerns that limited awareness of guideline recommendations amongst general practitioners (gps) [ , ] leads to misdiagnosis and inappropriate management [ , ] . copd affects an estimated million people worldwide [ ] and globally, is predicted to be the third leading cause of death by [ ] . although copd burden varies between countries, almost % of copd deaths occur in low-and middleincome countries (lmics) [ ] . the national copd guideline [ ] is not widely used in bangladesh. some clinicians follow global guidelines [ ] , however, substantial gaps exist between guideline recommendations and gps' practice. closing this gap is a priority research need for the international primary care respiratory group (ipcrg) [ ] . blended learning was introduced initially in undergraduate teaching [ ] [ ] [ ] [ ] and is now extending to postgraduate learning [ ] , though the concept is relatively new in bangladesh [ ] . an online component allows practitioners increased time and flexibility for study, wider and easier access to learning resources, and a higher level of autonomy in learning than in exclusively face-to-face courses [ , ] . management of copd requires acquisition of practical skills (spirometry; inhaler technique) necessitating a face-to-face component. therefore, we aimed to assess the feasibility of a blended learning approach to a copd cme course for gps in bangladesh. our mixed-methods feasibility study was conducted in june to august . quantitative data measured pre-post self-assessment of adherence to copd guidelines and qualitative focus groups and interviews explored trainee and trainers' perspectives of the blended learning. gps providing public and private primary healthcare services in bangladesh were invited to participate. gps in bangladesh have an mbbs (bachelor of medicine and surgery) are registered by the bangladesh medical and dental council, have at least two years' experience of clinical service but with no specialist post-graduate training. we excluded gps who had previously participated in post-graduate copd training at any time. the copd course, which was provided free of charge, was advertised nationally through the training management portal of the international centre for diarrhoeal disease research, bangladesh (icddr,b), and social media was used to disseminate the course advertisement. potential participants applied through the icddr,b portal. we screened applicants for eligibility, randomly selected participants who were randomly allocated (using a computer generated randomisation list) to either blended learning or the traditional face-to-face course. this was a feasibility study, so no sample size calculation was required [ , ] . resource availability allowed us to run two courses, so we allocated participants to each group. this is our normal group size, and is a sufficient sample size for assessing feasibility [ ] . the total training hours was h in both blended and traditional learning approaches and the courses contained the same content: components aimed at enhancing copd knowledge ( h) and skills ( h). a private facebook group was created to provide online learning support for both groups monitored by a tutor and for peer discussion. the tutors were gps with expertise in respiratory care and had considerable experience of delivering training. the learning approaches are summarised in table with further details in additional file . to assess how the training impacted on participants' practice and adherence to copd guidelines, the copd physician practice assessment questionnaire (copd-ppaq) was administered to all participants prior to starting training and after course completion. due to fellowship time restrictions, the copd-ppaq was administered only month after the course completed. this validated questionnaire is designed for the selfassessment by physicians of their implementation of key items (two domains: diagnosis and assessment; treatment and follow-up) of copd guidelines. the answers are globally reproducible [ ] . in line with the usual assessment on completion of icddr,b courses, skills were assessed by an oral examination and knowledge was assessed using a written multiple-choice questionnaire examination. following completion of training, all participants were examined on their copd knowledge and skills. from previous experience we anticipated that knowledge of copd and spirometry skills of gps with no prior copd training would be very low; we therefore did not assess this pretraining. all participants who completed the blended learning training were invited to participate in one of three focus groups facilitated by mnu supported by a note-taker. discussion addressed participants' perceptions of blended learning, preferences compared to previous experiences of face-to-face or online learning, advantages/ disadvantages of the blended learning. the three course trainers were interviewed individually to explore their views and opinions about the practicalities of delivering training using this approach (see additional file ). all discussions were digitally recorded and transcribed verbatim in the spoken language (bengali). the emotional context such as pauses, laughter, emphasis and non-verbal communication were included as notes in the transcripts to aid analysis. transcripts were translated (by mnu who led the focus groups) from bengali to english for analysis. examination scores, and copd-ppaq scores are expressed as percentages. summary statistics were calculated as means, proportions as necessary. stata statistical software (statacorp lp, college station, texas, usa) was used for data analysis. we used thematic analysis for the qualitative data [ ] using a coding framework developed by mnu in discussion with the other authors. the focus group discussions with trainees and interviews with trainers were analysed separately. this involved coding the whole data set and the codes were then synthesised into emerging themes which were combined into overarching themes including synthesised data from participants and tutors. the first author is a gp, employed by icddr,b, to deliver cme to healthcare professionals. he was involved in developing the learning materials, and facilitating training sessions which might have influenced the interviews/ focus groups and his interpretation of the data. to mitigate against this, themes were discussed within the multi-disciplinary author group. we received a total of online applications which were screened for eligibility. the commonest reasons for ineligibility were less than the minimum two years of clinical service (n = ), and already having specialised post-graduate training (n = ). did not provide complete information (eg. no qualification dates or experience) leaving eligible applicants. we randomly selected participants and allocated to each group. of the allocated participants, ( %) completed blended learning and ( %) traditional learning. the commonest reason for withdrawal in both groups was inability to take time out of practice. other reasons were illness, domestic or family responsibilities. most of the gps ( %) were between to years and half had - years' experience of patient care. almost half the participants of both groups were used to consulting with or more patients daily (table ) . the quantitative results are presented with the caveat that this was a feasibility study which was not powered to show a difference. detailed outcomes are therefore placed in additional files and without any statistical comparisons to avoid over interpretation. the overall end-of-course examination scores was similar in both groups, both for overall knowledge, and for assessment of skills. gps self-reported adherence to copd guidelines using copd-ppaq showed similar improvement in both groups. the self-assessment of key recommendations suggested that participants in both groups scored substantially better in all aspects of their practice except in smoking cessation and referral to specialist. eighteen of the blended learning course attendees (trainees) who completed the training participated in one of the three focus groups. they were aged - years and from nine districts of bangladesh. the location of their workplaces varied from three to over km from the training venue. the number of participants from urban, semi-rural and rural areas were nine, five and four respectively ( table ) . all trainees had previous experience of attending traditional training, half had participated in entirely online training and six had previous experience of a blended learning approach. interviews were conducted with the three trainers who were between and years of age. no further details are provided to maintain confidentiality of trainers. three main themes emerged in the analysis of both focus group discussions with trainees and interviews with course trainers. the themes and sub-themes are listed in table and described below. this was echoed by the trainers who were positive about the online resources being available ' hoursanytime, anywhere'. in contrast, one trainee preferred the traditional approach because it enabled him to focus on the topic for the duration of the course, whereas online learning could too easily be postponed. he also considered that the traditional approach was better for practical demonstrations (e.g. cardio-pulmonary resuscitation). one of the course trainers preferred the traditional approach, although he recognised that it was difficult for busy gps to be away from their practice. almost all the trainees felt confident of their knowledge and skills in diagnosing and managing copd patients after completing the training. most wished to participate in future courses using a blended approach and said they would recommend it to others. one participant was sufficiently confident in his acquired knowledge and skills that he felt he would be able to disseminate what he had learnt to staff in his practice. in contrast, a few participants felt that they did not get enough time to perform spirometry manoeuvres during "during practical session i expected more to learn about spirometer (how to operate the machine). however, we didn't have the scope to learn spirometer, especially with real patient". (trainee, p ) theme ii: educational advantages and disadvantages advantages of blended learning reasons provided for preferring the blended learning approach were the convenience of not having to relocate and the option to do some of the training in their own time which fitted around their practice work. reducing their physical presence in class was considered very helpful as it caused minimal interruption to their patient care. this view was particularly apparent in accounts from doctors who worked in rural areas and remote places where learning opportunities are limited, and staff resource is at a critically low level. "those of us who live in remote areas; the blended approach is a blessing for us which would allow us to add to our knowledge deficit quite a lot. those who stay centrally, get many opportunities to attend scientific seminars, cme (continued medical education) etc which we couldn't manage". (trainee, p ) in the blended learning approach, participants learned online before they attended face-to-face classes when they could solve the queries that had arisen while using the online resources. "we got learning contents in advance and were able to go through online. we know in advance what we will learn tomorrow. we solved our queries that arose during online learning when we were in faceto-face classes." (trainee, p ) a few participants said that blended was more attractive and interactive compared to a traditional approach or only online training. two of the trainers mentioned that the blended approach offered two-way learning with scope for providing better student support compared to either traditional or entirely online training. most of the trainees did not mention any generic drawbacks of the blended-learning approach. instead they discussed the weakness of the particular e-learning module they had used, and highlighted a few areas of the face-to-face classes which needed improving. some trainees found reading online content uncomfortable, mentioning that they were more comfortable with familiar paper rather than online documents. specifically, excessive screen exposure caused eye pain and headache to one of the trainees. although most participants completed the online module, a few mentioned that they had neglected the online learning either deliberately thinking that they would learn it from the faceto-face classes or procrastinating and not quite getting round to doing it in their busy schedules. "because of having the face-to-face part, we often have neglected the online part thinking that we have face-to-face classes"! (trainee, p ) apart from sharing the concern about the discomfort of online reading, trainers had some additional concerns about blended learning. one trainer was concerned that the online component might be considered as an extra pressure by some trainees. another trainer thought that the three-week gap between the online and face-to-face learning might increase participant dropout from the course. in addition, one of the trainers noted that unreliable internet access in some locations might limit the usefulness of the blended approach in bangladesh. in addition, this trainer was concerned that many physicians were not accustomed to using computers and if they only completed the minimum face-to-face tasks it might affect skill development of the trainees. almost all participants (trainees and trainers) thought the elearning module needed further development, with suggestions about more videos, animation, and quizzes with analytical questions to make it more interactive and attractive. opinions were divided about whether the contents were 'somewhat disorganised'. some trainees suggested including the content of the subsequent face-to-face classes in the e-learning module so that learning was reinforced. "practical sessions like inhaler techniques may be given online which would help us to learn better as we may not learn the technique in one face-to-face class. in future, if we get confused, we can watch the video and make our technique correct". (trainee, p ) most of the trainees wanted prompt feedback via the online platform rather than having to use a separate facebook group for this purpose. facebook was associated with social communication during leisure time and not as an effective medium for solving professional queries. indeed, some people noted that it was a distraction which wasted a lot of time. moreover, participants had only met once during the orientation class, so some did not feel sufficiently familiar with each other to be able to engage proactively in online group discussions. from a practical perspective they had to open facebook separately alongside the e-learning module which they found burdensome and although delegates tried it at least once, only delegates engaged in discussion. "yes, we had a facebook group [for solving queries]. but to me, when i logged on it, a lot of time went away unknowingly." (trainee, p ) a few trainees said that provision of a tutor for a scheduled online discussion would be helpful to solve queries and this would allow more time for practical tasks during face-to-face classes. two of the trainers with previous experience of online discussions, agreed and considered that the online discussion could help trainees to engage and learn more. "the provision of online discussion would help participants to learn more. even participants could ask question online which they couldn't understand in face-to-face classes". (trainee, p ) in contrast, some trainees considered that a fixed time for an online discussion was unlikely to be convenient for everyone, and reduced the flexibility that was an advantage of the online learning. they suggested that face-to-face classes were a better option for solving their queries. "i don't think we can align our time with the online tutor". (trainee, p ) "since we had the opportunity of face-to-face classes, here we didn't have the need of online classes". (trainee, p ) other trainees suggested that the e-learning platform should have a discussion board where a mentor would give his/her feedback, and everyone could see answers and learn accordingly. "i'd say that the online platform itself should keep an option of asking question […] a coordinator will reply to our queries in a particular time of a day". (trainee, p ) the majority of the trainees encountered challenges reading the online contents; only two participants did not have any problems. there were difficulties reading documents in full screen, sometimes a chapter showed as 'incomplete' even though it had been completed. a few trainees with previous experience of online courses suggested that chapters should be completed in order to qualify for the chapter accomplishment quiz. one trainee wanted the option of a mobile-based application along with the provision of offline access to the contents that they completed earlier for rereading as necessary. "mobile based app could be introduced where we can even get access without having internet connection [smiling]". (trainee, p ) almost all trainees shared that the practical sessions should involve "patients", if only for a short period of time. the practical classes were mostly device oriented. since we will apply our knowledge on patients, i think the practical classes need to be real patient-based which will make the course much more effective". (trainee, p ) the majority of the trainees thought that face-to-face classes would be more convenient if they were delivered days apart, preferably during weekends, so they would not need to leave their practice during working days. we all are busy, or it is difficult to manage leave for two-three consecutive days for face-to-face training. classes could be taken seven days apart and during weekend". (trainee, p ) two of the participants wanted an honorarium for participating in the course while one participant strongly opposed this issue. "we have been provided with food during training. if you could provide us some honorarium, that would be very good. after a certain age, we have more financial liabilities." (trainee, p ) in contrast, one trainer was concerned about the nonattendance of some participants suggesting that a course fee should be paid by the participants to make them more responsible. "this time we found that few participants didn't complete the course although there were many applicants who were very interested to attend the course. […..] one of the reasons might be that the participants didn't have to pay the course fee of their own". (trainer, t ) of the trainees allocated to each group, completed blended learning and completed the traditional faceto-face learning. inability to take time-out of practice was the commonest reason for attrition in both groups. the gain in knowledge and skills by the participants in both groups was similar. in addition, self-reported adherence to copd guidelines before and after training revealed similar improvement in both groups. all participants, except one trainer and one trainee, preferred the blended learning approach as it was more convenient within their busy work schedules. although a few participants 'neglected' the online modules, for most the online learning optimised the benefits of the face-toface sessions. there were a number of practical problems with internet connections and finding it 'uncomfortable' to read on-screen documents and most participants suggested improving interactivity. online support from tutors was valued, but embedded in the learning platform rather than using facebook which was associated with social interaction. a strength of our mixed method design is that it allowed triangulation of results; for example, the participants' perception of increased confidence in managing copd was matched by measured gains in skills and knowledge. the quantitative data will inform potential outcomes for a future evaluation of blended learning on copd and the qualitative data gave insights into both positive and negative perspectives. moreover, the practical suggestions and operational challenges will be helpful in refining future training. the examiners were aware of the allocation of both groups which risked biasing the quantitative outcomes, but the same examiners assessed participants from both groups ensuring consistency of assessment. blinded assessment was not possible within the resources of the study. we were aware of the impact of reflexivity, as the researcher conducting the focus groups and interviews (mnu) was also involved with training coordination and development of learning materials. involvement of a multidisciplinary author group unconnected with icddr,b or the course helped ensure a balanced interpretation of the data. although we achieved data saturation with respect to the trainee opinions, the limited number of trainers meant we only heard three perspectives. our aim was to assess the feasibility of the blended learning intervention, and the single location (dhaka) of the course and the small numbers limit generalisable, though our findings may be applicable to others working in similar settings in bangladesh or beyond. studies show that blended learning allows greater flexibility and responsiveness in adult learning processes [ , , ] . the addition of online learning overcomes limitations of time and space, reaches more students and supports instructional methods that may be hard to achieve without increased resources [ ] . some studies have found a mismatch regarding preferred learning approaches where trainers assumed that technology-based learning suited the trainees' style; however, trainees felt differently [ ] . in our study, trainees and trainers almost all agreed that blended learning overcame two limitations compared to entirely online or traditional learning. first, the e-learning component reduced the need for prolonged time out of practice to attend a course, and second, the prior online work optimised the learning of skills in the face-to-face class. a previous study with gps also found e-learning a useful way to gain knowledge and the face-to-face component a suitable way of transferring practical knowledge [ ] . furthermore, some participants in our study suggested blended learning was cost-effective [ ] as a substantial number of doctors could be trained within a short period of time [ ] . in contrast, a few trainees found it difficult to adapt their learning styles to a blended approach [ ] . some felt that provision of paper versions of the e-learning module would be helpful as they were accustomed to reading paper books [ ] . flexibility is generally seen as a strength as e-learning allows participants to learn at a convenient time [ ] . in our study, it was also viewed as a challenge because some gps found it difficult to schedule study time. also, some neglected online study hoping to catch-up in the face-to-face sessions. trainers living at a distance found it less efficient to schedule face-to-face classes involving long travel time for shorter meetings. the lack of a blended learning approach to cme in lmics may be associated with limited technological resources [ ] . echoing other studies that have highlighted poor access to technology as a barrier to the implementation of technology-enhanced teaching [ ] , our participants described annoying technical problems such as losing information on progress, or the need to switch between pages. the use of social media (in particular facebook) was associated with social communication and considered an ineffective way of interacting with fellow participants and solving queries though other studies have successfully used this approach [ ] . like several other studies, some trainees and trainers considered that, for productive interaction, it is important that tutors actively moderate online discussions [ ] [ ] [ ] . more patient involvement in skills development was wanted, and contributing to online modules could be a convenient way to incorporate patients. the dropout of participants ( in in our study) was another challenge. an outbreak of dengue fever in bangladesh was one factor and cultural context is also important. in lmics like bangladesh, food and honorarium are two important issues that need to be considered when developing education. government employees typically expect to receive an honorarium when they participate in any training. provision of accessible cme is central to maintaining the quality of primary healthcare and the morale of the workforce [ ] . in the context of copd, where underdiagnosis and inadequate management is common [ ] [ ] [ ] , our blended-learning course was a feasible approach to enhancing knowledge and skills of gps about copd. the observation by some of the participants that they were sufficiently confident in their learning to be able to pass on the knowledge to others in their practices is encouraging but needs further evaluation. 'train the trainer' programmes have been used successfully by the international primary care respiratory group [ ] , and blended learning offers the potential for online modules to be used to pass on knowledge. the flexible and practical blending of online and face-to-face learning has the potential to be used for cme of other long-term conditions in bangladesh and beyond. with some caveats, blended learning was an acceptable educational model and preferred by most of the busy gps in bangladesh. quality improvement requires a multifaceted approach, but adequate knowledge and skills are a core component; blended learning is a feasible option which could contribute to improved implementation of guideline recommendations. online cme was a novel approach in our lmic setting, but learning with limited face-to-face contact is likely to become the norm in the current covid- pandemic making this a timely message. received: june accepted: september the status of family medicine training programs in the asia pacific family medicine vocational training and career satisfaction in hong kong the health workforce crisis in bangladesh: shortage, inappropriate skill-mix and inequitable distribution blended learning: the convergence of online and face-to-face education. promising practices in online learning. north american council for online learning perceptions toward a pilot project on blended learning in malaysian family medicine postgraduate training: a qualitative study copd patients need more information about self-management: a cross-sectional study in swedish primary care copd management in primary care: is an educational plan for gps useful? diagnosing copd in primary care: what has real life practice got to do with guidelines? under-and over-diagnosis of copd: a global perspective chronic obstructive pulmonary disease (copd): key facts projections of global mortality and burden of disease from to national guidelines: asthma, bronichiolitis, and copd global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease the international primary care respiratory group (ipcrg) research needs statement teaching differential diagnosis in primary care using an inverted classroom approach: student satisfaction and gain in skills and knowledge improving education in primary care: development of an online curriculum using the blended learning model a blended learning approach to teaching basic pharmacokinetics and the significance of face-to-face interaction student perceptions of a virtual learning environment for a problem-based learning undergraduate medical curriculum blended learning for postgraduates; an interactive experience improving physicians' capacity for chronic obstructive pulmonary disease care through blended e-learning: a pilot study in the past, present and future of blended learning: an in depth analysis of literature amee guide : e-learning in medical education part : learning, teaching and assessment nuts and bolts of conducting feasibility studies information for authors: pilot and feasibility studies an audit of sample sizes for pilot and feasibility trials being undertaken in the united kingdom registered in the united kingdom clinical research network database the physicians' practice assessment questionnaire on asthma and copd using thematic analysis in psychology blended learning: strengths, challenges, and lessons learned in an interprofessional training program learning from focus groups: an examination of blended learning introducing an online community into a clinical education setting: a pilot study of student and staff engagement and outcomes using blended learning blended learning in cme: the perception of gp trainers blended learning: efficient, timely and cost effective building effective blended learning programs a new vision for distance learning and continuing medical education the role of blended learning in the clinical education of healthcare students: a systematic review the uses of information and communication (ict) in teaching and learning in south african higher education practices in the western cape : research : information and communication technologies facebook as a learning tool: perception of stroke unit nurses in a tertiary care what are the perceived benefits of participating in a computer-mediated communication (cmc) environment for distance learning computer science students? online discussion in blended courses at saudi universities blended learning in teacher education: an investigation across media global initiative for chronic obstructive lung disease. global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. gold executive summary prevalence and underdiagnosis of copd by disease severity and the attributable fraction of smoking report from the obstructive lung disease in northern sweden studies management, morbidity and mortality of copd during an -year period: an observational retrospective epidemiological register study in sweden (pathos) improving care for people with asthma: building capacity across a european network of primary care organisations-the ipcrg's teach the teacher programme publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we gratefully acknowledge the contribution of mohammod rafiqul islam for online learning management system coordination. we are thankful to the trainers for their contribution in delivering the intervention. icddr,b acknowledges with gratitude the commitment of nihr global health research unit on respiratory health (respire) to its research efforts. icddr,b is also grateful to the governments of bangladesh, canada, sweden and the uk for providing core/unrestricted support. supplementary information accompanies this paper at https://doi.org/ . /s - - - .additional file . programme outline.additional file . topic guide for focus group discussion and interview. additional file . practice assessment of trained physicians using copd physician's practice assessment questionnaire (copd-ppaq). the qualitative data that support study findings may be available from the corresponding author on request.ethics approval and consent to participate ethics approval obtained from the international centre for diarrhoeal disease research, bangladesh (icddr,b) ethical review committee (pr- ) and sponsored by the academic and clinical central office for research and development (accord ac ). all participants provided written informed consent. not applicable.competing interests mnu, and au are involved with developing cme courses at icddr,b. the other authors declare no competing interests. key: cord- - jquy authors: stewart, r.; martin, e.; bakolis, i.; broadbent, m.; byrne, n.; landau, s. title: comparison of mental health service activity before and shortly after uk social distancing responses to the covid- pandemic: february-march date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: jquy this study sought to provide an early description of mental health service activity before and after national implementation of social distancing for covid- . a time series analysis was carried out of daily service-level activity on data from a large mental healthcare provider in southeast london, from . . to . . , comparing activity before and after . . : i) inpatient admissions, discharges and numbers, ii) contact numbers and daily caseloads (liaison, home treatment teams, community mental health teams); iii) numbers of deaths for past and present patients. daily face-to-face contact numbers fell for liaison, home treatment and community services with incomplete compensatory rises in non-face-to-face contacts. daily caseloads fell for all services, apart from working age and child/adolescent community teams. inpatient numbers fell . % after th march, and daily numbers of deaths increased by . %. the first wave of the covid- pandemic had an impact across many healthcare sectors: not only because of the direct effects of the virus itself on communities and healthcare staff, but also arising from the national public health policies enacted to reduce spread. mental healthcare faced a range of challenges including the heightened vulnerability of its patient populations (e.g. through cardiovascular and respiratory disorders), already-reduced lifeexpectancies ( ), and frequently described problems accessing healthcare ( ; ). in addition, services had to be radically reconfigured to cope with suspected or confirmed infections in inpatient and outpatient settings, staff sickness or self-isolation, the need to minimise face-to-face contacts, and the need to accommodate increasing pressures on acute medical care from cases of viral pneumonia. these in turn were accompanied by the as yet unknown impacts of social distancing on already isolated or otherwise vulnerable populations, and of challenged national economies on already impoverished and disadvantaged communities. there therefore continues to be a pressing need for research ( ). taking advantage of a mental healthcare data platform that receives -hourly updates from its source electronic records, we sought to describe daily activity in key services for the months of february and march and to quantify statistically the early changes observed. register at the south london and maudsley nhs foundation trust (slam) has been described previously ( ; ). in summary, slam is one of europe's largest mental healthcare providers, serving a geographic catchment of four south london boroughs (croydon, lambeth, lewisham, southwark) with a population of around . million residents. slam has used a fully electronic health record (ehr) across all its services since , and the nihr brc case register was set up in , providing researcher access to de-identified data from slam's ehr via the clinical record interactive search (cris) platform and within a robust, patient-led security model and governance framework ( ). cris has been extensively developed over the last years with a range of external data linkages and natural language processing resources ( ). of relevance to the work presented here, cris is updated from slam's ehr every hours and thus provides relatively 'real-time' data, although prior to the covid- pandemic had mostly been used to support historic cohort analyses. slam's ehr is itself immediately updated every time an entry is made, which include date-stamped fields indicating patient contacts ('events') and those indicating acceptance of a referral, a discharge from a given service (or slam care more generally), including admissions to and discharges from inpatient care. mortality in the complete ehr (i.e. all slam patients with records, past or present) is ascertained weekly through automated checks of national health service (nhs) numbers (a unique identifier used in all uk health services) against a national spine. cris has supported over peer reviewed publications to date. cris has received approval as a data source for secondary analyses (oxford research ethics committee c, reference /sc/ ). activity and caseload data were extracted via cris and enumerated for every day from st february to st march . for inpatient care, the following were calculated: number of new admissions from the community, number of new discharges from inpatient care to the community, number of current inpatients. in addition, numbers of inpatients classified as on leave were calculated for illustration but not analysis. for other selected services, daily caseloads were calculated by ascertaining patients who were receiving active care from a given service on a given day, based on the date a referral to that service was recorded as accepted to the point a discharge was made from that service. daily contact numbers were ascertained from recorded 'events' (i.e. standard case note entries) for that service and were divided into the following groups according to structured compulsory meta-data fields for that event in the ehr: i) face-to-face contacts attended; ii) non-face-to-face contacts attended; iii) appointments cancelled or not attended ('dna'); iv) contacts listed as 'other'. non-face-to-face contacts included those recorded as being made by email, fax, mail, phone, online, or video link. this fourth group was investigated with manual inspection and was found to comprise a miscellaneous collection of contacts, including those with other staff members, other services (e.g. social care) or with patients' friends/family. the following slam services were chosen for description and comparison, on the basis that they represented the largest and most strategically important groupings: finally, mortality data (number of deaths for all patients with records) were extracted. caseload and contact data were extracted on nd april ; because of delays in registrations . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . and incorporation of this information coming in the case register, number of deaths were extracted for the time period of interest on rd april . the primary objective was to present descriptive data, which were displayed graphically (mon-sun for inpatient, liaison and htt services; mon-fri for cmht and camh services). in addition, caseloads and core activity (face-to-face and non-face-to-face contacts) were formally compared across the period of interest. in this respect, th march was chosen as an index date, being the date on which the national self-isolation strategy was announced (https://www.gov.uk/government/speeches/pm-statement-on-coronavirus- -march- ). activity levels before and after that date were therefore compared. because of the heterogeneity in levels of service delivery at weekends, statistical comparisons considered the weekday observations only (between the rd of february and the th march inclusive) for all measures. all variables represented counts of some type and were modelled using a negative binomial regression model to allow for overdispersion where this was indicated. to account for systematic trend over time, and also systematic weekly patterns the models included fixed effects of week ( levels) and weekday ( levels) factors. more complex modelling could not be supported by the relatively small sample size of observations to date. the negative binomial model assumed that the daily counts were statistically independent. time series data are often thought to display extra autocorrelations due to unaccounted shortterm effects. to account for these, a sensitivity analysis that fitted an autoregressive correlation structure (with one autocorrelation parameter) to the daily error terms within a week was carried out using generalised estimating equations (gee). observations from different weeks were still assumed independent. gee with a negative binomial distribution requires provision of the overdispersion parameter. this parameter was set to the value estimated in the negative binomial regression, provided the parameter had tested statistically . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . significant at the % level. however, many of these models fitted a negative autocorrelation parameter, which may indicate unaccounted systematic trend rather than error dependencies. either way, as will be described, inferential results were little affected by relaxing the independence assumption. daily counts for each service are graphically displayed in figures - , and comparisons before and after the th march are summarised in table table ). for all other services, there was a common pattern of reduced face-to-face and increased non-face-to-face contacts per day, although estimated trends in combined contact numbers were always negative (table ). liaison services (figures - ) exhibited a substantial (estimated %) fall in total contacts, and a small ( %) but statistically significant overall reduction in daily caseload (table ) . both working age and older adult htts showed reductions in total contacts ( % and % respectively) and daily caseloads ( % and % respectively), both more pronounced for the older adult services (table ) . considering community team services (figures - ) , all (working age, camh, older adult) showed reductions in total assessments ( %, % and % respectively), but only older adult daily caseloads fell (by %), while those for working age and camh services did not change significantly after the th march (table ) . daily numbers of deaths are displayed in figure and showed a significant % increase after th march (table ) . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint we present findings from an early extract of data from a large multi-team provider on changes in mental health service provision before and in the initial stages of the covid- pandemic first wave in the uk, analysing these in relation to the enacting of a national social distancing policy. in summary, all grouped liaison, home treatment and community mental health services had substantially reduced face-to-face patient contacts, with variable and only partial compensatory increases in non-face-to-face contacts. many had also reduced their caseloads, although those for working age cmht and camh services remained level. numbers of patients in inpatient care had also been substantially reduced. daily numbers of deaths in past and present patients had increased significantly over a relatively short time period. at the outset, the potential impact of the covid- pandemic was widely discussed in a general sense, rightly focusing on the initial priorities of infection control, treatment options for severe complications, and the preparedness of critical care services ( ). however, a second wave of evidence gathering grew in importance, because of the potentially sizeable indirect consequences on other healthcare sectors. for mental healthcare, there continues to be a need to understand the population-level impact of both viral infection (severe or otherwise) and the social distancing being imposed by many national governments ( ; ; ). for people with pre-existing mental disorders, there has been a concern expressed that vulnerability to covid- infection may be higher than expected -because of infection susceptibility, comorbidity and barriers to health service access ( ). also discussed has been a potentially higher risk of mental health deterioration due to the stress of the pandemic itself, the stress of quarantine as a consequence ( ), and reduced access to routine outpatient visits . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . / . . . doi: medrxiv preprint for evaluations and prescriptions, and there were concerns raised about a higher risk of suicide as a result of the rapid social, economic and health changes ( ). in addition, there may be higher rates of new presentations to services as a result of complex bereavements and post-traumatic stress disorder following severe hospitalised infections. some of these outcomes may still only become apparent after enough follow-up has been accrued for adequately powered analyses, by which time it may be too late for intervention. at the time the data were extracted for this report, the scale of mental healthcare changes had not yet been fully quantified, although recommendations had been made in china for tighter admission criteria and reduced hospital outpatient visits, amongst others ( ). while it was not our intention in this paper to investigate factors underlying the observed service changes, many will be unsurprising. clearly an inevitable outcome of social distancing, coupled with the rising awareness of staff risk from infections (and of the potential for staff-to-patient transmission), was a reduction in face-to-face clinical assessments. at the time of analyses, these had not been fully matched by increases in nonface-to-face assessments (for example, those carried out over the phone or via video calls) in all services evaluated. while it is possible that contacts labelled as 'other' might have included some direct assessments, numbers of contacts in this category were not markedly changed over the period of interest. the largest reductions after th march in total contacts were seen in liaison services, followed by htt services and then cmhts. on the other hand, reductions in median daily caseload were highest in older adult and working age htt services followed by small reductions in liaison and older adult cmht caseloads and no significant reductions in working age cmht and camh services. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . https://doi.org/ . a rise in daily numbers of deaths after th march was also noted, although these findings were derived over a relatively short duration of surveillance. considering contemporaneous national reports for total mortality ( ), the % increase observed in the slam case register was of a similar order to the national % increase in care home residents, % increase in hospital inpatients and % increase in private home residents reported at the time ( ). strengths of this study included the relatively 'real time' data from a large mental healthcare provider, which allowed investigation of very early changes in service activity following dramatic and rapid transitions. clearly generalisability needs to be evaluated, as there may be a number of local and national factors that influence service transitions. london saw some of the earliest accelerations in covid- infections in the uk and there will have been pressures arising from local medical services (e.g. to free up mental health inpatient beds for 'overflow' from acute care) which are likely to have been felt by other london mental healthcare providers, but which may have occurred ahead of other areas of the uk. considering other limitations, data for this manuscript were drawn from specific services of interest and do not reflect slam's full activity; they were also combined by broad service categories and we did not seek to investigate within-service variation. daily contact numbers were quantified from structured fields applied to case note entries and might reflect recording behaviour rather than activity levels (e.g. if multiple contacts were recorded within one entry); also, the dichotomy between face-to-face and non-face-to-face contact is a relatively crude one and does not reflect the quality or depth of assessments being recorded. finally, statistical power was limited because of the short period evaluated, as well as being limited by lack of data on cause of death and applied to a heterogeneous sample of past and present service users. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . first author's note, in the interests of transparency: the findings reported in this paper were submitted in manuscripts to bmj open, bjpsych open, and bjpsych bulletin, with the first submission on st april after a data extraction on nd april (daily deaths data were updated in a subsequent extraction for later submissions). the findings were adjudicated to be insufficiently informative by the first two journals and the manuscript was rejected by the third because of difficulties obtaining reviews. by the time final feedback was received ( st july ), the study was judged by the authors to be too out of date for further attempts to seek peer-review. in the meantime, a number of approaches received from policy bodies for dissemination of findings reported here could not be accommodated because of results being under consideration for publication. the experience of attempting to follow the traditional academic publishing route in the context of rapidly changing circumstances requiring up-to-date data is a reason underlying recent dissemination of pandemic-relevant output from cris primarily via pre-print ( - ). the manuscript presented here has been amended from that originally submitted to remove statements of inference that might warrant peer-review. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . college hospital nhs foundation trust. the views expressed are those of the author[s] and not necessarily those of the nihr or the department of health and social care. ( ) chang c-k, hayes rd, perera g, broadbent mtm, fernandes ac, lee we, et al. life expectancy at birth for people with serious mental illness, substance use disorders, and depressive disorders from a secondary mental health care case register in london, uk. plos one ; :e . ( . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this this version posted september , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint the copyright holder for this this version posted september , . . working age adult community mental health team contacts by contact type (daily caeloads per day figure : working age adult community mental health team active caseloads (daily caseloads per day figure : child and adolescent community mental health team caseloads (daily older adult community mental health team contacts by contact type (daily number of face-to-face contacts number of non-face-to-face contacts caseloads per day figure : older adult community mental health team caseloads (daily key: cord- -clyhurjl authors: jumat, muhammad raihan; wong, peiyan; foo, ke xiang; lee, irene cheng jie; goh, suzanne pei lin; ganapathy, sashikumar; tan, thean yen; loh, alwin hwai liang; yeo, yen ching; chao, yinxia; cheng, lionel tim-ee; lai, siang hui; goh, sok hong; compton, scott; hwang, nian chih title: from trial to implementation, bringing team-based learning online—duke-nus medical school’s response to the covid- pandemic date: - - journal: med sci educ doi: . /s - - - sha: doc_id: cord_uid: clyhurjl nan in response to the increasing community spread of covid- in the first quarter of , the singapore healthcare system moved to prioritize pandemic management over other nonessential services. the delivery of medical school curriculum and learning processes, which heavily involves clinical faculty from various healthcare institutions, had to be reconfigured and reengineered as healthcare staff reassignment and infection containment practices are escalated. a few years earlier, in , duke-nus had implemented an elearning week, where face-to-face activities were conducted online in order to prepare for unforeseen disruptions to the curriculum. during the covid- pandemic, we first put these practices to use when enhanced social distancing restrictions were mandated across the country in february , and university guidelines required that all classes with or more students be moved online [ ] . as the pandemic escalated, singapore imposed increased movement restrictions in april and all educational institutions were instructed to move to full home-based learning [ ] . the transition to online learning may be smoother for a traditional lecture-based course, as educators can share prerecorded lectures, or even deliver live lectures through videoconferencing platforms. learning resources can be posted on their institution's learning management system for their students to access remotely. however, a growing trend in higher education is towards the use of "flipped classrooms", where the acquisition of information is done by the student prior to class, and the faculty use class time to reinforce the knowledge that students have acquired by providing opportunities for students to apply the knowledge through application exercises [ ] . a disruption in face-to-face teaching is challenging for duke-nus, for two reasons. first, the foundational science concepts covered in the first academic year are revisited and built upon later during the clinical years. disrupting the delivery of the foundational science content would have profound effects on subsequent parts of the curriculum. second, duke-nus employs a complex learning pedagogy which emphasizes peer-to-peer learning through faculty-facilitated, studentled discussions [ ] . known as teamlead (learn, engage, apply and develop), the primary mode of teaching for the first-year medical students at duke-nus is an adaptation of team-based learning (tbl). the processes of teamlead and tbl have been described elsewhere [ ] [ ] [ ] . in brief, the three defining features of teamlead and tbl are pre-class preparation, the readiness assurance tests (rats), and the team application exercises [ ] . in the teamlead and tbl class formats, students first take the readiness assurance tests individually (individual readiness assurance test (irat)), then as a team (group readiness assurance test (grat)). it is after completion of the grat that teamlead diverges from tbl. known as the modified teamlead readiness assurance process (mtrap), teams will now submit any unresolved queries to the whole class. the facilitator then assigns other teams to work on these queries, after which these queries are addressed in a faculty-facilitated, class-wide discussion. thus, at duke-nus, tbl represents a flipped classroom process that requires face-to-face interaction and is heavily dependent on student attendance and participation. here, we detail the experiences learnt from the elearning week in and the challenges faced in moving an entire module to online learning during the covid- outbreak in . in , a week of the body and disease module was delivered in an online format to the class of during elearning week. body and disease is the final module of the first-year medical curriculum, where students learn to integrate different knowledge tracks: microbiology, immunology, pharmacology, pathology and clinical investigations [ ] . the educational leadership designed an online tbl format de novo, adhering to the core principles of tbl [ ] . during the elearning week, students received hours' worth of video-recorded lectures as preassigned material. the online class session started in a similar manner to a face-to-face session, with students attempting the irat by logging into a test-taking platform, but from their homes. for the grat, the students logged onto a virtual chat room (chatzy.com) to carry out their discussions and keyed their answers into an in-house assessment tool that provided immediate feedback. the mtrap process was carried out using a shared google document (google llc, menlo park, ca, usa). students would post their questions on the shared document and the assigned team would submit their responses in the same shared document. a faculty member, a content expert on the topic, served as a facilitator. members of the education administration team provided logistical and technical support for the class. students did not use any videoconferencing platform for their discussions in . here, we present the impact of elearning on students' perception of tbl by analysing students' feedback from the elearning week, which occurred during academic week , and for the preceding week, academic week , which was carried out face-to-face. we analysed the students' ratings on whether elearning achieved the same desired tbl outcomes of developing verbal, written, collaboration skills as a face-to-face session. as a control, we analysed the standard evaluation feedback, which was administered after every session, from both academic weeks. lastly, we compared the standard evaluation feedback from the elearning week of ay / with a corresponding academic week from ay / within the body and disease module. the students from the ay / cohort felt that elearning mode of tbl was less effective in fostering their verbal, collaboration and leadership skills, compared with the face-toface mode in academic week ( table ) . a comparison of the feedback from those two academic weeks showed no difference in the perception on how elearning versus face-toface class sessions would affect their written skills (table ) . this is perhaps unsurprising, as only a chat room utility and a shared online document were used to conduct intra-and interteam communication during the elearning week. we then compared the students' standard evaluation feedback for the elearning week and academic week within ay / cohort. we found that moving the class sessions online did not significantly affect the students' perceptions of their learning experience (supplementary table ). the different study material assigned across the elearning week and academic week , however, may play a role in how the students perceived the class session. as such, we compared the standard evaluation feedback from the ay / cohort's elearning week with the ay / cohort's corresponding academic week (supplementary table ) , where students received a similar set of study material. no significant differences were found between each cohort's perceptions of their learning experience for this particular academic week. to ensure that the lack of difference in students' perception was not due to a cohort effect, we looked at the overall perceptions that students had for the face-to-face class sessions in the body and disease module. no significant differences were found between the cohorts of ay / and ay / either (supplementary table ). taken together, these findings suggested that the study material assigned during this academic week and cohort effect did not have an impact on the students' perceptions of tbl outcomes. given how moving the class online did not affect students' perceptions of their learning experience, this suggests that the elearning mode reached most of the same objectives as the face-to-face mode. students were overall receptive of this innovation. however, students felt that the online instructional mode adopted during the elearning week did not provide the opportunities to develop verbal communication skills, which they would have had in a face-to-face teamlead session. this perception was likely due to the communication during the class being limited to text-based exchanges, rather than other factors. these findings indicated to the educational leadership that a sustainable online version of this module would need to provide avenues to develop verbal communication skills. transitioning teamlead from face-to-face to online in when the national university of singapore mandated that all classes be moved online in february , the educational leadership deployed the infrastructure for online learning that was in-place after the elearning experience. while the elearning experience was a week-long, in all classes were moved online indefinitely. to ensure successful implementation and continuity of tbl online, constant feedback was sought from students, faculty and the administrators through student feedback surveys and regular faculty debriefs. keeping in mind that students preferred to have verbal communication during online classes, in , students were instructed to log on to a video-conferencing software for the entirety of the teamlead session (zoom.us, san jose, ca, usa). this proved to be a useful medium to dispense instructions to the class and for facilitated discussions during mtrap. students chose their preferred platform for communicating with their teammates during grat. this may be an alternate video-conferencing program or instant messaging platforms on their mobile phone. although the breakout room function in zoom has proven useful for online tbl [ ] , we found manually assigning students into teams to be cumbersome. additionally, using a separate communication platform allowed teams to be connected even during classwide discussions. this helped us to recreate the "side-discussions" amongst teammates that were frequently seen in class. similar to the elearning experience in , students used a university-sanctioned, password-protected, shared online document to submit their queries during the mtrap. teams assigned to answer those questions responded on the same document. to enhance communication, the assigned teams are instructed to present their answers through the videoconferencing tool. after which, the facilitators gave the class time for an open discussion. students could take this time to interact with the faculty through video. this provision was crucial as, according to the social cognitive theory, individual consciousness can only be formed through communicative interactions [ ] . in online tbl, the role of the facilitator took on a different form from face-to-face tbl [ ] [ ] [ ] . in brief, the facilitator ensured that all the participants were muted throughout the session and that only one person speaks at any one time. students were allowed to key question into the text-chat function of the video-conferencing platform. the facilitator had to be cognizant of these different prompts and channel them accordingly. the facilitator's ability to manage the participants and all the key processes in a time-sensitive manner was key in creating a conducive online learning environment. the backbone of the online classes is the administrative team from the office of education at duke-nus that helms the logistical demands of tbl. this team of administrators was pivotal in the transition and ensuring the continuity of the curriculum during the pandemic. prior to the classes, the administrative team was responsible for maintaining the online learning resources and granting access for all participants. they were also responsible for conducting training sessions the tbl reaction outcomes for the elearning week, which occurred during academic week of the body and disease module, and for the preceding week that had face-to-face classes, during academic week were compared. students from the ay / cohort felt that the elearning mode of instruction did not facilitate their development in the following tbl outcomes: verbal communication, collaboration and leadership skills n = for the elearning week, and n = for the face-to-face week in the cohort of ay / data is presented as mean (standard deviation). all comparisons were analysed using wilcoxon rank sums tests *evaluation items are scored on the following likert scale: = strongly disagree; = disagree; = neutral; = agree; = strongly agree for students and faculty on how to use the various online platforms and helping users to resolve technological problems in real time [ ] . for example, they worked with hospitalbased faculty to overcome the poor wi-fi access in their institutions. three to administrators would attend each class session to provide technical support. this included monitoring the attendance of all participants, cueing students on when to begin each phase of the assessment and communicating the scores and item analysis of the rats to the faculty. in addition, the administrative team was also responsible for troubleshooting any technological issues. they did so by remaining contactable via multiple communication modes during the class, through email, instant messaging or phone calls. examples of contingencies that they had in place include sending soft copies of the resources through email and giving instructions or acting as a conduit for student-faculty discussions through the phone. the greatest strength of this online tbl is the ability to provide an effective alternative tbl format to ensure continuity of learning amidst a global pandemic. students were still able to engage in an interactive intellectual discourse with peers and faculty [ ] . additionally, in our online iteration of the mtrap session, we used a combination of text and video. the real-time shared online document created a dynamic mtrap session, due to the ability to edit and comment on responses during the discussion. this encouraged students to remain engaged throughout the discussion. having the mtrap hosted on a shared online document is an improvement from face-to-face sessions, as the information is now stored electronically for the entirety of the module, instead of being written on a whiteboard and erased at the end of the session. having an electronic record available for an extended period also allows faculty to insert their comments retrospectively. this feature was important as clinical faculty, faced with increasing clinical demand during the pandemic, were not always available during the virtual class time. the combined use of a shared online document and a video-conferencing platform for the facilitated class discussion during the mtrap is a unique feature of our iteration of online tbl. based on the cognitive theory of multimedia learning, the simultaneous use of text and video enhances the learning experience. this theory posits that the brain interprets data from multimedia sources in an organized and dynamic manner, resulting in the production of logical mental constructs [ ] . with this, we provided students with a dynamic and interactive learning environment [ ] . difficulty in getting access to a reliable internet network or internet-enabled devices posed a major obstacle for all participants. perhaps to ensure that students can carry out online learning, the school should consider supporting their access to devices that would allow for the various processes of online learning. for the clinical faculty, they are in locations where internet separation was practised. due to the singapore health services being breached by a series of cyber-attacks in [ ] , all workstations in hospitals were disconnected from the internet. to overcome this obstacle, faculty participating from the hospitals did so from their personal devices. technological literacy ability of participants was another challenge that had to be overcome. some participants were unfamiliar with the video-conferencing platform or unsure about how to access the online documents. we overcame this through the efforts of the administrative team who provided pre-and in-class technological support. the strong dependence on the administrative team also presents as a weakness with our iteration of online tbl. without dedicated staff to manage the learning process, the faculty would face an uphill task in teaching and running the logistics of the course. institutions interested in implementing online tbl should train an administrative team to ensure the smooth running of the course or ensure that there is a co-host available to help with the administrative demands of the class. this format of online learning may suit the teaching of theoretical knowledge well but may not be ideal for the teaching of practical skills, which is an important component of medical education. faculty have also expressed concern about the inability to assess professionalism through online learning. avenues to teach practical skills and assess professionalism online need to be developed to overcome these obstacles. the potential for online tbl is far-reaching. while initially deployed to facilitate remote learning in a pandemic, this mode of learning can connect students with faculty who are not in the same geographical locality. this will be highly useful in teaching niche subjects where few experts are available. there is also an opportunity to develop a single online platform that can house all the different features of online tbl. currently, students switch between multiple platforms for each phase of the lesson. an all-encompassing video-conferencing software which contains features that allow the administration of the irat/grat, mtrap and discussion processes will be ideal. such features should include the ability to administer tests securely and store shared files. being able to carry out online tbl will give the institution the capability to conduct remote learning tbl courses. these can be credit-bearing courses which are open for any student regardless of location. most major universities offer online courses, but these courses are predominantly lecture-based modules with limited collaborative learning capacity. having this option will increase the repertoire of courses that reaches the unique learning objectives reached by tbl and appeal to the segment of learners who prefer tbl to traditional learning. while preliminary observations (table and supplementary tables and ) suggest that learning can occur through this modified online tbl format, it is unclear whether this mode of learning is sustainable and/or achieves the same the educational objectives as face-to-face modules. taking the tests online and unsupervised presents a tangible threat to the learning process. students with integrity issues might not adhere to the university's honor code. testing higher-order thinking skills and developing secure exam-taking software may mitigate this shortcoming. a worrying trend observed with the increased use of videoconferencing is hacking. incidences of "zoom bombing" have been reported by multiple institutions globally, where hackers gained access and interrupted ongoing online classes [ ] . if this trend escalates, confidential data might be compromised. in response to these intrusions, the university had suggested several guidelines to increase the security during video-conferencing sessions [ ] . video-conferencing software providers must maintain vigilance and continuously work to enhance security in order to prevent unauthorized interruptions. the data collected from the elearning experience was instrumental in our response to the covid- pandemic in . the concerns raised by the students in guided the leadership in modifying the online format for the rollout. in , we found that we were able to reproduce the face-to-face tbl conditions online by utilizing the videoconferencing tool judiciously. furthermore, students in generally appreciated the online tbl format of learning and found it easy to communicate with their peers. given our observations, further studies comparing the impact of online and face-to-face tbl classes on student's academic performance will need to be carried out. these studies would also need to ascertain if taking an online course for a prolonged period has an effect on student's well-being and mental health. overall, the preparedness of the educational leadership and the dynamic work ethic of the administrative team allowed for the successful deployment of online tbl. coronavirus outbreak: singapore raises dorscon level to orange; schools to suspend inter-school, external activities covid- : singapore makes 'decisive move' to close most workplaces and impose full home-based learning for schools, says pm lee motivation and cognitive load in the flipped classroom: definition, rationale and a call for research. higher education research & development ten steps to complex learning: a new approach to instruction and instructional design the essential elements of team-based learning team-based learning: a practical guide: amee guide no. implementation of team-based learning on a large scale: three factors to keep in mind* perspective: guidelines for reporting team-based learning activities in the medical and health sciences education literature body and disease : an integrated course teaching pathology, pharmacology, immunology and microbiology online team-based learning sessions as interactive methodologies during the pandemic social foundations of thought and action: a social cognitive theory essential skills for a medical teacher: an introduction to teaching and learning in medicine twelve tips for facilitating team-based learning redesigning team-based learning facilitation for an online platform to deliver preclinical curriculum: a response to the covid- pandemic cooperative learning, collaborative learning, and interaction: three communicative strands in the language classroom multimedia learning: are we asking the right questions? st century learning in medicine: traditional teaching versus team-based learning singapore health system hit by 'most serious breach of personal data' in cyberattack; pm lee's data targeted janowski d advisors beware of zoom bombing clarifications on the use of zoom and best practices for securing zoom meetings | it security publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations acknowledgements the authors gratefully acknowledge the administrative support of ms. jean huijuan xie. the authors would also like to thank the rest of the members of the education administrative team (ms. alia binte dhahfier, ms. avery soo yee ng, mr. francis kim huat law, mr. andy guanghui toh, mr. siang wee lim, and ms. chew ting puah) for their efforts in transitioning and maintaining the medical curriculum online during the covid- pandemic. conflict of interest the authors declare that they have no competing interests.ethical approval the data collected for the analysis of the elearning experience was approved by national university of singapore institutional review board.informed consent all subjects of the panel survey gave consent for anonymized data to be used for publication purposes. key: cord- - r pq o authors: heald, adrian h; stedman, michael; tian, zixing; wu, pensee; fryer, anthony a title: modelling the impact of the mandatory use of face coverings on public transport and in retail outlets in the uk on covid‐ ‐related infections, hospital admissions and mortality date: - - journal: int j clin pract doi: . /ijcp. sha: doc_id: cord_uid: r pq o introduction: the rapid spread of the pandemic caused by the severe acute respiratory syndrome coronavirus (sars‐cov‐ /)(covid‐ ) virus resulted in governments around the world instigating a range of measures, including mandating the wearing of face coverings on public transport/in retail outlets. methods: we developed a sequential assessment of the risk reduction provided by face coverings using a step‐by‐step approach. the united kingdom office of national statistics (ons) population survey data was utilised to determine the baseline total number of community‐derived infections. these were linked to reported hospital admissions/hospital deaths to create case admission risk ratio and admission‐related fatality rate. we evaluated published evidence to establish an infection risk reduction for face coverings. we calculated an infection risk score (irs) for a number of common activities and related it to the effectiveness of reducing infection and its consequences, with a face covering, and evaluated their effect when applied to different infection rates over months from (th) july , when face coverings were made compulsory in england on public transport/retail outlets. results: we show that only . % of all community‐based infection risk is associated with public transport/retail outlets. in the week of (th) july, the reported weekly community infection rate was , new cases at the start ( th july). the rate of growth in hospital admissions and deaths for england was around ‐ %/week, suggesting the infection rate, r, in the most vulnerable populations was just above . . in this situation, average infections over the evaluated week follow‐up period, would be , /week with face covering of % effectiveness, thus reducing average infections by /week, hospital admissions by /week and deaths by . /week; a fall of % over the period total. if, however, the r‐value rises to . , then average community infections would stay at , /week and mandatory face coverings could reduce average weekly infections by , , hospital admissions by and deaths by . /week; a % reduction. if the r‐value rose and stayed at . , then expected average community‐derived hospital admissions would be /week and % effective face coverings would reduce this by /week and reduce possible expected hospital deaths from /week to /week. these reductions should be seen in the context that there was an average of , /week all‐cause hospital emergency admissions in england in june and , total reported deaths in the week ending th august . conclusion: we have illustrated that the policy on mandatory use of face coverings in retail outlets/on public transport may have been very well followed, but may be of limited value in reducing hospital admissions and deaths, at least at the time that it was introduced, unless infections begin to rise faster than currently seen. the impact appears small compared to all other sources of risk, thereby raising questions regarding the effectiveness of the policy. wearing face masks was associated with a lower risk of infection (relative risk · , % ci · to · ). the american college of physicians also raises questions around the evidence to support the effectiveness of face coverings in reducing transmission. the only study we identified that examined the introduction of face coverings on public transport and in retail outlets examined the association between introduction of face coverings in a specific region of germany relative to when they were introduced in other comparator regions. while this study suggested that 'face masks reduce the daily growth rate of reported infections by around %', the design of the study means that it is difficult to assign the observed effect to the introduction of compulsory face coverings in a causal fashion. we developed a sequential assessment of the risk reduction provided by face coverings using a step-by- step approach. as a baseline, we utilised the office of national statistics (ons) population survey data to determine the baseline total number of community-derived infections. the ons population survey released on the th july provided data that estimated, for the most recent week for which data was available ( to july ). this excluded those in hospitals, care homes or other institutional settings (but not those who work in these settings). this baseline figure of , cases per day is used in subsequent modelling. step : source of infection. we considered the impact on the number of infections within the community rather than in hospitals or care homes, as these are where people using retail and public transport will be most reflected. there will be some cross infections but the level of this is beyond the scope of this analysis but is likely to be small. given that it is unlikely that people displaying more severe symptoms of infection would use public transport or visit retail outlets, we then utilised ons and wider literature data to estimate the proportion of asymptomatic or pre-symptomatic cases. the ons data suggests that only around one-third of individuals testing positive for covid- on a swab test reported having symptoms. this was based on self-reported symptoms and therefore may be an that between and % of infections may be derived from people without symptoms. while posted on the preprint service website, medrxiv, early in the pandemic, these data were reviewed and assessed by the centre for evidence-based medicine on rd july . according to yin and jin, there is no difference in transmissibility between those with and without symptoms. for the modelling, we used a conservative estimate of % of infections from pre-or asymptomatic cases. step : infection risk by activity. we calculated an infection risk score (irs) for a number of common activities. firstly, based on location, we categorised daily activities into the following: home, work, public transport, retail outlets, other activities (indoors) and, other activities (outside). we calculated the average length of time spent per day accepted article on each of these activities. this was based on the united kingdom time use survey, - , as quoted in a scottish government report, and a resolution foundation report in july . step : impact of the use of face coverings. the effectiveness of face coverings in reducing infections will be dependent on two broad factors: (i) the range for the uk of . - . and a growth rate was given as - % to - % as of th july . consequently, three r values; namely . (the accepted level at the time of the introduction of mandatory face coverings), . (a worsening to equilibrium) and . (the pandemic restarting) were used in our analysis. for each of these, we calculated the total number of consequent future infections that could be expected to flow from the original infections. accepted article baseline effectiveness of face coverings and the irs calculated above for retail outlets and public transport was applied to each scenario to calculate the expected infections, hospitalisations and deaths over the next months. the sensitivity of the results to the assumptions on face-covering effectiveness was tested by calculation of the above for no face coverings ( %), %, %, % and %. baseline data & proportion of pre-symptomatic and asymptomatic cases. based on the ons survey data, we modelled the impact of face coverings based on , community cases per day. of these, % are estimated to be due to transmission from pre-symptomatic and asymptomatic cases. these generate a baseline figure for assessment of the impact of face coverings of , community cases. infection risk by activity. figure a shows graphically the impact of the different assumed r-value ( . , . , . ) on the infection outcomes over the weeks and the potential cumulative numbers for both with or without face coverings for the levels of r then on infections (figure b) , community hospitalisation ( figure c ) and deaths (figure d) we have modelled the potential impact of the use of face coverings worn in retail outlets and on public transport on the number of uk covid- infections and associated hospital admissions and mortality rates. overall, we demonstrated that only around % of all community-based infection risk for those aged more than years of age is associated with public transport and retail outlets. this contrasts with % associated with work or study, for those aged years and over. this illustrates the limitations of the impact of any policy to reduce infections in the public transport and retail outlets sectors alone, irrespective of the efficiency of the intervention. it perhaps suggests that measures targeted at the workplace may be more worthwhile. in addition to this, the requirement to wear face coverings may increase anxiety in some people and thereby result in a reluctance to utilise public transport and/or visit retail outlets. this may, therefore, reduce the time spent on these activities. while it is also possible that the use of face coverings may increase the confidence of other people, it is difficult to say whether this will negate the above effect. certainly, public transport usage and retail footfall does not appear to have returned to pre-pandemic levels, , and hence the . % may be an overestimate of the contribution of these activities to overall risk. however, in our modelling, given the difficulty in calculating this impact, we assumed this change in behaviour to be neutral. this raises interesting questions around the timing of the implementation of the policies to mandate the use of face coverings in the retail and transport contexts; a time when the r-value was less than one (most uk government reports suggested . - . ) and the daily infection rate was relatively low in comparison to the peak in april . use of face coverings in retail outlets and on public transport is of limited value, particularly when the r-value is below , in contrast to march/april when the r-value was much higher. we also used a range of efficiencies of face coverings, reflecting the wide range of types of coverings, variability in correct usage (particularly over prolonged periods) and uncertainty around which modes of transmission could be influenced by their use. realistically, an estimate of around % is likely to be a sensible conservative estimate, particularly in the context of the work by van der sande et al. advice on the use of masks in the context of covid- : interim guidance, th report on face masks for the general public uk department of health and social care. face coverings: when to wear one and how to make your own face masks and coverings for the general public: behavioural knowledge the outcome and implications of public precautionary measures in taiwan-declining respiratory disease cases in the covid- pandemic physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov- and covid- : a systematic review and meta-analysis use of n , surgical, and cloth masks to prevent covid- in health care and community settings: living practice points from the american college of physicians (version ) face masks considerably reduce covid- cases in germany: a synthetic control method approach face masks and gdp ijcp personal protective equipment (ppe) and infection among healthcare workerswhat is the evidence? accepted article this article is protected by copyright. all rights reserved mental health before and during the covid- pandemic: a longitudinal probability sample survey of the uk population prevalence of and risk factors associated with mental health symptoms among the general population in china during the coronavirus disease multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science psychopathological responses and face mask restrictions during the covid- outbreak: results from a nationwide survey mask anxiety, face coverings and mental health coronavirus (covid- ) infection survey pilot: england coronavirus (covid- ) infections in the community in england the role of asymptomatic sars-cov- infections: rapid living systematic review and meta-analysis the centre for evidence-based medicine. the role of asymptomatic sars-cov- infections: systematic review accepted article this article is protected by copyright. all rights reserved comparison of transmissibility of coronavirus between symptomatic and asymptomatic patients: reanalysis of the ningbo covid- data united kingdom time use survey the scottish government. centre for time use research time use survey - ; results for scotland the time of your life: time use in london and the uk over the past years, resolution foundation coronavirus (covid- ) infection survey world health organisation. transmission of sars-cov- : implications for infection prevention precautions all rights reserved . european centre for disease prevention and control. transmission of covid- professional and home-made face masks reduce exposure to respiratory infections among the general population epidemiological bulletin: infection environment of covid- outbreaks in germany european centre for disease prevention and control transmission of covid- uk gov guidance the r number and growth rate in the uk % .&text=the% r% number% range% for,as% of% % july% . accessed st office for national statistics deaths week ending th all rights reserved office for national statistics population survey modelled daily incidence the use of facemasks to prevent respiratory infection: a literature review in the context of the health belief model mental health before and during the covid- pandemic: a longitudinal probability sample survey of the uk population this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved key: cord- -ab ecwvw authors: moret-tatay, carmen; baixauli-fortea, inmaculada; grau-sevilla, m. dolores title: profiles on the orientation discrimination processing of human faces date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: ab ecwvw face recognition is a crucial subject for public health, as socialization is one of the main characteristics for full citizenship. however, good recognizers would be distinguished, not only by the number of faces they discriminate but also by the number of rejected stimuli as unfamiliar. when it comes to face recognition, it is important to remember that position, to some extent, would not entail a high cognitive cost, unlike other processes in similar areas of the brain. the aim of this paper was to examine participant’s recognition profiles according to face position. for this reason, a recognition task was carried out by employing the karolinska directed emotional faces. reaction times and accuracy were employed as dependent variables and a cluster analysis was carried out. a total of two profiles were identified in participants’ performance, which differ in position in terms of reaction times but not accuracy. the results can be described as follows: first, it is possible to identify performance profiles in visual recognition of faces that differ in position in terms of reaction times, not accuracy; secondly, results suggest a bias towards the left. at the applied level, this could be of interest with a view to conducting training programs in face recognition. faces represent a fundamental characteristic of our identity. not surprisingly, it is the first part we would hide to avoid being recognized. we all have witnessed advances in facial biometrics in our environment for many fields, from security and health care systems to social networks. even if this issue has become crucial in smart cities, many challenges still remain [ ] . among these, one should bear in mind that some face-recognition technology is able to do this process under not the most optimal conditions, e.g., even for people wearing masks to combat the spread of covid- [ ] . current approaches have focused their attention on predictions through artificial intelligence. in this way, computer vision performance often employs algorithms as depicted in approaches such as the convolutional neural network [ ] . however, is this effect transferable to the cognitive abilities of human beings? in other words, are we able to recognize a face in complex situations? the human brain is able to process a great number of characteristics belonging to a familiar face in a matter of milliseconds and without apparent cognitive cost [ ] . this type of processing seems to be inherent to the human being and fundamental for multiple areas; among them, one of the most crucial ones would be socialization [ ] [ ] [ ] . of interest, this process occurs in the area intended for human face recognition, named as ffa (face form area), which has been described as one of the most specialized regions for facial recognition in the human visual system [ ] . more precisely, the ffa is located in the fusiform gyrus, brodmann area , and has also been related to other tasks: word recognition [ ] and objects [ ] , among other processes. however, even if all these processes might be sharing the same brain areas [ ] , their nature is different, as, e.g., words have to be learned in comparison to face recognition [ ] . visual processing, as described in the literature, begins with the coding of the orientation of the local border in the primary visual cortex named v [ ] . the responses of the neurons belonging to the v area oversee the preferred orientation, producing a maximum level of response. some of the most relevant models in face recognition have focused on neural components [ , , ] . through anatomic-functional evidence, it is stipulated that the human brain would make use of different but connected cognitive processes related to aspects of the stimulus in terms of variance and invariance. thus, the most consistent and least variant stimuli would be supported in areas such as the intraparietal groove (related to spatial attention) and the auditory cortex (such as prelexical perception for associated names, among others) [ , , ] . on the other hand, the more abstract and variant aspects would make use of the amygdala and the limbic system to address aspects of emotional processing, and the anterior temporal zone for aspects of identity recognition [ , , ] . there is undeniable consensus on some inherent aspects of face recognition in neurotypical patients across the life span. newborns show a preference for the upper, as opposed to the lower, part of a face [ ] , suggesting that not only sensory properties but also structural characteristics are of interest. on the other hand, evidence has shed light on how facial recognition can be affected in older adults, for both detection [ ] and identification proposes [ ] . although studies with clinical samples are of interest, at a more basal level, other studies seem to indicate that the maturation of specialized processing throughout the life span also depends on previous experiences [ ] . in this way, several factors can interfere, such as the number of expositions and even the way that a stimulus is presented [ , ] . the aging process seems to be related to qualitative changes as well as quantitative changes in the perception of the face, which would be reflected in aspects such as processing components or reaction time [ ] . some progress has been made in understanding the molecular mechanism of face recognition. however, there is no single or simple answer for the rehabilitation approach in behavioral terms. some research points to the role of cognitive strategies [ , ] . in this way, it has been described that good recognizers would be distinguished not only by the number of faces they recognize but also by the number of these stimuli that they can reject as unfamiliar [ ] . when it comes to the role of stimulus on face recognition, it is important to remember that position, to some extent, would not entail a high cost, unlike other stimuli, such as written words [ ] . moreover, in our daily routine, it is common to constantly face different positions for a face in our environment. hence, the identification of a human face may imply the recognition of the invariant structure of aspects in dynamic environments of our daily life [ ] . the most ecological environments will be related to low viewing conditions [ ] , in terms of lighting [ ] or distance [ ] , among others. one of the most interesting variants that can include all the variables described above is the movement or the position of presentation and a face. however, the scientific literature supports the effects of cultural configuration on visuospatial skills [ ] . habits such as reading have a strong influence on the cognitive system and can introduce spatial biases at both the perceptual and representational levels of a wide range of stimuli. specifically, biases towards the left have been found in readers of french origin [ ] and towards the right in readers of hebrew [ ] . this might be related to attentional issues, but different strategies might also be expected in a participant profile. therefore, an analysis of the participants' performance in face recognition is proposed. the starting point for evaluating the best participants, as marked by the literature, would be the ability to discard new and unfamiliar faces by choosing different position levels. a total of spanish university students participated in this study. therefore, a total of men and women volunteered to participate in the study, ranging from to years old. in order to participate, all participants gave written informed consent as described by the university ethics committee (ucv/ - / ). g*power [ ] was employed to examine effect size, f = . , probability of error, α = . , and sample size under a repeated measures design. the karolinska directed emotional faces (kdef) from the karolinska institutet [ ] was used. this consists of a total of images of facial expressions with different emotions and a total of different positions: central, partial right, right profile, partial left and left profile (see figure for an exemplification). a sample of stimuli was chosen in order to exclusively select neutral expressions under these positions. each stimulus was repeated several times under a repeated measures design. therefore, for the present study, a total of pictures ( men and women) matched in physical characteristics were selected. the total number of stimuli was . after a presentation block, participants were instructed to identify the previous stimuli and discard the novel ones. a windows operating system computer was used with the free experimental dmdx software [ ] . participate, all participants gave written informed consent as described by the university ethics committee (ucv/ - / ). g*power [ ] was employed to examine effect size, f = . , probability of error, α = . , and sample size under a repeated measures design. the karolinska directed emotional faces (kdef) from the karolinska institutet [ ] was used. this consists of a total of images of facial expressions with different emotions and a total of different positions: central, partial right, right profile, partial left and left profile (see figure for an exemplification). a sample of stimuli was chosen in order to exclusively select neutral expressions under these positions. each stimulus was repeated several times under a repeated measures design. therefore, for the present study, a total of pictures ( men and women) matched in physical characteristics were selected. the total number of stimuli was . after a presentation block, participants were instructed to identify the previous stimuli and discard the novel ones. a windows operating system computer was used with the free experimental dmdx software [ ] . the experiment consisted of two phases, a first called "presentation" with photographs that appeared at random. after min, the participants passed the second phase called "recognition", where the previous stimuli appeared plus another ( in total). in this phase, the participants had to press the green key (m) if they recognized the image of the previous block and press the letter z, or red, if they considered the image novel. each session lasted approximately min. as mentioned before, this was an experimental design under repeated measures. this approach was selected as it reduces the variance of estimates in comparison with other designs, such as between subjects' ones. moreover, all participants came across all conditions, allowing statistical inference to be made with fewer subjects in comparison with other designs. in order to know the response profiles in the discarding of new information, a cluster analysis was performed, which, as a multivariate technique, seeks to group elements (or variables) to achieve maximum homogeneity in each group, as well as the greatest differences between them. one should bear in mind that cluster analysis has enabled the formation of homogeneous groups within multiple fields of cognitive science and public health [ , ] . for example, studies have developed dendrograms from the hierarchy clustering analysis based on the strength of functional connectivity among the face-selective specified regions of interest (or roi's) when the participants performed a face recognition task [ ] . this procedure was similar to the previous literature for small samples [ , ] . data were analyzed using spss ibm statistical software for windows version . (ibm corp., armonk, ny,usa). data were checked for multicollinearity and multivariate outliers. in addition, the kolmogorov-smirnov test was used to verify that the scores on the variables had a normal distribution. cluster analysis was performed under the registration probability test based on the schwarz bayesian inference criterion (bic). the proposed two-stage cluster analysis was replicated with a hierarchical cluster. the experiment consisted of two phases, a first called "presentation" with photographs that appeared at random. after min, the participants passed the second phase called "recognition", where the previous stimuli appeared plus another ( in total) . in this phase, the participants had to press the green key (m) if they recognized the image of the previous block and press the letter z, or red, if they considered the image novel. each session lasted approximately min. as mentioned before, this was an experimental design under repeated measures. this approach was selected as it reduces the variance of estimates in comparison with other designs, such as between subjects' ones. moreover, all participants came across all conditions, allowing statistical inference to be made with fewer subjects in comparison with other designs. in order to know the response profiles in the discarding of new information, a cluster analysis was performed, which, as a multivariate technique, seeks to group elements (or variables) to achieve maximum homogeneity in each group, as well as the greatest differences between them. one should bear in mind that cluster analysis has enabled the formation of homogeneous groups within multiple fields of cognitive science and public health [ , ] . for example, studies have developed dendrograms from the hierarchy clustering analysis based on the strength of functional connectivity among the face-selective specified regions of interest (or roi's) when the participants performed a face recognition task [ ] . this procedure was similar to the previous literature for small samples [ , ] . data were analyzed using spss ibm statistical software for windows version . (ibm corp., armonk, ny, usa). data were checked for multicollinearity and multivariate outliers. in addition, the kolmogorov-smirnov test was used to verify that the scores on the variables had a normal distribution. cluster analysis was performed under the registration probability test based on the schwarz bayesian inference criterion (bic). the proposed two-stage cluster analysis was replicated with a hierarchical cluster. first, face recognition was analyzed based on reaction time on the position stimuli. we were interested in the participants' profile when discarding new information. in this way, a descriptive analysis was carried out. after examining the assumptions of interest, a cluster analysis was carried out. descriptive statistics (response latencies and correct answers) were included in table , as well as the increase in latencies (∆) between the target and distractor stimuli. the dependent variable of interest is the reaction time, as this is considered to reflect the cognitive architecture, and not surprisingly, is a star variable in the literature [ ] . however, the rts (reaction times) are drawn from positively skewed distributions; for this reason, extreme data were trimmed, as in previous literature [ ] . moreover, different assumptions were checked in terms of outliers and multicollinearity, and no more than % of the data were trimmed. the kolmogorov-smirnov test was used to examine whether the variables were normally distributed, p > . . this was the same case for the shapiro-wilks normality test. levene's test indicated equal variances (all p > . ). the anova on the distractor rts showed that the target images were processed faster than the distractor images: f ( . ) = . ; mse = , . ; p < . η = . . no position effect was found for response latencies, and no difference in efficacy across the hit rate (all p > . ). secondly, an exploratory two-stage cluster analysis was performed to identify the number of clusters in the participants on the distracting stimuli. likewise, the schwarz-bayesian inference criterion (bic) is shown in table . we used it to select the lowest bic value in the different estimated models, in this case for two clusters. after the analysis, % of the cases were included, the size ratio was optimal, with a value of . . two groups were formed with . % and . % of cases respectively. these two profiles were described as follows (see table ): a profile named g with slower and more conservative processing (n = ) and a g profile with faster and more efficient processing (n = ). in addition, depending on the values ∆, different response patterns can be described (see table ). the participants' sex was not related to the distribution of the new groups; moreover, it seemed to be distributed in a proportionate way, as the g was composed of seven men and seven women, while the g by six men and six women. as expected, the test χ did not depict sex differences for new clusters. in the analysis of these new groups, a non-parametric approach was chosen, as shown in table . as depicted in table , the mann-whitney u test showed statistically significant differences for all conditions by cluster group. in addition to the mann-whitney u-test, jointly, the vovk-sellke indicators are offered to examine the maximum possible probability in favor of h over h [ ] . this information was included to complement traditional p-value-based analyses, as suggested in the previous literature, through the use of probability [ ] . all conditions were statistically significant for differences between groups. also included was the hodges-lehmann's estimate, with its confidence intervals, which would indicate the difference in the median between the two groups, and the bias-range correlation coefficient, which can be considered an effect size and is interpreted as the same as pearson's correlation coefficient [ ] . as depicted in table , the increments were addressed (∆) following the previous procedure. this analysis attempts to shed light on differences in patterns by estimating the distance between target and distracting condition latencies. as well as the central position, considered more ecological, not presenting changes in the group increments, the differences between groups seem to mark a bias towards the left side, and the right side was the one that distinguishes the participants with better execution in the task. finally, the proposed two-stage cluster analysis was replicated with a hierarchical cluster. the objective was to replicate the exploratory structure of the previous analysis. in relation to the new hierarchical cluster, a representation of the suggested dendrogram is included, which replicates the previous structure. in figure , this structure is presented in a tree diagram format that tries to illustrate the groupings of the participants. two large groups are presented, consistent with the previous analysis, except for two subjects, who, although they are not within this subgroup, are closely linked. in relation to the new hierarchical cluster, a representation of the suggested dendrogram is included, which replicates the previous structure. in figure , this structure is presented in a tree diagram format that tries to illustrate the groupings of the participants. two large groups are presented, consistent with the previous analysis, except for two subjects, who, although they are not within this subgroup, are closely linked. lastly, the box and whiskers diagrams for all experimental conditions by cluster group are shown in figure . this representation allows us, in a very visual way, to know not only the central tendency statistics but also their relationship with the variability, which was markedly lower for group . lastly, the box and whiskers diagrams for all experimental conditions by cluster group are shown in figure . this representation allows us, in a very visual way, to know not only the central tendency statistics but also their relationship with the variability, which was markedly lower for group . familiar versus unfamiliar recognition is of interest in the field of face processing, and its expert role in the visual system [ , , ] . the holistic and features segmentation approaches have been familiar versus unfamiliar recognition is of interest in the field of face processing, and its expert role in the visual system [ , , ] . the holistic and features segmentation approaches have been described for both face and word recognition, suggesting the need for more research in terms of holistic versus feature perspective in the visual process as a continuum (and not only in isolated steps such as the perceptual, attentional or decisional one). the current results' differences according to internal and external characteristics emphasize the role of participants' strategies. in this way, the scientific literature supports the effects of cultural configuration on visuospatial skills [ ] . it has been found that habits such as reading have a strong influence on the cognitive system and can introduce spatial biases at both the perceptual and representational levels of a wide range of stimuli. this aspect is of special interest when we must recognize a face, since, as a stimulus, unlike, for example, written words, it can appear in multiple positions and be processed, apparently without effort. as mentioned before, a total of two profiles were found regarding their capacity to discard new information. the literature has described profiles of good recognizers, which would be distinguished not only by the number of faces they recognize but also by the number of these stimuli they are able to reject as unfamiliar [ ] . the patterns between the two suggested groups showed differences between latencies or response times, so a more conservative pattern will be found for one of the profiles. from a qualitative approach, these results could support sensitivity to oblique information in the near horizontal range or biases [ , ] or preferences towards one of the orientations [ , ] . there are different limitations in this study. first, the sample of men and women is too small to examine possible gender differences. in addition, aspects such as the city of origin and its density have not been considered, which is stipulated to possibly moderate the recognition process. future lines of research should conduct both direct and systematic replications over these issues and are expected to address these limitations. these should involve controlling the sex of participants and the density of their home populations. moreover, the chosen stimuli were neutral, and therefore, future lines of research should include aspects such as the emotional valence of a face. as a first approach, a simpler manipulation has been proposed, and in this way, we hope it will serve for future manipulations that contemplate a greater variability gradient of the stimulus. thus, the type of battery of stimuli used in this study, the karolinska directed emotional faces, is ideal for such a purpose as it was designed for emotional manipulations. in sum, we consider these results of interests for training programs, where profiles can be of interest to understand participants' strategies. at a theoretical level, this information is of interest to multiple fields, such as psychology or forensic medicine, by reducing errors within the psychology of testimony, and obviously, whether it is possible to determine face recognizer profiles would be of great interest for its social and personal consequences. at the applied level, this could be of interest not only with a view to conducting training programs in face recognition but also to better understand cognitive strategies. in this way, the literature has demonstrated the plastic capacity of the process, even in some clinical profiles [ ] [ ] [ ] . although the sample used is not a clinical one, we hope that future replications of the study can reach this level. the aim of this paper was to examine recognition profiles, according to face position. this might shed light on differences in terms of strategies to deal with familiar versus unfamiliar stimuli. therefore, a cluster analysis was carried out. the results can be described as follows: first, it is possible to identify performance profiles in visual recognition of faces that differ in position in terms of reaction times, not accuracy; secondly, results suggest a bias towards the left. in sum, the main contributions and implications of the current work are listed as follows: first, to develop recognition profiles and encoding of facial stimuli in relation to the ability to discard new information. secondly, to examine the role of facial stimulus invariance according to its orientation on human recognition, as described above. this type of contribution could offer a starting point in strategies based on the two points described in non-clinical participants. face recognition systems: a survey 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intervention program in gender-based violence the hierarchical brain network for face recognition cluster analysis in family psychology research age slowing down in detection and visual discrimination under varying presentation times the mediational role of distracting stimuli in emotional word recognition calibration of ρ values for testing precise null hypotheses scientific method: statistical errors rank-biserial correlation uncovering phonological and orthographic selectivity across the reading network using fmri-ra let's face it: reading acquisition, face and word processing the orientation selectivity of face identification faces are "spatial"-holistic face perception is supported by low spatial frequencies perception of musical pitch in developmental prosopagnosia use of a correlative training method in the rehabilitation of acquired prosopagnosia this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to thank the participants involved in the study and the universidad católica de valencia, san vicente mártir. the authors declare no conflict of interest. key: cord- - yf ae d authors: chen, y.; dong, m. title: how efficient can non-professional maskssuppress covid- pandemic? date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: yf ae d the coronavirus disease (covid- ) pandemic is caused by the severe acute respiratory syndrome coronavirus (sars-cov- ), which can be transmitted via respiratory secretions. since there are currently no specific therapeutics or vaccines available against the sars-cov- , the commen nonpharmaceutical interventions (npis) are still the main measures to curb the covid- epidemic. face mask wearing is one important measure to suppress the pandemic. in order to know how efficient is face mask wearing in reducing the pandemic even with low efficiency non-professional face masks, we exploit physical abstraction to model the non-professional face masks made from cotton woven fabrics and characterize them by a parameter virus penetration rate (vpr){gamma}. monte carlo simulations exhibit that the effective reproduction number r of covid- or similar pandemics can be approximately reduced by factor {gamma} with respect to the basic reproduction number r ,if the face masks with % <{gamma}< % are universally applied for the entire network. furthermore, thought experiments and practical exploitation examples in country-level and city-level are enumerated and discussed to support our discovery in this study and indicate that the outbreak of a covid- like pandemic can be even suppressed by the low efficiency non-professional face masks. the global spread of coronavirus disease (covid- ) has already affected over countries and regions within only a few months, and led to more than , deaths until the middle of may [ ] , [ ] . the covid- is a pandemic caused by severe acute respiratory syndrome coronavirus (sars-cov- ), which can lead to acute respiratory distress syndrome. one main reason for the rapid expansion of this outbreak is the efficient human-to-human transmission [ ] . sars-cov- can be detected in nasal and throat swabs samples obtained from patients indicating high viral loads in upper respiratory tract samples [ ] . therefore, it appears to be likely that virus can be transmitted via respiratory secretions in the form of droplets (> µm) or aerosols (< µm). it has been reported that the virus can remain active in aerosols for multiple hours [ ] . since there are currently no specific therapeutics or vaccines available against the sars-cov- , the classical public health measures are needed to curb the covid- epidemic. the primary goal of all the measures is to interrupt person-to-person transmission [ ] . to accomplish this goal, many common non-pharmaceutical interventions (npis) such as isolation and quarantine, social distancing, correspondence to: yejian chen; email: yejian.chen@nokia-bell-labs.com and community containment have been applied. except these measures, face mask wearing is emerging as one of the important npis for suppressing the pandemic, especially when considering that the pre-symptomatic or asymptomatic cases may also play a critical role in the transmission process [ ] , [ ] . compared with the societal lockdown, universal masking is far more sustainable than the other measures from economic, social, and mental health standpoints [ ] . there are two main types of face masks: the professional mask such as n masks and medical masks, which have high efficiency, and the non-professional face masks such as homemade face masks with low efficiency. in our study, we mainly focus on the efficiency of different types of non-professional face masks, since medical masks are in short supply during the covid- pandemic and preferentially used in hospitals not for the public social network. we introduce certain types of cotton face masks which are characterized by their different dimensions of pore diameters, and exploit physical abstraction to model the capability of these face masks to block aerosols. based on the investigated physical abstraction and parameters, monte carlo simulations are carried out to demonstrate the outbreak of covid- pandemic with or without face masks in a social network to check if the low efficiency non-professional face masks manage to slow down the outbreak and spread of covid- or similar pandemics. in this study, abstracting physical and statistical models are our major methodologies for simulating a social network, in which the covid- pandemic starts to be suppressed with the usage of different non-professional face masks. the face mask is modeled as shown in fig. (a) . four different face masks can be characterized by their dimensions of pore diameters. for a given surface area on the face masks, the density of the pores equivalently represents the capability of face masks to block the particles. according to the investigation in [ ] for cotton woven fabrics, the pore size varies from µm to µm. hence, the face masks, used in this study, are made from cotton woven fabrics, and the corresponding pore size is selected from this range. it is well known that respiratory droplets and aerosols are the major virus carriers. in this study, as illustrated in fig. (b) , we focus on the spherical aerosol, which is with even smaller dimension, and can thus be critical during the outbreak of the pandemic. it is reported that the diameter of sars-cov- virus is around . µm to . µm. the median diameter of aerosols is . µm, and % of the aerosols have the diameter less than . µm [ ] . thus, we model the diameter d of aerosols exactly based on the observations in [ ] , by means of continuous poisson distribution [ ] with distribution function as ) for x > , λ ≥ and λ stands for the mean value of diameter d. furthermore, for a given surface on a face mask, e.g. fig. (a) , we assume that the diffusion of sars-cov- aerosols obeys uniform distribution, and the same amount of aerosols approaches the face masks. as illustrated in fig. (b) , we assume that aerosols can penetrate the pore of a face mask, if the geometric center of the spherical aerosol locates in the red shadowed region within a pore. we use monte carlo simulations to repeat the same scenario for different non-professional face masks and count the number of aerosols and their diameters, which penetrate the pores of the face masks individually. for instance, for face mask k, we can compute the sum area of the surfaces of the total penetrated aerosols as where n k stands for the number of penetrate aerosols out of all n attacking aerosols, and d i,k denotes the diameters of these penetrate aerosols. notice that the sum area s k represents the amount of the penetrated viruses by deploying face mask k, if the density of viruses per unit area on the aerosols is assumed to be constant. hence, we introduce the virus penetration rate (vpr) γ k as a ratio between the sum area s k of penetrated aerosols and the sum area of total approaching aerosols. it holds furthermore, we can similarly define the successful aerosol block rate (abr) α k by exploiting face mask k as in [ ] , it is shown that the basic reproduction number of a pandemic r can be formulated as a function where transmission rate β provides the rate of infection of a given contact between a susceptible and infected individual, social contact rate c determines the average number of contacts between susceptible and infected individuals and duration of infectiousness is denoted by τ . obviously, face masks can play a role for reducing transmission rate β with respect to the vpr γ k . with face mask k, the effective transmission rate β k can be formulated as where the amount of viruses per contact is reduced by factor γ k , if both susceptible and infected individuals use face masks. thus, this reduces the rate of infection. throughout the monte carlo simulation in the following section, we assume that there are several options of non-professional face masks within the social network. they are characterized by their vpr γ k and abr α k individually. one of the important motivations of this paper is to demonstrate that even these non-professional face masks can play a significant role to control the pandemic. we will also illustrate how the vpr γ k of face mask k numerically impacts the effective reproduction number r k . as shown in fig. , we have a complete overview of vpr γ k and abr α k for the face masks with different pore diameters, which are modeled by equations ( ) to ( ) through the monte carlo simulations. the face masks with pore diameters µm ≤ d k ≤ µm are non-professional face masks, consisting of single layer cotton woven fabrics. the corresponding vpr and abr satisfy . % ≤ γ k ≤ . % and . % ≤ α k ≤ . %, respectively. in details, the face mask with pore diameter d k = µm can block . % aerosols and . % viruses, and the face mask with pore diameter d k = µm can block . % aerosols and . % viruses. we notice that the inequality α k < − γ k holds, and introduce the compensation factor θ k , defined as . cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . the compensation factor θ k indicates the fact that abr α only counts the number of successfully blocked aerosols. for face masks generally with large pore size, once a successful block happens, the number of the viruses on the aerosol plays a more important weighting in computing γ k than in α k . the compensation factor θ illustrates that the nonprofessional face masks with relatively large pore diameters should not be underestimated. empirically, we observe that the compensation factor θ is bounded by θ max = π , which belongs to a part of future analytical investigation. finally, we add the effective vpr γ k to fig. , if the face mask k is exploited by both infectious individuals and susceptible individuals systematically. in this section, we study the outbreak of covid- pandemic in a social network by means of monte carlo simulation, and reveal different progressing, if the face masks are introduced in the social network. we refer to the covid- pandemic parameters in [ ] and [ ] . the transmission rate and contact rate are assumed to be β = . and c = , respectively. the average duration of infectiousness is τ = days. in fig. , the outbreak of covid- pandemic in a social network is demonstrated by a one-shot monte carlo simulation. with the selected parameters β, c and τ , the number of daily new infected cases is counted. the infectious transmission, characterized by the generations of the viruses, is also illustrated with different colors. on one side, visualizing the infectious transmission and virus generation development serves as a plausibility check for the simulation. on the other side, fig. also illustrates that the basic reproduction number can be underestimated at the early stage of the pandemic, as mentioned in [ ] and [ ] due to lack of data, or as shown in fig. due to counting only on a one-shot monte carlo simulation for the pandemic. thus, in the following investigation, we repeat such one-shot monte carlo simulation as shown in fig. for , times and take a final averaging, to get a stationary result for a given pandemic parameter setting. furthermore, we introduce five types of face masks, which are categorized as class a+ (γ k = %, pore size d k = µm), class a (γ k = %, pore size d k = . µm), class b (γ k = %, pore size d k = . µm), class c (γ k = %, pore size d k = . µm) and class d (γ k = %, pore size d k = . µm). the corresponding parameters are obtained from the results in section iii.a. in fig. , the accumulated daily number of infections is presented, assuming that one type of face mask out of class a+ to class d is systematically exploited in entire social network, without considering the impact from social distancing and hand hygiene [ ] . first of is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . fits to the early analysis in [ ] and [ ] . the systemic wearing of face masks can effectively slow down spread of the covid- pandemic. by introducing the doubling time t d , with the assumed average infectious duration τ , the corresponding reproduction number of individual face mask can be estimated asr in table i , the reproduction numbersr k with exploitation of ( ) and summarized. empirically, we discover the one-toone correlation of the basic reproduction number r and the reproduction numberr k aŝ equation ( ) illustrates the fact that even face masks with large pores can effectively reduce the reproductive index r by a factor of γ k . from the monte carlo simulation in fig. with class a+ face mask, it is visible that the outbreak curve can be flattened both at the beginning of covid- pandemic or one week after the outbreak, if exploiting the face masks by cotton woven fabric with pore size d k = µm in the entire network. as an extension of fig. , we start the monte carlo simulations to study the effect of class a+ face masks in the social network to suppress covid- for longer period, when face masks obligation is applied at different stages of the pandemic. basically, fig. illustrates the fact that the exploitation of face masks is more effective when exploited in the early stage of pandemic. as shown in fig. , the red curve (day ) reveals much stronger effect on suppressing the infections than the blue curve (day ), which exploits the face masks only days later. in fig. , the daily increasing of the number of covid- infections in usa is presented. it can be clearly noticed that there are two stages during the early development of the pandemic. in the first stage, the number of infections increases exponentially. this stage is fitted by the red curve considering mmse criterion. the exponential growth factor can be approximated as r /τ ≈ . . since the covid- pandemic was relatively underestimated in usa at the early outbreak stage, we select a longer infectiousness duration τ = days. thus, the basic reproduction number in usa is approximately r ≈ . . in the second stage, the development of the pandemic can be linearly fitted. furthermore, we realize that the green straight line follows the tangent direction at the turning point of the red exponential curve. it is clearly showed that if the period of first stage can hardly be reduced, we should possibly try to flatten the red exponential curve. the usage of face mask can achieve this goal. in fig. , the number of infections will be doubled every t d = τ ln / ln r ≈ . days. let us assume that the social network exploit a face mask with γ = %, which is comparable to class c or class d face masks in the monte carlo simulations for fig. . the new doubling time of the covid- pandemic in usa is t d = τ ln / ln(γ r ) ≈ days. especially, as an important consequence, the slope of the green curve in the second stage will also be reduced, which indicates that the usage of face masks with relatively low efficiency can still be very effective at the early stage of a pandemic. in previous section, we exploit physical abstractions, mathematical or statistical models, and thought experiments to clarify that even non-professional face masks can help to suppress the propagation of covid- pandemic. in this section, we will verify our models focusing on the develop-. cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june , . . ment of the pandemic in different countries or cities, which are impacted by exploitation of face masks. in fig. fig. . compare the pandemic in germany, austria and czech [ ] development of covid- pandemic in germany, austria and czech are compared to each other. considering the fairness of the comparison, normalization is introduced, so that the number of infections per million population is studied for three countries. during the early exponential stage, the reproduction number r of austria was even bigger than that of germany and czech. czech introduced strict mandatory face masks policy on march, which prohibited the movement outside without having mouth and nose covered by a respirator, face mask or similar [ ] . the pandemic was effectively controlled. we further compare the development of pandemic in austria and germany. after the pandemic stepped into the linear stage, the virus reproduction in austria was still faster than that of germany, which coincides with the discussion in the previous section. on march, the austrian government announced that everyone entering a store had to wear a face mask, effectively since april [ ] [ ] . and even more strict face masks mandatory policies were introduced in austria on april. the instantaneous reproduction number of austria reduced significantly. on april, most german states introduced face masks obligation, which belonged to relatively soft mandatory policies [ ] . the daily growth of accumulative infectiousness of germany behaved similar to austria before activating strict face masks obligation on april. in fig. , the spread of covid- pandemic in different german cities is presented. we select three cities, namely stuttgart, ulm and jena for comparison. stuttgart is the center of the famous industry region, accommodating thousand population. ulm and jena are typical german cities with median scale, with thousand and thousand population, respectively. for the fairness reason, we investigate the number of covid- infection per thousand population for three cities. it can be also observed that situation in jena seemed to be the worst among three cities at the early outbreak stage [ ] of covid- pandemic. on march, jena was the first german city to announce an obligation to wear masks, or makeshift masks including scarves, in supermarkets, public transport, and buildings with public traffic [ ] , [ ] and the policy was in effect on apr. with the mandatory face masks policy, the daily infection number of jena decreased dramatically and reached to for complete days until april. although stuttgart and ulm adopted similar policies except the obligation for face masks, the number of infections could not be reduced during the same time period from april to april. on april, stuttgart and ulm started the mandatory face masks policy. the curve of number of infectiousness started to becoming flattened. in this study, we exploit physical abstraction, statistical and numerical methods to illustrate the important features and the corresponding behaviors of face masks to successfully slow down the outbreak of covid- or similar pandemic. with monte carlo simulations, it is numerically demonstrated that even the non-professional face masks can significantly impact the pandemic, if they are systematically deployed in the entire social network. with the example of current development of covid- pandemic in usa, we demonstrate that the outbreak of covid- , in sense of the increasing of infection numbers in the social network, consists of an early exponential increasing stage and a linear increasing stage afterwards. it is analytically shown that the speed of the reproduction of the infectiousness in the network can be effectively slowed down, if face masks are applied in the exponential stage. especially, the reduced reproduction in exponential increasing stage can yield consequently a linear increasing stage with reduced infectiousness reproduction, which will be meaningful. finally, we explore the data from the reality to compare the outbreaks of covid- pandemic in different locations in country-level or city-level. the results clearly prove the finding obtained in our study and lead to the final conclusion: face mask wearing is one essential measure to suppress the covid-. cc-by-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june , . . pandemic. even the low efficiency non-professional face masks can reduce the virus transmission. since face mask wearing is far more sustainable than the other measures, it should be applied strictly and universally in the social network during the covid- pandemic period. coronavirus disease (covid- ) situation daily reports worldometer covid- coronavirus pandemic live update (web source a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster sars-cov- viral load in upper respiratory specimens of infected patients aerosol and surface stability of sars-cov- as compared with sars-cov- isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus ( -ncov) outbreak diagnosis, treatment, and prevention of novel coronavirus infection in children: experts' consensus statement universal masking is urgent in the covid- pandemic: seir and agent based models, empirical validation, policy recommendations aisha rehman; madeha jabbar; muhammad umair a study on the interdependence of fabric pore size and its mechanical and comfort properties potential utilities of mask-wearing and instant hand hygiene for fighting sars-cov- continuous counterparts of poisson and binomial distributions and their properties notes on r estimating the reproductive number and the outbreak size of covid- in korea high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus coronavirus pandemic in the czech republic coronavirus pandemic in austria maskenpflicht, regierung verschärft maßnahmen einschätzung der aktuellen lage in city jena current status: case numbers of the day coronavirus pandemic in germany erste deutsche großstadt führt maskenpflicht ein key: cord- - jr nnx authors: oeppen, r.s.; shaw, g.; brennan, p.a. title: human factors recognition at virtual meetings and video conferencing: how to get the best performance from yourself and others date: - - journal: br j oral maxillofac surg doi: . /j.bjoms. . . sha: doc_id: cord_uid: jr nnx during the current coronavirus pandemic, social distancing and restrictions on travel have resulted in a dramatic rise in the use of technology (including video conferencing) for remote meetings. from local multidisciplinary team (mdt) meetings to national and international committees, this form of communication has been vital to ensure patient-related and other business can continue, albeit in a sometimes unfamiliar environment. in this article we consider some of the human factors elements of remote meetings and provide suggestions to enhance the experience of team and committee members during this unsettling time. it is possible that this form of communication will continue to flourish after the pandemic is over. in just a few months, the coronavirus (covid- ) pan-q demic has changed our current way of life both personally and professionally. social distancing regulations across the world are proving beneficial in reducing the spread of the virus. however, this necessary alteration to the way we interact has resulted in the cancellation and postponement of many national meetings, conferences (including the baoms annual scientific meeting in june ), surgical exams including mrcs and frcs as well as other events involving close interaction between colleagues. however, national and * corresponding author. tel.: + ; fax: + . e-mail address: peter.brennan@porthosp.nhs.uk (p.a. brennan). international business and essential meetings requiring significant participation at local trust level, such as cancer and other multidisciplinary teams (mdt) have to continue. as a result, there has been an exponential rise in the use of virtual meeting technology including such platforms as microsoft ® teams, gotomeeting ® , powwownow ® to name just a few. when confidential conversations are taking place such as those relating to patient care, it is important to ensure that the platform being used is secure. the use of video-communication is not new and has considerable benefits for connecting individuals in diverse locations, reducing travel time and expense. over years ago, researchers investigated various factors that improve one's presence on teleconferencing including how cameras are set up and positioned to ensure eye contact with other participants. however, limited bandwidth can result in major shortcomings, frustration, reduced performance and less effective action planning when compared to standard face to face meetings. speaking time also increases during virtual meetings and various non-verbal communication gestures that occur during face to face meetings might be difficult or impossible to convey to others thereby reducing decision making quality. the authors have attended and chaired many virtual meetings in the last few weeks. our experiences have been variable, encountering many issues supporting the findings of a study that concluded virtual technology was unlikely to replace the traditional face-to-face cancer mdt. broadband and login issues, long arduous meetings, and difficulties in agreeing outcomes that are more readily achievable in face-to-face meetings prompted review of human factors (hf) knowledge and experiences to develop suggestions to improve the virtual experience. before discussing these issues, it is important to emphasise that adequate preparation is a prerequisite to any committee or meeting and members should have read the relevant circulated papers and agenda before the meeting itself. setting the agenda some meetings may be conducted by video technology, or this if not available, by teleconference. video links can utilise significant bandwidth, leading to connectivity issues, slurring of images and sound problems, all of which can result in potential boredom or disengagement. it is important that the chair or leader of the meeting begins by setting a clear agenda and format, discusses timings and ensure that everyone is equally valued. it must be emphasised that only one participant should speak at any time. as with face-to face meetings, one or more loquacious individuals may dominate virtual meetings, which can be counterproductive or even disruptive for the rest of the attendees. while all individuals must be allowed to appropriately voice their opinion or expertise, the chair should provide clarity from the outset of the time constraints and need for brevity as well as inclusivity. when using video conferencing, we recommend that all attendees other than the chair and current speaking participant turn off their cameras to reduce bandwidth usage and improve sound quality. the additional advantage of this technique is that it can alert the chair when someone else wishes to speak, akin to the raising of a hand during a face-to-face meeting. while not relevant for short meetings of perhaps less than minutes, during those lasting for a half day or longer, we believe it is important to build in breaks within the virtual meeting agenda. it can be even more difficult to concentrate when participating in remote discussions compared to face-to-face interactions, particularly for the chair who is denied non-verbal communication clues and other committee dynamics that can help the effective running of meetings. lack of concentration can lead to agenda items being missed, or improperly understood and discussed in a similar way to loss of situational awareness leading to potential error. furthermore, it is much harder for committee members to look out for each other or prompt the chair if they are missing something important or going off track. we recommend a minimum -minute break every minutes, with a longer break of at least minutes after three hours. participants can remain logged or connected in to the hosting platform or dial in number. during this time, just as in clinical practice, it is important to rehydrate and eat regularly. a cup of coffee and comfort break may make longer virtual meetings more enjoyable than shorter but more intense face-to-face meeting where breaks and drinks are considered unnecessary (fig. ) . we are exposed to potential distractions throughout the day. these can be readily classified as external, for example originating from other meeting members and/or the environment, and internal, namely actions or thoughts from ourselves. one distraction can readily lead to another. for example, a perceived dominant committee member or discussion that is seemingly taking too long or heading off at a tangent can lead individuals to focus their attention on smart phones or other non-meeting related tasks. smartphones themselves have many potential 'distractions' including games, short message services (sms) or interaction with others through social media. by using a smartphone simultaneously with another task, performance is undoubtedly reduced. while simply using a phone during a virtual meeting might not be as disruptive as during a face-to-face interaction, it could easily result in missing important discussion points. , when using a computer for a virtual meeting, it is all too easy to divert ones attention to other work-related matters or the internet. some have recommended placing a mirror close to the computer so the attendee can observe and maintains awareness of their own behaviour even though the camera is switched off so other members cannot see them. having a printed copy of the agenda to hand can be useful both to track progess and provide a wandering mind with a visual cue to keep their attention focused. repeated interruptions (including smart phone related) while concentrating on other tasks raises the risk of medical errors. repeated interruptions such as urgent emails to respond to, or staff members at work and family members at home seeking attention while engaged with a virtual meeting can lead to annoyance with the virtual meeting and a situation termed 'crisis mode work climate.' , low levels of background noise can reduce performance and concentration. for this reason we recommend the use of headset when attending videoconferencing. another potential advantage of a headset is as a remnder of the aviation industry where hf is embedded in practice and becomes second nature. it is also recommended that the microphone function on the computer is set to mute to reduce background noise during virtual meetings, and only switched on when speaking. group dynamics can often be challenging, especially where authority, experience or seniority gradients exists. the chair can manage this by setting the tone at the outset and reinforcing through regularly seeking contributions from other members. group think occurs when members would rather concur than cause disharmony, and perhaps coupled with boredom or desire to progress could risk a less than optimum comment to an agenda item. one effective means to counter this is for the chair to seek contradictory opinion/evidence, especially from members who have not led the debate. this is a powerful tool to ensure that the aims of the session have been achieved (this may contrast with the agenda items) and to summarise key findings. it also offers a closing opportunity for any further contributions. table some recommendations for improving the virtual meeting experience. setting the agenda and timings note taker if possible projecting in a virtual white board one person only to speak at a time judicious use camera to reduce bandwidth muting of microphone when not speaking familiarity with technical platform use of a headset taking regular breaks ( - minutes every minutes) as for face-to-face meetings adequate hydration and nutrition ensure a diversity of opinion has been represented in debate a physical copy of the agenda to hand to track progress check the aims of the session have actually been achieved rather than the agenda simply followed reflect on the session for future enhancement similarly a review of how well the session has worked, and any suggested improvements might also prove helpful q (table ) . at this unsettling time, the use of alternate methods allowing important virtual meetings to continue from local to international level has dramatically increased. it is likely that when some sort of normality returns following the pandemic, many will continue with these arrangements, which can offer convenience, flexibility and savings in both time and travel expenses when compared to traditional face-to-face meetings. virtual meetings are used to assess progress and provide support at some medical schools as well as aiding education. , it is difficult to predict the future application of this resource. consideration and understanding of the relevance and application of human factors to virtual meetings will enable individuals and teams to improve their experience while optimising meeting efficiency and effectiveness. we have no conflicts of interest. n/a. an updated estimation of the risk of transmission of the novel coronavirus ( -ncov) telepresence in videocommunications: a study on stereoscopy and individual eye contact the influence of the modality of telecooperation on performance and workload getting with the times: a narrative review of the literature on group decision making in virtual environments and implications for promotions committees what is a virtual multidisciplinary team (vmdt)? video conferences through the internet: how to survive in a hostile environment telepsychiatry at the service of autism review: avoid, trap, and mitigate -an overview of threat and error management looking after ourselves at work: the importance of being hydrated and fed does talking on a cell phone, with a passenger, or dialing affect driving performance? an updated systematic review and meta-analysis of experimental studies analysis of smartphone interruptions on academic general internal medicine wards. frequent interruptions may cause a' crisis mode' work climate human factors awareness and recognition during multidisciplinary team meetings the frequency and impact of task interruptions in the icu interruptions and distractions in healthcare: review and reappraisal associations between perceived crisis mode work climate and poor information exchange within hospitals background noise lowers the performance of anaesthesiology residents' clinical reasoning when measured by script concordance: a randomised crossover volunteer study randomized evaluation of videoconference meetings for medical students' mid-clerkship feedback sessions medical education adaptations during a pan-q demic: transitioning to virtual student support key: cord- - nhr hv authors: patel, samir n.; hsu, jason; sivalingam, meera d.; chiang, allen; kaiser, richard s.; mehta, sonia; park, carl h.; regillo, carl d.; sivalingam, arunan; vander, james f.; ho, allen c.; garg, sunir j. title: the impact of physician face mask use on endophthalmitis after intravitreal anti-vascular endothelial growth factor injections date: - - journal: am j ophthalmol doi: . /j.ajo. . . sha: doc_id: cord_uid: nhr hv purpose: to evaluate the effect of physician face mask use on rates and outcomes of post-injection endophthalmitis. design: retrospective, comparative cohort study methods: . setting: single-center study population: eyes receiving intravitreal anti-vascular endothelial growth factor injections from / / to / / . intervention: cases were divided into “face mask group” if face masks were worn by the physician during intravitreal injections or “no talking group” if no face mask was worn but a no talking policy was observed during intravitreal injections. main outcome measures: rate of endophthalmitis, visual acuity, and microbial spectrum. results: of , intravitreal injections administered, out of , ( . %) cases of endophthalmitis occurred in the “no talking” group, and out of , ( . %) cases occurred in the face mask group (odds ratio, . ; %ci, . – . ; p= . ). sixteen cases of oral flora-associated endophthalmitis were found in the “no talking” group ( in , injections) compared to none in the face mask group (p= . ). mean logmar visual acuity at presentation in cases that developed culture-positive endophthalmitis was significantly worse in the “no talking” group compared to the face mask group ( . lines lost from baseline acuity vs . lines lost; p= . ), though no difference was observed at six months following treatment (p= . ). conclusion: physician face mask use did not influence the risk of post-injection endophthalmitis compared to a no talking policy. however, no cases of oral flora-associated endophthalmitis occurred in the face mask group. future studies are warranted to assess the role of face mask use to reduce endophthalmitis risk, particularly due to oral flora. the use of intravitreal anti-vascular endothelial growth factor (anti-vegf) injections has become the standard of care for the treatment of common retinal diseases including neovascular age-related macular degeneration, retinal vein occlusion, and diabetic macular edema. since the introduction of intravitreal anti-vegf therapy, intravitreal injections have become one of the most commonly performed procedures in all of medicine. although these medications have excellent safety profiles, acute bacterial endophthalmitis remains an uncommon but potentially devastating complication. multiple prior studies have evaluated patient-related and procedure-related risk factors associated with post-injection endophthalmitis. [ ] [ ] [ ] [ ] [ ] in particular, one study found that oral flora-associated endophthalmitis was reduced after instituting a "no talking" policy where speaking was minimized during the procedure. understanding potential risk factors for oral flora-associated endophthalmitis is of particular importance given its poor visual prognosis. [ ] [ ] [ ] [ ] surgical face masks reduce transfer of nasopharyngeal flora from respiratory emissions. previous studies demonstrated that surgical masks reduced forward bacterial dispersion into the surgical field. , two laboratory investigations involving simulated intravitreal injections suggest that face mask use may reduce bacterial dispersion associated with speech. , partly due to this data, some have suggested including face mask use as part of the standard of care for intravitreal injections. , however, it is unclear whether decreased bacterial dispersion in these simulations correlates with an impact on clinical practice. both studies also found that maintaining silence during the simulated injection was equally effective as wearing a face mask. , however, other studies have suggested that face mask use may increase bacterial dispersion and infection risk. [ ] [ ] [ ] [ ] there are no known clinical studies, to our knowledge, investigating the potential impact of physician face mask use during intravitreal injection administration in a clinicbased setting on the rates of endophthalmitis. this lack of data is particularly relevant given that the use of personal protective equipment like face masks has become a standard of care for routine medical care by ophthalmic providers since the covid- pandemic. prior to the covid- precautions, within our practice, a subset of physicians have consistently worn face masks while performing intravitreal injections, while other physicians have used a no talking technique without face mask use during the procedure. the purpose of this study is to evaluate the rate and outcomes of postinjection endophthalmitis with physician face mask use compared to a no talking policy without face masks. this retrospective, single-center, comparative cohort study received prospective approval from the institutional review board at wills eye hospital. data were collected in accordance with health insurance portability and accountability act of guidelines, and the study conformed to the tenets of the declaration of helsinki. billing records and j o u r n a l p r e -p r o o f endophthalmitis logs were used to identify patients who developed endophthalmitis following anti-vegf injections. billing data was used to determine the total number of intravitreal injections, patients, type of anti-vegf injection (bevacizumab, ranibizumab, and aflibercept) used, gender, age, and indication for treatment. charts of all patients who were treated for endophthalmitis were reviewed, and the diagnosis was confirmed. recorded data included date of causative injection; date of tap and injection and/or vitrectomy; best available visual acuity (va) based on the better of habitual correction or pinhole testing before causative injection, at time of tap and inject and/or vitrectomy, at months post-procedure, and at last follow-up; and microbial culture results. physician face mask use was determined by a survey of physician practice patterns. all patients diagnosed with presumed infectious endophthalmitis following an intravitreal injection of bevacizumab, ranibizumab, or aflibercept were included in this study. dates of inclusion were july , to september , . endophthalmitis was defined as patients who presented with a clinical suspicion that was high enough to warrant either intravitreal antibiotic injection with vitreous/aqueous tap or pars plana vitrectomy with injection of antibiotics. in general, these patients presented with decreased visual acuity and pain, and had signs of intraocular inflammation on examination (generally ≥ + anterior segment cellular reaction and/or posterior segment vitritis). culture-positive endophthalmitis was defined as any patient with bacterial growth on culture or a positive gram stain from a vitreous or anterior chamber tap. a culture was considered to be oral flora-associated when enterococcus or streptococcus species was grown on culture. endophthalmitis was considered culture-negative when both the gram stain and culture plates were negative. patients with presumed inflammatory endophthalmitis treated with topical steroids without additional interventions were excluded. all intravitreal anti-vegf injections were performed in office-based settings, either in a designated procedure room or in a clinical room where the exam was conducted. all eyes were routinely prepared with topical anesthetic. no physicians routinely used lidocaine gel, topical pledgets, or subconjunctival lidocaine for anesthesia. after ocular anesthesia, all eyes received topical % povidone-iodine at least seconds prior to injection, and povidone-iodine administration was repeated just prior to injection at physician discretion. injections were performed with a -gauge needle for ranibizumab and aflibercept injections, or -gauge needle for bevacizumab injections, and inserted . - mm from the limbus. lid retraction was achieved through manual lid retraction with no routine use of lid speculum by any of the providers. surgical gloves, surgical caps, and sterile drapes were not used by physician providers for intravitreal injection administration during the study period. injection techniques were not altered during the study period and were otherwise similar between the two groups (supplementary table available at ajo.com). for the "no talking" group, all injections were administered under a strict policy of silence in which the physician, patient, and others in the room including technicians and family members did not speak during the injection procedure. during the informed consent portion of the procedure, patients are informed of the importance of minimizing speech during the procedure prior to entering the injection room. families are asked to not come into the injection room unless required for certain reasons such as help with mobility as their presence may encourage conversation. technicians are trained not to talk during preparation of the injection or during the procedure. physicians do not talk during the procedure except to cue the patient to look in a certain direction prior to uncapping the injection needle. when speaking close to the patient, physicians directed their faces away from the eye to be injected. for the face mask group, a subset of physicians wore a surgical mask (procedure mask mckesson pleated earloops # - , mckesson, irving, tx) when administrating an intravitreal injection. additionally, technicians who assisted with drawing drug from the vial, placing the needle on a prefilled syringe, or assisting with lid retraction wore a face mask. during the timeframe of the study, patients did not wear face masks during the injection administration. patients and others in the room were still asked not to speak during the procedure as per the "no talking" policy above, but the physician could speak to give instructions and reassurance. all eyes developing presumed infectious endophthalmitis immediately underwent a pars plana vitreous tap with aspiration or anterior chamber paracentesis with injection of intravitreal antibiotics or consideration for immediate pars plana vitrectomy with vitreous culture and intravitreal antibiotics. patients typically received intravitreal vancomycin ( mg/ . ml) and ceftazidime ( mg/ . ml). intravitreal amikacin ( μg/ . ml) was substituted for ceftazidime for patients with penicillin allergy at the discretion of the treating physician. a subset of patients did not have microbiologic specimens sent for processing if they were being treated at a satellite office without immediate access to a microbiology facility. patients were variably prescribed cycloplegic agents, topical antibiotics, and topical steroid drops based on physician discretion. all data were analyzed using statistical software (ibm spss statistics, armonk, ny, usa). the primary outcome was the rate of endophthalmitis following intravitreal injection in the face mask group compared to the "no talking" group. the secondary outcomes were va and microbial spectrum of culture-positive cases. va at months was used for the analysis based on prior studies. snellen va was converted to logmar equivalent for the purpose of statistical analysis. as established by prior studies, , vision levels of counting fingers, hand motion, light perception, and no light perception were assigned va values of . / , . / , . / , and . / (logmar equivalent . , . , . , . respectively). for categorical variables, significant differences between groups were analyzed using a pearson's chi-squared test or fisher's exact test. for continuous variables, significant differences between groups were analyzed using two sample t-test, mann-whitney u test, or analysis of variance with a tukey's honest significant difference post-hoc test. statistical significance was considered to be a -sided p value < . . during the study period, physicians contributed cases with a mean (sd) , ( , ) (range, - , ) injections per physician. a total of , intravitreal anti-vegf injections ( , bevacizumab, , ranibizumab, and , aflibercept) were performed with , injections in the "no talking" group and , injections in the face mask group. overall, a total of cases of suspected endophthalmitis after intravitreal injection were identified ( . %; in injections). over the six-year study period, the annualized rate of post-injection endophthalmitis ranged from . % ( in injections) to . % ( in injections) with no significant difference among the annualized rates (p = . ). cultures were performed in of these cases, and mean follow-up for all suspected endophthalmitis cases was . months (range, days - . months). mean (sd) duration of follow-up was . ( . ) months (range, . - . months) for the face mask group and . ( ) months (range, - months) for the "no talking" group (p = . ). in the "no talking" group, suspected endophthalmitis occurred in cases of , injections ( . %; in , injections), of which cases were culturepositive ( table ). the most common causative organism was staphylococcus epidermidis in cases. there were cases of oral flora-associated endophthalmitis ( . %; in , injections), and causative organisms included cases of streptococcus mitis, cases of streptococcus viridians, cases of streptococcus pneumoniae, and cases of undifferentiated streptococcus. in the face mask group, suspected endophthalmitis occurred in cases of , injections ( . %; in , injections) of which cases were culture-positive (table ). causative organisms included cases of gram-positive cocci (by stain), case of staphylococcus epidermis, and case of staphylococcus aureus. there were no cases of oral flora-associated endophthalmitis. overall, patients with presumed endophthalmitis presented an average of . days after intravitreal anti-vegf injection (range, - days). the vast majority of cases presented within days of intravitreal injection ( . %). patients in the face mask group presented an average of . days after injection compared to an average of . days in the "no talking" group (p = . ). of the cases sent for culture, in the face mask group, / ( %) cases were culture-positive compared to / ( %) endophthalmitis cases in the "no talking" group (p = . ). endophthalmitis cases in the face mask group were oral floraassociated in / ( %) cases compared to / ( %) cases for the "no talking" group (p = . ). of the , injections in the face mask group, , ( %) were bevacizumab, , ( %) were aflibercept, and , ( %) were ranibizumab. of the , injections in the "no talking" group, , ( %) were bevacizumab, , ( %) were aflibercept, and , ( %) were ranibizumab. compared to the "no talking" group, the face mask group was more likely to use aflibercept (p < . ) and less likely to use ranibizumab (p < . ). overall, there were cases of endophthalmitis after ranibizumab injection ( . %; in ranibizumab injections), cases of endophthalmitis after aflibercept injection ( . %; in aflibercept injections), and cases of endophthalmitis after bevacizumab injection ( . %; in bevacizumab injections). endophthalmitis cases were associated with ranibizumab in / ( %) cases, aflibercept in / ( %) cases, and bevacizumab in / ( %) cases. endophthalmitis cases in the "no talking" group were associated with bevacizumab in / ( %) cases, aflibercept in / ( %) cases, and ranibizumab in / ( %) cases. endophthalmitis cases in the face mask group were associated with bevacizumab in / ( %) cases, aflibercept in / ( %) cases, and ranibizumab in / ( %) cases. there was no significant difference in the risk of endophthalmitis between the face mask group and the "no talking" group based on drug type (table ) . overall average baseline va at the causative injection prior to endophthalmitis was logmar . (approximately / ) with no significant difference between the face mask group (logmar . ; approximately / ) and the "no talking" group (logmar . ; approximately / ) (p = . ) ( table ). at -months follow-up, average va was logmar . (approximately / ) for the face mask group vs. logmar . (approximately / ) for the "no talking" group (p = . ). for the face mask group, / ( %) cases had a va of count fingers or worse at -months follow-up compared to / ( %) for the "no talking" group (p = . ). at -months follow up, / ( %) cases in the face mask group lost or more lines of va from baseline compared to / ( %) cases in the "no talking" group (p = . ). at last follow-up, average va was logmar . (approximately / ) for the face mask group vs. logmar . (approximately / ) for the "no talking" group (p = . ). for the face mask group, / ( %) cases had a va of count fingers or worse at last follow-up compared to / ( %) for the "no talking" group (p = . ). average va at presentation for culture-positive endophthalmitis cases was logmar . (approximately / ) in the face mask group compared to logmar . (approximately / ) in the "no talking" group (p = . ) ( table ). at -months follow-up, average va for the culture-positive endophthalmitis cases was logmar . (approximately / ) in the face mask group vs. logmar . (approximately / ) in the "no talking" group (p = . ). for the culture-positive endophthalmitis cases in the face mask group, / ( %) cases had a visual acuity of count fingers or worse at months follow-up compared to / ( %) for the "no talking" group (p = . ) furthermore, at -months follow up, / ( %) cases in the culture-positive face mask group lost or more lines of va from baseline compared to / ( %) cases in the culture-positive "no talking" group (p = . ). at last follow-up, average va for culture-positive endophthalmitis cases was logmar . (approximately / ) in the "no talking" group vs. logmar . (approximately / ) in the face mask group (p = . ). for the culture-positive endophthalmitis cases in the face mask group, / ( %) cases had a va of count fingers or worse at last follow-up compared to / ( %) for the "no talking" group (p = . ). overall, visual outcomes were significantly worse for culture-positive and oral flora-associated endophthalmitis cases. comparing vision loss from baseline, at months follow up, oral flora-associated cases lost an average of lines of visual acuity, non-oral flora-associated culture-positive cases lost . lines of visual acuity, and culture-negative cases lost . lines of visual acuity (p < . ). this study examined the impact of physician face mask use on the rates and outcomes of endophthalmitis after intravitreal anti-vegf injections. in this single-center study of , intravitreal injections, we found that physician face mask use did not affect the overall rate of post-injection endophthalmitis. injection techniques for both the face mask and "no talking" groups were similar. however, the injecting physicians in the face mask group likely did not uniformly adhere to a strict policy of silence for all people in the room during the procedure compared to the physicians in the "no talking" group. in spite of this, no cases of oral flora-associated endophthalmitis were observed in the face mask group. although all forms of endophthalmitis are visually threatening, oral floraassociated endophthalmitis is associated with a particularly poor visual prognosis. [ ] [ ] [ ] therefore, there is significant interest in understanding potential risk factors and prophylaxis measures for reducing the incidence of oral flora-associated endophthalmitis. a meta-analysis of the literature covering , intravitreal injections from to found that streptococcal species were three times more likely to be the causative organism in post-injection endophthalmitis cases than in intraocular surgeries in which a surgical mask is typically worn. furthermore, prior studies have established that oral flora-associated endophthalmitis may be reduced with the implementation of a strict "no-talking" policy by the physician and patient during intravitreal injection administration. , refraining from speaking during an intravitreal injection is thought to minimize the potential to contaminate the uncapped needle or conjunctival surface with oral flora immediately before or during the injection. similarly, face mask use by the physician administering the injection may serve to further limit bacterial dispersion during speech. within the neurology literature, multiple outbreaks of iatrogenic oral flora associated meningitis have been reported. as a result, face mask use has become the standard of care for any clinician performing spinal injections. [ ] [ ] [ ] in one case of iatrogenic meningitis, the causative bacteria was genotyped and shown to be identical to that of a throat swab taken from the neurologist who performed the lumbar puncture. within ophthalmology, an in vitro study involving surgeons and simulated intravitreal injection scenarios found that the rate of oral flora bacteria was significantly reduced when speaking with face masks compared to speaking without face masks. furthermore, another in vitro study of volunteers who underwent simulated intravitreal injection administrations demonstrated significantly more bacterial dispersion occurred when speaking without a face mask compared to speaking while wearing a face mask. however, there was no significant difference in bacterial dispersion when speaking with a face mask compared to not speaking without a face mask (simulating a "no-talking" policy). these in vitro studies correlate with our study findings as all intravitreal injections were administered with either a "no-talking" policy or face mask use by the physician. some studies have suggested that the presence of a beard or the tendency to excessively move one's face beneath a surgical mask , may increase bacterial dispersion and shedding, presumably from the beard and facial skin. in addition, other studies have suggested that extended use of the same face mask may increase infectious risk as the external surface can function as a fomite. furthermore, physicians speaking with a loose fitting face mask may result in upward or downward bacterial dispersal. collectively, these concerns may explain why the majority of retina physicians surveyed in two recent studies did not wear face masks during intravitreal injections. , at a minimum, our study findings suggest that physician face mask use does not increase the risk of post-injection endophthalmitis and may be equivalent to a strict "no talking" policy. these findings are particularly relevant as routine use of face masks by physicians has exponentially increased with the emergence of the covid- pandemic, and it is unclear what the duration of these precautions will be. although this study focused on the impact of physician and technician assistant face mask use, current covid- guidelines recommend universal face mask protocols for all individuals in the injection room which includes the patient. with regard to patient face mask use, it is possible that bacterial dispersion around the edges of the face mask may be directed towards the eye, which could potentially increase the risk of endophthalmitis. indeed, current guidelines from the center for disease control and prevention recommend cloth face covering, which may not adhere to the face as well. further studies are indicated to understand the effects of universal face mask use on rates of various types of endophthalmitis. overall, va outcomes following endophthalmitis were similar in the face mask group compared to the "no talking" group. va at the causative injection, endophthalmitis presentation, and six months following treatment were similar between the two groups. patients in the "no talking" group were more likely to have a visual acuity of cf or worse at months compared to the face mask group ( % vs %), though these findings were not statistically significant. regardless of face mask use, our findings were similar to prior studies that have established that visual outcomes are worse for culture-positive cases compared to culture-negative cases. , when assessing culture-positive endophthalmitis cases, visual outcomes at endophthalmitis presentation were worse for the "no talking" group with a mean loss of . lines of vision from baseline acuity compared to a loss of . lines for the face mask group. furthermore, at -months follow up, patients in the "no talking" group were more likely to have a va of cf or worse compared to the face mask group ( % vs %), though these findings were not statistically significant. strengths of the study include the large number of intravitreal injections from a single institution with a standardized injection protocol, including injection technique and preparation, amongst multiple retina specialists. endophthalmitis following intravitreal injection is an uncommon event with reported incidence rates ranging from as high as in approximately injections to as low as in , injections with the majority of large recent studies reporting an incidence rate of in - injections. , , , - . therefore, any prophylaxis measure to potentially lower the risk of endophthalmitis requires an assessment of a large number of intravitreal injections to achieve adequate power to detect a difference. although we report one of the largest single center studies of post-injection endophthalmitis, our study findings may be limited by the study's imbalanced sample size with , injections in the face mask group compared to , injections in the "no talking" group. assuming the risk of oral flora-associated endophthalmitis is in , injections as reported in this study, and that face mask use may reduce the risk of oral flora-associated endophthalmitis to in , injections, a study would need , injections to be sufficiently powered to detect a j o u r n a l p r e -p r o o f significant difference between the two groups with a confidence of . and power of . . ideally, a randomized controlled study could evaluate the risk of endophthalmitis with and without physician face mask use; however, the low incidence of endophthalmitis makes such a study prohibitive. furthermore, the granularity of physician-specific practice patterns, like face mask use, may not be captured in large-scale insurance claims databases or clinical registries. another limitation is the imbalance in medication distribution as the face mask group was more likely to use aflibercept and less likely to use ranibizumab compared to the "no talking" group. these findings may be particularly relevant as the prefilled syringe use for ranibizumab was introduced during the study period, and prior studies have reported prefilled syringes may reduce the risk of endophthalmitis. , furthermore, during the study period, there was a clustered spike in cases with intraocular inflammation after intravitreal aflibercept injections, which may explain the increased proportion of endophthalmitis associated with aflibercept compared to ranibizumab or bevacizumab in this study. the authors' standard practice is to have a low threshold to administer intravitreal antibiotics whenever the examining physician believes there is a possibility the case could represent infectious endophthalmitis; however, when sterile inflammation is suspected, topical medications alone were typically prescribed. regardless, there were no differences in endophthalmitis risk between the face mask group and "no talking" group based on drug type. another limitation is that microbiologic cultures were obtained in of ( %) cases. however, there were similar rates between the two groups as cultures were performed in of ( %) cases for the "no talking" group and of cases ( %) for face mask group (p > . ). recent studies have suggested that culture results have limited impact on clinical management. , furthermore, another limitation is that a positive gram stain was considered culture-positive even if there was no bacterial growth on culture. however, prior studies have suggested that any bacteria detected on gram stain of a sterile site specimen, such as vitreous or aqueous samples, should be considered significant. in addition, a culture result was considered to be oral flora-associated when enterococcus or streptococcus species was grown, which may not represent all potential oral flora. however, there were no cultures that grew other common oral flora including lactobacilli, corynebacteria, or bacteroides in either group. furthermore, streptococcal associated post-injection endophthalmitis is of particular concern given the poor visual prognosis relative to other forms of endophthalmitis. - additional limitations of this study are inherent in its retrospective nature. it is possible that patients could have developed endophthalmitis and sought treatment at an outside institution, although it is unlikely given the tertiary care nature of our institution. in summary, our study indicates that physician face mask use did not influence the risk of endophthalmitis or visual outcomes compared to a strict no talking policy during the injection procedure. no cases of oral flora-associated endophthalmitis occurred in the group in which the injecting physician wore a face mask though this study was underpowered to detect a difference. these findings are particularly relevant as routine use of face masks by retina specialists has increased with the emergence of the covid- pandemic. however, it is important to note that patients in the face mask group did not wear a mask which is unlike the current universal face mask protocols in place. additional studies are warranted to assess the potential role of face mask use to reduce the risk of endophthalmitis, particularly those due to oral flora. table . visual acuity outcomes for culture-positive endophthalmitis after intravitreal anti-vascular endothelial group factor injection in the face mask group vs. "no talking" group this study evaluated the rate of post-injection endophthalmitis with physician face mask use compared to a "no talking" policy without face mask use. in evaluating , intravitreal injections, physician face mask use did not reduce the rate of post-injection endophthalmitis compared to a "no talking" policy. no cases of oral flora-associated endophthalmitis were identified with physician face mask use. trends of anti-vascular endothelial growth factor use in ophthalmology among privately insured and medicare advantage patients international practice patterns for the management of acute postsurgical and postintravitreal injection endophthalmitis: european vitreo-retinal society endophthalmitis study report endophthalmitis following intravitreal injections performed in the office versus operating room setting outcomes and risk factors associated with endophthalmitis after intravitreal injection of antivascular endothelial growth factor agents the role of topical antibiotic prophylaxis to prevent endophthalmitis after intravitreal injection the impact of prefilled syringes on endophthalmitis following intravitreal injection of ranibizumab effect of a strict 'no-talking' policy during intravitreal injection on post-injection endophthalmitis microbial spectrum and outcomes of endophthalmitis after intravitreal injection versus pars plana vitrectomy endophthalmitis after intravitreal injection: the importance of viridans streptococci endophthalmitis following intravitreal injection effect of surgical mask position on bacterial contamination of the operative field unmasking the surgeons: the evidence base behind the use of facemasks in surgery bacterial dispersal associated with speech in the setting of intravitreous injections reducing oral flora contamination of intravitreal injections with face mask or silence endophthalmitis after intravitreal injections: should the use of face masks be the standard of care? mask wiggling as a potential cause of wound contamination the effect of facial hair and sex on the dispersal of bacteria below a masked subject surgical face masks and downward dispersal of bacteria surgical masks as source of bacterial contamination during operative procedures preparedness among ophthalmologists: during and beyond the covid- pandemic long-term visual outcomes and clinical features after anti-vascular endothelial growth factor injection-related endophthalmitis functional status and quality of life measurement among ophthalmic patients novel method for analyzing snellen visual acuity measurements meta-analysis of endophthalmitis after intravitreal injection of antivascular endothelial growth factor agents: causative organisms and possible prevention strategies iatrogenic meningitis by streptococcus salivarius following lumbar puncture iatrogenic meningitis: the case for face masks guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings current practice preferences and safety protocols for intravitreal injection of anti-vascular endothelial growth factor agents real-world trends in intravitreal injection practices among american retina specialists use of cloth face coverings to help slow the spread of covid- changes in management based on vitreous culture in endophthalmitis after intravitreal anti-vascular endothelial growth factor injection trends in vitreoretinal procedures for medicare beneficiaries eliminating antibiotic prophylaxis for intravitreal injections: a consecutive series of , injections by a single surgeon endophthalmitis: then and now association of acute endophthalmitis with intravitreal injections of corticosteroids or anti-vascular growth factor agents in a nationwide study in france aflibercept-related sterile intraocular inflammation outcomes endophthalmitis after cataract surgery: changes in management based on microbiologic cultures the spinal tap: a new look at an old test key: cord- - vyik e authors: probst, thomas; humer, elke; stippl, peter; pieh, christoph title: being a psychotherapist in times of the novel coronavirus disease: stress-level, job anxiety, and fear of coronavirus disease infection in more than , psychotherapists in austria date: - - journal: front psychol doi: . /fpsyg. . sha: doc_id: cord_uid: vyik e this study investigated stress-level, degree of job-related anxiety, and fear of coronavirus disease (covid- ) infection in psychotherapists in the early weeks of the covid- lockdown in austria. one thousand five hundred and forty-seven psychotherapists participated in an online survey, assessing stress [perceived stress scale- (pss- )], work-related worries and fears of existence [job anxiety scale (jas)], fear of covid- infection during face-to-face psychotherapy, and adherence to five protective measures against covid- infection during face-to-face psychotherapy. stress-levels were higher than in a representative sample (p < . ). when psychotherapy was the sole income, stress-level (p = . ) and job anxiety (p < . ) were higher. experiences with teletherapy, the psychotherapy format used during covid- , as well as reductions in number of patients treated during covid- , had no effect on stress-level or job anxiety. psychotherapists still conducting face-to-face psychotherapy during covid- reported less fear of infection compared to those conducting no face-to-face psychotherapy (p < . ), whereby the fear of infection was further reduced when they were more able to adhere to protective measures against covid- (p < . ). mental hygiene is important for psychotherapists to manage stress and job-related anxiety during covid- , especially in those whose income relies on psychotherapy. previous research suggested that emotional stressors and existential stressors due to financial concerns range among the major stressors' psychotherapists are exposed to (petrowski et al., ; puig et al., ) . the novel coronavirus disease and the measures necessary to fight it (i.e., quarantine, isolation, and social distancing; see nussbaumer-streit et al., ) are new stressors, which can increase and even cause public mental health problems (brooks et al., ; hossain et al., ; sharma et al., ) . mental health care is, therefore, essential during and after covid- (fiorillo and gorwood, ; pfefferbaum and north, ; xiang et al., ) . psychotherapists are specifically qualified to provide mental health care. yet, they might face problems in dealing with the impact of covid- on their life and professional activity (pfefferbaum and north, ) . for example, sessions are usually provided in personal contact (faceto-face), which has to be reduced now and most likely in the near future as well. although providing psychotherapy via telephone or internet (teletherapy) is possible (whaibeh et al., ; wright and caudill, ) , many state that face-to-face contact is an essential part of the therapy (connolly et al., ) . thus, the required reduction of face-to-face contacts might lead to a reduced number of patients (humer et al., ; probst et al., ) as some reservations against teletherapy have been shown in psychotherapists (schuster et al., ) and the general population (apolinário-hagen et al., ) . this situation might reinforce distress and job anxiety in psychotherapists, especially in those not used to provide teletherapy. moreover, psychotherapists still providing psychotherapy face-to-face during covid- might be especially stressed because of fear of becoming infected with covid- . consequences of these examples might be increased mental burden of psychotherapists, and this distress may negatively impact process and outcome of psychotherapy (salyers et al., ; la verdière et al., ) . the issue of preventing psychotherapists' burnout is a central concern in this context. research suggests that helpers who experience increased psychological distress are unable to respond optimally or to use their core skills (west and shanafelt, ; kitchingman et al., ) . thus, exploring stress-level, job anxiety, and fear of covid- infection in psychotherapists is essential to know if psychotherapists need to increase their mental hygiene during covid- . to the best of our knowledge whether and to what degree psychotherapists experience stress, job-related anxiety, and fear of infection in situations of exposing public health emergency, such as during the covid- outbreak, have not been studied previously. therefore, the current study aimed to investigate the stress-level, degree of job-related worries and fears of existence, as well as fear of covid- infection in psychotherapists in the early weeks of the covid- outbreak in austria. throughout the present study, job anxiety refers to generalized job-related worrying, as well as worrying about job security and the future. in austria, the first covid- infections were reported on th of february . to combat the rapid spread of the virus, a lockdown became obligatory on th of march (bundesgesetzblatt für die republik Österreich, a,b,c). in general, entering public places was strictly prohibited. people were only permitted to leave their homes if they had a good reason for doing so, such as to meet necessary basic needs of daily life or to fulfill work responsibilities. in these exceptions, a minimum safe distance of m ( feet) had to be maintained between people. certain areas in austria were under quarantine at the time of the study and had even stronger restrictions. in the present study, the following research questions (rqs) were addressed. • rq : how are stress-level, job-related worries and fears of existence, and fear of covid- infection in psychotherapists in the early weeks of the covid- outbreak? we hypothesized higher stress-level, as well as job-related worries and fears of existence than pre-pandemic scores from representative samples. in the current study, eligible participants included all licensed austrian psychotherapists. in austria, psychotherapy is an independent profession regulated by the austrian law since (psychotherapy act, st federal act of june , on the exercise of psychotherapy). in brief, candidates have to complete a professional training comprising two stages (a general training followed by a specialist training) to qualify frontiers in psychology | www.frontiersin.org as a psychotherapist. all licensed psychotherapists in austria are registered in the list of psychotherapists of the austrian federal ministry of social affairs, health, care and consumer protection. in the current study, all psychotherapists who provided a valid e-mail address in this list (~ , psychotherapists of more than , licensed psychotherapists) were contacted by the first author in cooperation with the austrian federal association for psychotherapy (Öbvp). psychotherapists received a link to an online survey, which was open from th of march until st of april . to start the survey, participants had to agree to the data protection declaration (electronic informed consent). no incentives were provided, and participation was voluntary. the survey followed the principles outlined in the declaration of helsinki, and the ethics committee of the danube university krems (austria) approved the study. the perceived stress scale with items (pss- ; cohen et al., ) was used to measure the psychotherapists' stresslevel on a five-point response scale ( = "never" and = "very often"). the questions in this scale ask about feelings and thoughts during the last month, such as "how often have you been upset because of something that happened unexpectedly, " or "how often have you felt nervous and stressed. " the positively worded items of the pss- ( , , , and ) were reverse scored. the total score of the pss- was obtained by summing up the items, so that higher scores indicate higher stress-level. in previous studies, cronbach's alpha of the pss- was evaluated at > . , and test-retest reliability was > . (see review by lee, ) . in our sample, cronbach's alpha was . . job anxiety was measured with the items of the "worrying and fear of existence" dimension of the job anxiety scale (jas; linden et al., ) . this dimension consists of the subscales "worrying" and "fears of existence" and has shown good internal consistency (cronbach's alpha: . ). the instruction was adapted, so that participants were asked to rate the statements in relation to the psychotherapeutic work in the current situation around covid- . psychotherapists rated statements that described situations, thoughts, and feelings which one can have experienced in connection with the workplace on a five-point response scale ( = "strongly disagree" and = "totally agree"). the "worrying" scale describes generalized worrying about minor matters concerning the workplace and the work itself, comprising of five items such as "colleagues or family have already told me that i should not always worry that much about work. " the "fears of existence" scale focuses on worries about job security and the future, consisting of five questions like "a loss of my workplace is/would be existentially threatening. " the score for the worrying and fears of existence dimension was obtained by averaging the items, with higher scores indicating more job-related worries and fears of existence. values above the cut-off point of two points indicate high job-related worries and fears of existence (muschalla et al., ) . cronbach's alpha was . in our sample. psychotherapists were asked about their number of patients treated on average per week in the covid- lockdown as well as (retrospectively) in the months before. these numbers were given for face-to-face psychotherapies, for psychotherapy via telephone, and for psychotherapy via internet. for psychotherapists not treating during/before covid- , these numbers were set to . using these numbers, reductions of total (face-to-face, telephone, and internet) number of patients treated on average per week during covid- vs. in the months before were calculated (number in the months before covid- was subtracted from the number during covid- , i.e., during covid- -before covid- , so that more negative values indicate more reductions). as reported in another paper (probst et al., ) , the reductions of patients treated on average per week was statistically significant [m = . (sd = . ), p < . ]. psychotherapists were asked whether psychotherapy is their sole source of income or whether they have additional sources of income. psychotherapists were asked to rate their fear to become infected with covid- during psychotherapy in which they are face-to-face with patients on a sliding scale ranging from ("not at all") to ("extreme"). psychotherapists treating patients face-to-face during the covid- lockdown rated for each of the five protective measures against covid- how well they can adhere to the protective measure during face-to-face psychotherapy on a four-point response scale ( = "cannot adhere to the measure at all" and = "can completely adhere to the measure"). the following five protective measures were suggested by the government (austrian federal ministry of social affairs, health, care and consumer protection, ): ( ) wash your hands frequently! regularly and thoroughly wash your hands with soap or clean them with a disinfectant. ( ) maintain social distancing! maintain at least m ( feet) distance between yourself and all other persons who are coughing or sneezing. ( ) do not touch eyes, nose, and mouth! hands can pick up viruses and transfer the virus to your face! ( ) practice respiratory hygiene! cover your mouth and nose with your bent elbow or tissue when you cough or sneeze and dispose of the used tissue immediately. ( ) if signs and symptoms occur, do not leave your home and contact health care professionals or emergency services by phone. statistical analyses were performed with spss (ibm analytics). descriptive statistics were calculated to characterize participants and address rq . the comparison of the pss- with a norm sample was conducted using a t-test. for the job-related worries and fears of existence dimension of the jas, we compared the average score against the cut-off of two points indicating high job-related worries and fears of existence. to address rq a,b and rq a, independent t-tests were used to compare two groups of psychotherapists in each rq. for rq c, univariate anovas were performed to investigate four groups of psychotherapists. frontiers in psychology | www.frontiersin.org september | volume | article to address rq d and rq b, pearson's correlation analysis was performed. we report effect sizes using hedge's g with % cis. all statistical tests for significance were conducted two-tailed with an alpha level of . . in total, , psychotherapists participated. their mean age was . (sd = . ) years, and . % of them were female. a comparison of the distribution of their psychotherapeutic orientations with the distribution of therapeutic orientations in the official austrian list of psychotherapists (march ) showed that the humanistic orientation was overrepresented in the survey (% in the study sample vs. % in the austrian list of psychotherapists): psychodynamic . vs. . %, humanistic . vs. . %, systemic . vs. . %, and behavioral . vs. . % (not specified for % of the survey sample). the average year in profession (indicated as the time since psychotherapists were registered in the austrian list of psychotherapists in march ) was . (sd = . ) years. of the participating psychotherapist, ( . %) were treating only adults, ( . %) only children and adolescents, and ( . %) adults as well as children and adolescents. in total, , psychotherapists ( . %) were self-employed practitioners, ( . %) were regularly employed, and ( . %) worked self-employed as well as regularly employed. the average stress-level of the participating psychotherapists on the pss- was m = . (sd = . ). compared to the stress-level of employed persons in a representative german sample (m = . , sd = . ; klein et al., ) , the stress-level of the psychotherapists was higher, p < . , but the effect size was very small, hedge's g = . , % ci = . , . . on average, psychotherapists scored m = . (sd = . ) on the "worrying and fears of existence" dimension of the jas, thus scoring below . , the threshold differentiating between low and high job-related anxiety in a nonclinical employees sample (muschalla et al., ) . the average fear to become infected with covid- during face-to-face psychotherapy was m = . (sd = . ). compared to psychotherapists with additional sources of income (n = ), psychotherapists whose income relied solely on psychotherapy (n = ) reported significantly higher stress-levels, t( , . ) = . , p = . , hedge's g = . , % ci = . , . , and higher job-related worrying and fears of existence, t( , . ) = . , p < . , hedge's g = . , % ci = . , . . means and sds are shown in table . compared to psychotherapists who already used telephone or internet for psychotherapy in the months before covid- (n = ), psychotherapists who did not use telephone or internet for psychotherapy in the months before covid- (n = , ) reported no differences regarding perceived stress, t( , ) = . , p = . , hedge's g = . , % ci = − . , . , and job-related worrying and fears of existence, t( , ) = . , p = . , hedge's g = . , % ci = − . , . . table shows the means and sds. between psychotherapists treating only face-to-face (n = ), face-to-face as well as via teletherapy (telephone or internet, n = ), only via teletherapy (telephone or internet, n = ), or not at all (n = ) in the early weeks of the covid- lockdown, stress-levels, f( , , ) = . , p = . , and job-related worries and fears of existence, f( , , ) = . , p = . , did not differ. of the psychotherapists treating not at all reported that they treated patients in the months before covid- , whereas reported that they did not. means and sds are shown in table . psychotherapists with more reductions in the total (face-toface + telephone + internet) number of patients treated on average per week in covid- as compared to the months before experienced comparable stress-level, r = − . , p = . , as well as comparable job-related worries and fears of existence, r = − . , p = . , as psychotherapists with less reductions in the total number of patients treated on average per week. psychotherapists who conducted no face-to-face psychotherapy in the early weeks of the covid- lockdown (n = ) reported higher fear of infection (m = . , sd = . ) compared to the psychotherapists who still conducted face-to-face psychotherapy during the covid- lockdown (m = . , sd = . ), t( , . ) = . , p < . , hedge's g = . , % ci = . , . . table shows the means and sds regarding how well psychotherapists could adhere to the five protective measures against covid- during face-to-face psychotherapy in the early weeks of the covid- lockdown. in addition, the correlation coefficients for associations between the psychotherapists' ability to adhere to the protective measures and fear of covid- infection during face-to-face psychotherapy are given in table . the correlation coefficients between ability to adhere to the protective measures and fear of covid- infection were all negative and statistically significant (all values of p < . ). this means that psychotherapists treating face-to-face during the covid- lockdown had significantly less fear of covid- infection when they were more able to adhere to the protective measures against covid- . this survey explored stress-level, job-related worries and fears of existence, and fear of covid- infection during face-toface psychotherapy in psychotherapists in austria. stress-level was higher than scores of a german-speaking norm sample. job-related worries and fears of existence were below the cut-off that defines high job-related anxiety. these results confirm the hypothesis that stress-level was elevated, but reject the one that job-related worries and fears of existence were high. stress-level and job-related worries and fears of existence were significantly higher in psychotherapists who had no other sources of income besides psychotherapy. this confirms our hypothesis. since mental well-being of psychotherapists represents a key determinant of their ability to deliver high-quality psychological health care (salyers et al., ; la verdière et al., ) , this illustrates the need to reduce existential stressors due to economic uncertainty, especially for psychotherapists whose income relies solely on psychotherapy. besides professional policy, stressmanagement interventions for health care professionals might cohen et al., ) . job-related worrying and fears of existence were measured with the items "worrying and fears of existence" dimension of the job anxiety scale (jas; linden et al., ) . mean parameter values for each of the analyses are shown for the psychotherapists with psychotherapy as sole income (n = ) and the psychotherapists with additional sources of income (n = ), as well as the results of the two-tailed t-tests (assuming unequal variance) comparing the parameter estimates between the two groups of psychotherapists. (cohen et al., ) . job-related worrying and fears of existence were measured with the items "worrying and fears of existence" dimension of the jas (linden et al., ) . (cohen et al., ) . job-related worrying and fears of existence were measured with the items "worrying and fears of existence" dimension of the jas (linden et al., ) . frontiers in psychology | www.frontiersin.org be further options for psychotherapists who derive all their income from psychotherapy (ruotsalainen et al., ) . stress-level and job-related worries and fears of existence were not lower for psychotherapists who practiced psychotherapy via telephone or internet already before covid- . this result contrasts with our hypothesis assuming that those psychotherapists already used to teletherapy experience less stress-level, as well as job-related worries and fears of existence during covid- . maybe switching to telephone or internet to provide psychotherapy was easy for those psychotherapists who did not use these formats for psychotherapy before covid- . it has also been reported that in the context of the forced transition toward teletherapy because of the covid- pandemic, the majority of surveyed psychotherapists from north america and europe developed a positive attitude toward teletherapy (békés and aafjes-van doorn, ) . therefore, it is possible that psychotherapists without previous teletherapy experience felt more at ease using teletherapy after they gained first experiences. also previous studies showed that therapists reported that they were pleasantly surprised by the functionality and ease of use of videoconferencing upon using teletherapy (connolly et al., ) . the context of this forced transition to teletherapy because of the covid- pandemic might have further increased the psychotherapists' motivation to use remote psychotherapy in order to be able to continue the sessions with all or most of their patients. stress-levels as well as job-related worries and fears of existence did not differ between psychotherapists treating only face-to-face, face-to-face as well as via teletherapy, only via teletherapy, or not at all. one explanation why psychotherapists treating not at all during covid- did not differ from the other groups regarding stress and job anxiety might be that they did not depend financially on psychotherapy. indeed, about one-third ( out of ) of the psychotherapists providing no psychotherapy at all during covid- did not treat patients in the months before covid- , either. thus, they could afford to quit practicing during the lockdown without additional stress and job-related worries. however, one has also to consider that both groups of psychotherapists were rather small (n = psychotherapists practicing only face-to-face and n = psychotherapists practicing not at all), which limits the overall significance of the current findings. details on the number of patients treated with respect to treatment format have been published recently (probst et al., ) . in brief, the total number of patients treated on average per week decreased from m = . (sd = . ) in the months before the covid- lockdown to m = . (sd = . ) in the early weeks of the covid- lockdown (p < . ). reductions in total number of patients treated on average per week in covid- as compared to the months before affected neither stress-level nor job-related worries and fears of existence. this result is in contrast to our hypothesis that more reductions in patients treated are associated with more stress-levels as well as more job-related worries. one explanation for this could be that, in the early weeks of the covid- lockdown, psychotherapists were hoping that the lockdown will soon be over and that they will be able to treat their usual number of patients by face-to-face psychotherapy soon again. the longer the lockdown, the higher the correlations (between reduced number of patients on the one side and stress-level or job-related worries or fears of existence on the other side) might be. psychotherapists still practicing face-to-face during the covid- lockdown had lower fear of covid- infection during face-to-face psychotherapy than psychotherapists not practicing face-to-face during covid- . this result rejects our hypothesis that fear of covid- infection during face-to-face psychotherapy is higher in psychotherapists still treating patients face-to-face during covid- . an explanation for this result might be that fear of covid- infection might be a reason for some psychotherapists to stop treating face-to-face. furthermore, it might be that those psychotherapists who have limited practice space, stopped treating face-to-face as they would not have been able to keep an appropriate safety distance. this is further supported by the negative correlation between the adherence to the protective measure of social distancing and the fear of covid- infection in psychotherapists treating face-to-face during the lockdown. similarly, also the ability to adhere to the other four protective measures against covid- of the austrian government was associated with lower fear of covid- infection for psychotherapists treating face-to-face. it should be kept in mind that most effect sizes for the significant results were small. the results refer to the early weeks of the covid- situation in austria (first covid- infections were reported on th of february , measures of the government became obligatory on th of march , and the survey was open from th of march to st of april ). stress-levels and job-related anxiety might change dynamically either positively or negatively depending on the durations and intensity of the restrictions. there are a number of limitations in this study. the major limitation is the cross-sectional design, so that we cannot say whether the psychotherapists' stress-level or job-related worries and fears of existence changed during covid- as compared to the time before. a further limitation is that the fear to become infected was operationalized by a single item measure. meanwhile, a validated scale to assess the fear of covid- became available (ahorsu et al., ) , which should be considered in future studies. in addition, only psychotherapists' self-ratings on number of patients treated on average per week could be analyzed and not health insurance data. due to the cross-sectional design, there might be a recall bias regarding the number of patients treated on average per week in the months before covid- . moreover, stress-level was operationalized only with self-reports and not complemented by more objectively quantifiable physiological measurements, such as cortisol analyses (dickerson and kemeny, ) . such analyses are not easily possible in online surveys, and lab studies would be necessary. another shortcoming is the online conduction of the survey, which might have caused some respondent bias, such as higher psychotherapists' participation with higher preference for new technologies, which might have contributed to the finding that experience with teletherapy did not affect stress-level and job-related anxiety. carrying out the survey online may also have introduced some selection bias toward fewer elder psychotherapists' participation (bethlehem, ) . although the sample largely reassembled the psychodynamic, behavioral, and systemic population of austrian therapists (deviation range from − . to − . % units), therapists with a humanistic orientation were overrepresented (deviation range of . % units), which further limits the generalizability of the findings to the population of austria's psychotherapists. since the study was conducted in austria, results may only be applicable to countries with similar mental health care systems (for example, psychotherapy -but not counseling -via internet is rejected by the official internet guideline for psychotherapists in austria at the time of the study; however, health insurances started to cover the costs for psychotherapy via telephone or internet during and comparisons with countries, which already implemented e-health solutions in routine psychotherapy would be interesting. overall, psychotherapists need to meet the challenges inherent in balancing stressors, especially in situations of increased mental, emotional, and economic challenges, such as during covid- , to ensure optimal psychotherapeutic services. this study suggests that mental hygiene is important for psychotherapists to manage stress and job-related anxiety during covid- . the finding that mainly being financially dependent on psychotherapy was associated with higher stress-level and job anxiety is important in regard to professional policy. this might also have an effect on therapeutic process, as increased mental burden of psychotherapists and distress may negatively affect process and outcome of psychotherapy. therefore, results suggest that especially psychotherapists whose income relies on psychotherapy need to increase their mental hygiene during covid- . the raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. the patients/participants provided their written informed consent to participate in this study. tp, ps, and cp: conceptualization. tp: methodology, formal analysis, investigation, and data curation. tp and eh: writingoriginal draft preparation. cp and ps: writing -review and editing. all authors have read and agreed to the published version of the manuscript. frontiers in psychology | www.frontiersin.org the fear of covid- scale: development and initial validation public attitudes toward guided internet-based therapies: web-based survey study austrian federal ministry of social affairs, health, care and consumer protection ( ) psychotherapists' attitudes toward online therapy during the covid- pandemic selection bias in web surveys the psychological impact of quarantine and how to reduce it: rapid review of the evidence . verordnung: verordnung gemäß § z des covid- -maßnahmengesetzes . verordnung: Änderung der verordnung gemäß § z des covid- -maßnahmengesetzes . verordnung: Änderung der verordnung gemäß § z des covid- -maßnahmengesetzes a global measure of perceived stress a systemic review of providers' attitudes toward telemental health via videoconferencing acute stressors and cortisol responses: a theoretical integration and synthesis of laboratory research the consequences of the covid- pandemic on mental health and implications for clinical practice mental health outcomes of quarantine and isolation for infection prevention: a systematic umbrella review of the global evidence provision of psychotherapy during the covid- pandemic among czech, german and slovak psychotherapists telephone crisis support workers' psychological distress and impairment the german version of the perceived stress scale-sychometric characteristics in a representative german community sample psychological health profiles of canadian psychotherapists: a wake up call on psychotherapists' mental health review of the psychometric evidence of the perceived stress scale die job-angst-skala (jas): entwicklung eines neuen fragebogens zur erfassung arbeitsplatzbezogener Ängste the significance of jobanxiety in a working population quarantine alone or in combination with other public health measures to control covid- : a rapid review occupational stressors in practicing psychological psychotherapists mental health and the covid- pandemic changes in the provision of psychotherapy in the early weeks of the covid- lockdown in austria burnout syndrome in psychotherapists: a comparative analysis of five nations preventing occupational stress in healthcare workers the relationship between professional burnout and quality and safety in healthcare: a meta-analysis the advantages and disadvantages of online and blended therapy: survey study amongst licensed psychotherapists in austria impact of isolation precautions on quality of life: a meta-analysis physician well-being and professionalism telemental health in the context of a pandemic: the covid- experience remote treatment delivery in response to the covid- pandemic timely mental health care for the novel coronavirus outbreak is urgently needed key: cord- - rmrkq k authors: ramos-morcillo, antonio jesús; leal-costa, césar; moral-garcía, josé enrique; ruzafa-martínez, maría title: experiences of nursing students during the abrupt change from face-to-face to e-learning education during the first month of confinement due to covid- in spain date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: rmrkq k the current state of alarm due to the covid- pandemic has led to the urgent change in the education of nursing students from traditional to distance learning. the objective of this study was to discover the learning experiences and the expectations about the changes in education, in light of the abrupt change from face-to-face to e-learning education, of nursing students enrolled in the bachelor’s and master’s degree of two public spanish universities during the first month of confinement due to the covid- pandemic. qualitative study was conducted during the first month of the state of alarm in spain (from march– april ). semi-structured interviews were given to students enrolled in every academic year of the nursing degree, and nurses who were enrolled in the master’s programs at two public universities. a maximum variation sampling was performed, and an inductive thematic analysis was conducted. the study was reported according with coreq checklist. thirty-two students aged from to years old participated in the study. the interviews lasted from to min. six major themes were defined: ( ) practicing care; ( ) uncertainty; ( ) time; ( ) teaching methodologies; ( ) context of confinement and added difficulties; ( ) face-to-face win. the imposition of e-learning sets limitations for older students, those who live in rural areas, with work and family responsibilities and with limited electronic resources. online education goes beyond a continuation of the face-to-face classes. work should be done about this for the next academic year as we face an uncertain future in the short-term control of covid- . the fast propagation of the severe acute respiratory syndrome coronavirus (sars-cov- ) led to its definition as a pandemic on march by the who [ ] , as it met the epidemiological criteria and had infected more than , people in countries [ ] [ ] [ ] . the main public health recommendation was to remain at home and stay safe within it [ ] . the world, in a globalized manner, is facing an extraordinary public health emergency in which the nurses are, as always, on the front line. challenges are even greater in this period of pandemic [ , ] , and nurses have the knowledge and aptitudes for providing the care necessary in the different clinical scenarios [ ] that are emerging. this research study was conducted in its entirety during the first month of the state of alarm in spain (which began on march ). the state of alarm implied the confinement of the entire population, the closing of all the schools and universities, closing of non-essential businesses, closing of borders and ceasing all non-essential activities. the people were only allowed to go out to the street for essential matters: shopping of food, going to pharmacies, banks, and to care for older people who were dependent, etc. in spain, bachelor's degree in nursing has a duration of four years ( european credit transfer system, ects) and it is common for a master's degree to have a duration of one year ( ects). the reference population in this study was students from every academic year in the bachelor´s degree in nursing, or nurses who were conducting their master's studies, enrolled in universities in murcia and granada (spain). the participants were selected through the use of a maximum variation sampling strategy [ ] to obtain heterogeneous and rich information that represented the main sociodemographic variables: gender, age, academic year, rural/urban, children, bachelor's/master's, university of murcia and granada. the maximum variation strategy is utilized to find the greatest diversity of discourses possible to identify and analyze the largest volume possible of expressions/presentation of the phenomenon studied to explain conditions/contexts where each one of them takes place. if one did not answer the request, the students themselves proposed a replacement with another participant with similar characteristics. none of the students contacted disagreed to participate. the students were invited to participate through the student delegation at the university, utilizing snowball sampling. this technique allowed us to build the sample by asking each interviewee for suggestions of people who had a similar or different perspective. this is an approach for locating information-rich key informants [ ] . the saturation criterion was applied to establish the number of informants needed, an accepted method to estimate the sample size [ ] . semi-structured interviews were conducted to obtain the information. the semi-structured interview is normally based on a script, where the subject matter and part of the questions have been planned before starting, but it also offers the possibility of changing or adding new questions as the interview and/or the research study moves forward, with new interviews conducted. it is the most common type of interview utilized in qualitative research on health. data were collected from march to april . this was done in the first month as it the period of time with the greatest cognitive and social impact on learning and to obtain results that could be used to support, or not, the education measures that were utilized. all the interviews were individual and were performed online through electronic resources after agreeing on a day and time. the interviews were recorded and notes were made after each interview. all the interviews were conducted by researchers who had sufficient training and experience in semi-structured interviews (a.j.r.-m., m.r.-m.). the interviewers did not have an academic relationship with the informants. the interview followed a script which shifted from general to specific matters, and dealt with general aspects of the confinement, teaching methodologies utilized, learning and expectations (table a ) . a prior pilot study of the script was conducted [ ] . the phases proposed for the thematic analysis were followed [ ] : ( ) familiarizing yourself with your data; ( ) generating initial codes; ( ) searching for themes; ( ) reviewing themes; ( ) defining and naming themes; ( ) producing the report. the recorded interviews were transcribed verbatim. once transcribed, the interviews were imported to the maxqda program for its posterior analysis. a.j.r.-m., m.r.-m., c.l.-c. and j.e.m.-g. coded the data. the transcriptions, coding and themes-subthemes were discussed by the research team for their verification. finally, participants provided feedback on the findings. the study was reported according to the consolidated criteria for reporting qualitative research (coreq) [ ] . this research study was approved by the research ethics commission from the university of murcia (id: / ). all the participants received an informational electronic document about the purpose and research process, which they later kept. they were advised that their participation was voluntary. they could ask and reflect prior to the interview. each participant was given a code to maintain anonymity. a total of interviews were conducted, and they lasted between and min. the shortest interviews corresponded to the more advanced academic years ( rd and th year students). of these participants, % were women and % men. the age of the participants oscillated between - years old, with an average age of . , and with a participation rate of % for the students from the university of murcia, and . % for the university of granada students. the sample was composed by . % of the students enrolled in their st or nd academic year or in the master's program, which accounted for about % of the sample, and . % from the rd and th academic years, for a total of about %. of those interviewed, . % had children and . % lived in a rural setting. some of the characteristics of the participants are found in table . six major themes were defined: ( ) practicing the nursing care; ( ) uncertainty; ( ) time; ( ) teaching methodologies; ( ) the context of confinement and the added difficulties; ( ) face-to-face education win. a detailed description of the themes and sub-themes can be found in table . the outstandingly practical component of care in nursing education was the most emotional aspect for the students. the experiences found were differentiated according to the group of students, depending if they had or not practice-based subjects during the education period affected by the state of alarm, the proximity to ending their training as nurses, or if they were health professionals who were conducting post-graduate studies. for st and nd year students, the learning is normally done with courses that are eminently theoretical or theory/practical. the informants indicated that this transitory e-learning will not have a special influence on their training, as long as all the clinical training on health care institutions is present: "in think that it's not something that will affect us excessively for good or bad. in my year [ st] . in other years it will, because they have clinical training" p by contrast, rd and th year students whose coursework is mainly based on clinical training in health care institutions placed value on clinical training. they linked it with the acquisition of competences and referred to it as being an essential part of health sciences degrees: "my education would not be good if clinical training was missing" p ; "without the clinical training, we can't acquire competences" p ; "especially in our degree, the clinical training . . . " p clinical training provides them with security in the learning of nursing care in health care services. part of the students in their last year ( th year) indicated that they would rather not graduate in july to do all the clinical training, therefore graduating later: "i don't feel prepared. my erasmus in italy was really bad because i was a nursing student and a foreigner. at the hospital, i don't feel confident" p ; "some of us prefer not to graduate in june and to do the clinical training" p the master's students indicated that not being able to do the clinical training implied the loss of job opportunities: "if you cannot do the clinical training, you will lose job opportunities" p all the participants expressed their wish to help during the pandemic. they expressed their desire to be nurses to help. at the university of granada, a list of volunteers in their th year was even created. the expectation was present that the government could mobilize them in case of need. independently of the academic year, for all the students, this crisis re-enforced their wishes to become nurses: "i wish i already had my degree" p ; "i wish to be a nurse already, too bad i wasn't in th year so i could go" p ; "if this happens in the future, i would like to be helping" p ; "i feel like left out, i can't be in the battlefield helping" p ; "now i really feel like being a nurse. it is a shame that we cannot help. in granada there is a list of volunteers. i really feel like helping" p master's students who work feel satisfied to be able to help (aside from being satisfied because they can work): "i feel very well with myself because i can help, even though is very difficult . . . " p ; "i really feel like being in the middle of it and help. i've seen that help is really needed, it is very important work, although not very much appreciated." p the lack of concretion about the different aspects related with their studies is mentioned by all the interviewees. this uncertainty is accompanied by unpleasant situations due to the possible outcomes. they are mainly related with matters that could not be resolved relatively fast, such as the clinical practice and the adaptation of evaluation processes: "we don't know how they are going to evaluate us. they will for sure evaluate what we have done in the last month of clinical practices" p ; "we don't know what's going to happen. i hope they don't give a general pass. i want to take the exams and the other things. i don't want them to evaluate me with just one work submitted" p ; "not knowing how things will be done. not getting the grades i want to get because of these circumstances" p this is especially important for the th-year students, who reported a great feeling of wasting time. they cannot go to the clinical practices and they only have, as well, one subject: the final project (tfg). one of the alternatives to not waste time completely and that is being done by the participants is to prepare for the access exam for clinical nurse specialist training (national post-graduate residency program, eir). some of the participants indicated that preparing for the eir exam was a means of escape from a situation of wasting time and total paralysis: "it takes my motivation away, and (finishing my degree) is getting really hard, because i don't see the end of it" p ; "i am not taking advantage of the time" p ; "i'm preparing for the eir exam at the academy as a means of escape. with the only the tfg . . . i need something else. right now all my time is tfg and the subjects from the eir" p the rd-year students find themselves in the same situation but without any subjects: "the rd years clinical training has been abandoned. they don't know if we are going to recover them" p the masters' students have a different point of view. the differences are many. the masters' degree can provide job opportunities, the change from traditional education to e-learning practically affects an entire trimester (half of the master's program), and in their discourse, they have fewer demands and less pressure for obtaining the degree. at the same time, they are the only ones who speak about the teaching guidelines, indicating that they are truly being followed. in comparison, only one bachelor's degree student referred to the teaching guidelines: "if the clinical training cannot be done, you miss job opportunities" p ; "i don't know how the teaching guidelines have changed" p ; "the clinical training have been postponed until september, and it bothers me some because it interferes with the summer contract for working as a nurse" p time is a determinant transversal aspect. two differentiated phases are observed as the state of alarm moved forward ( st shock and nd normalization). besides, participants reflected regarding a necessary time management and the influence in the future. two well-differentiated phases are distinguished in the timeline. on the first days, the shock phase appears ( st phase), within which we find "disorientation". this first phase lasts between - days. during this first week, it is observed that mental performance decreases, along with the ability to concentrate. this is a subtle expectant phase, where the situations are not well defined: "you think that the first week is for you, for resting, you take care of unfinished business and uncertainty increases" p ; "the first week was not assimilated, i didn't have routines" p ; "during the first week, i had less concentration and studies less" p ; "the timetable is different, it's more chaotic" p after the first phase, the students enter a normalization phase ( nd phase) in which they acquire new routines, attend online classes and seminars. the conditions of confinement start to be assimilated and the new everyday life is normalized: "now i do more things than before, i take more notes. it is very different from the first week, now it is easier" p ; "now i have the habits. before i didn't do anything, and now i do everything, it is as if i'm getting used to it" p the first phase, as well as the second phase also coincide with the period in which the university ensured that the online tools were fully functioning and instructions were given to the professors about how to continue with their teaching tasks: "only out of teachers give online classes, the rest upload presentations that we have to understand" p ; "the teachers do not agree with each other. one says one thing and another something else" p the st and nd year students, as well as the masters' students, have classes. this forces them to manage their time differently. the st and nd year students interviewed indicated that time management was necessary. they indicated that this was beneficial for having good "mental health", and that having due dates helped them with managing their time: "having self-discipline and a timetable. not rigid, but saying that the mornings were for university and the afternoons for watching t.v. series or exercising. if you don't organize your time, work accumulates" p ; "my planning is monday to friday mornings for work, and the afternoon for group work or leisure. i rest on the weekends. having due dates has helped me organize" p ; "the homework is good, because they help with following the course" p all of the participants, except for the ones who worked, indicated that they had changed their sleep schedule and go to bed much later, between : and a.m. the main reason mentioned was that the lack of activity did not make them tired, although this argument was ambivalent, as they went to bed later and got up later as well, so they slept the same number of hours: "it takes me longer to fall sleep. i'm not tired because i don't do anything during the day" p ; "i go to bed later and i get up later. i go to bed at - : a.m. and i get up at " p ; "i fall sleep very late. at : a.m. the hours have changed, you sleep when you shouldn't" p the participants indicate that this situation affects their future plans and expectations related with obtaining their degree and work. they believe that they can be singled out for being the promotion with missing education, their international training is paralyzed, and they are afraid. their professional expectations are also affected: "i'm afraid of having bad training and that the work exchange says that this year's promotion from the university of granada do not have the competences necessary" p ; "the plans for earning money to go to an erasmus program are cancelled . . . " p ; "the practices have been postponed to september, and yes, it bothers me because it interferes with the summer contract for working as a nurse" p the participants indicate that as for the teachers, different teaching methodologies are being utilized: real-time videoconferences (including chats), lessons recorded on video and uploaded to the e-learning platform, audio podcast, chat (exclusively), homework and uploading of documents (word, ppt, pdf). they also mention that as time goes on, the teacher's adaptation to the online resources continuously improve. it is without a doubt the best evaluated. this is because they think it is the most similar to a traditional class (face-to-face), and allow interaction with the professor, and provides them with nearness. another aspect they indicate as being valuable is that this methodology helps with the teacher's explanation of the subject that is more comprehensible as compared to other methodologies. the interaction is also valued, as it allows them to say that something has not been understood and that it should be explained in another way. lastly, they would like all the videoconferences to be recorded so they could be watched again whenever needed. this last aspect was pointed out by the students who were also working: "the interaction in the videoconferences is not the same, because the questions are written and it is not the same to write something than when you talk" p ; "the videoconference is where we receive feedback. you can say that you don't understand something and if it could be explained once again" p ; "it is a way to stay in touch. doubts emerge and the teacher can resolve them" p the master's students indicate that on some occasions, the duration of the videoconference classes is excessive. it is interesting to highlight that the bachelor's students did not state this at any time: "we've had videoconferences that lasted h. this can be done better. we had one who did a good summary and it lasted h. this is more relaxing, and then you broaden the knowledge with the documents provided" p despite the value of the videoconferences, the discourse is ambivalent, as negative aspects are identified, especially related with the quality of interaction with the professor. the traditional classwork contributes fundamental elements in the quality of communication, and this how it is felt by the participants. "it is worse. when the teacher sees you asking about a doubt, she/he knows where you are coming from. this is lost with e-learning. information is lost and the student does not obtain the same information as in the face-to-face class. the teacher doesn't see your face." p ; "i'm much more in favor of traditional classes. i always obtain more information in them and i'm more comfortable." p except for the recorded lessons, the rest of the methodologies are catalogued as sub-standard. the chats (exclusively) and the homework are not attractive, although they value them as positive aspects because it lets them stay connected with the subject and the university: "the worse thing is when they only upload class notes, no one forces you to read them" p ; "in the homework, there are questions because they are not easy to understand, with the explanation it is easy, but when you are going to do it, it is more difficult" p among the limitations, they point out that in some asynchronous methodologies and with a rigid format, limited learning is obtained, interaction is needed for explanation, and a certain amount of pressure is needed. another limitation is the lack of feedback with the homework: "we are going to learn the minimum, but not all, because they don't explain it to you, they don't explain it in different ways. the text [from the documents] is only written in one way . . . " p ; "the works that don't have feedback give you half the knowledge" p ; "if you only upload notes, no one is forcing you to read them. it is very easy to fall into laziness when they only upload notes" p a limitation of e-learning that was pointed out by all the participants was that everything that was practice-related could not be learned. they identified this as a great limitation, and point out that in nursing, practice was vital: "many things are not understood through the computer. for example, the basic care laboratories have to be observed and practiced" p ; "the practical things not, but the theoretical yes. they can make a video, but it's not the same. they can tell us how to give a bath on a bed, but if you don't do it . . . " p ; "it is impossible to learn the practical part. until you are not in that role, it is impossible to learn" p the students are not able to propose other methodologies that are distinct from the ones offered. two students pointed out that it could be completed with gamification (kahoot): "gamification would be good, for example when calculating the dose" p within the methodologies, it was found that the least complex, for example, providing word, ppt or pdf documents, were related to the older teachers. the videoconferences and recorded classes were given by younger teachers in general. at the same time, they indicated that teachers from other non-nursing departments utilized the least complex methodologies: "it depends on the difficulty of the course. physiology has only uploaded documents" p ; for example, pharmacology is a very dense and complicated subject, and you need someone to explain it to you, and until now, we have not received anything, only notes. i don't think it's enough, they are too schematic and hard to understand". p ; "the younger ones (teachers) feel like doing more things" p ; "it is more difficult for some teacher, especially those who are older" p they pointed out that it is good in the videoconferences. an inconvenience is that sometimes the teacher is not aware of the doubts posted on the chat if there are too many messages. in the chat, the interaction is good, but the interruptions, even though they may be short, makes it impossible to follow it. lastly, the students are surprised about how fast the teachers answers the e-mails: "the chat, if you miss min, you get lost" p ; "there is a good reception by the teacher for communicating" p ; "[tutoring} they are good, the answer sooner. they have improved" p the context of confinement has created some limitations for following e-learning education. these are related with internet access, access to electronic devices, and work and family responsibilities. in rural environments, situations exist where internet access is lacking, which creates problems with being up to date with the classes. another problem indicated is that not all had internet at home, and situations exist in which a person only has the limited amount of data available from a smartphone: "some people do not have all the means" p ; "i don't have internet at home, i only have data from the smartphone" p "i live here in the countryside, and the internet does not always work well, and if my kids are connected, then i can't do anything" p the confinement has obliged working from home whenever possible. this implies that it is possible for a family with three children to need an internet connection at the same time and the availability of five electronic devices simultaneously to be able to work and follow the classes. this availability is not very common. another limitation that was pointed out was working in the presence of children/siblings at home: "with the children at home, things cannot be done [mothers]" p ; "studying at home when the entire family is at home, it is very hard to concentrate sometimes, they make noise, i can't print, etc." p part of the students pointed out that is inconvenient, as they are used to studying in public libraries and have had to study at home: "i always study at the library, not at home" p ; "i used to go to the library to study or do homework. no one bothers me there. at home, i set the washer, put on my pajamas and go to sleep" p another difficulty added by the confinement is that one is not "trained" for shifting to e-learning. one has experience with an education system that has never been % online and where the traditional class is the learning stage. with respect to online exams, they do not feel secure either: "we are used to traditional classes. this has been difficult for everyone, and more for the bachelor students than the masters ones" p ; "i supposed they will give multiple-choice exams in a short time. it is the first time it will be online and one could be tense" p ; "if i hear it from the teacher beforehand, i understand it better, and now it's different. you take notes and then you have to understand them . . . " p . . face-to-face win . . . face-to-face is better . . . for everything the participants clearly preferred face-to-face to e-learning education. when faced with the possibility that some percentage of online classes will be provided along with traditional classes in future academic years, they do not think it is an option that will contribute much or needed. an exception is provided by students who have family or work responsibilities, who, exclusively for the theoretical classes, prefer them to be online and recorded, in order to be able to watch them at any time. another aspect that was underlined was that the traditional system of education is the one they know and are used to, and changing it is difficult: "face-to-face is better . . . for everything" p ; "the university of murcia is traditional, and we come from the same type of learning. it takes some time to adapt" p ; "face-to-face is better in every aspect. for example, you learn the lesson and the teacher can provide examples, it can go further than the powerpoint presentation. it is better to be face-to-face with the professor than through a screen" p the older students seem to be the most vulnerable group, and various problems are observed. on the one hand, they have to tend to their children now that they are all at home, they have more responsibilities at home, plus certain digital competences that they have yet to incorporate. the management of their time is a great problem, which is influenced by the use of time, space and the electronic devices by the rest of the family, to which they grant them priority without being aware: "for me the chat is not good, because i can't write that fast. i see the limitation in me. i miss the traditional classes. face-to-face classes are better . . . for everything" p ; "you have to be very alert with the online classroom, that you do not ignore the messages. yesterday there was a class, and did not know" p ; "some classmates are much older, and this is difficult. they write to the group [whatsapp] sending pictures, and asking "what do i do? where should i click?"" p ; "i'm much more in favor of face-to-face classes. i always obtain more information in them and i'm more comfortable" p it is necessary to underline that all the results and discussion are centered on the first month of confinement after the start of the state of alarm, and this brings with it very specific cognitive and social states that are needed for the proper understanding of the discussion of the present research study. although the sample included a greater number of students from the university of murcia as compared to those from the university of granada, and different percentages of men and women of different ages, we believe that the main sociodemographic variables were well represented through the use of maximum variation sampling. the nurses usually become nurses due to their desire to help other people to recover and maintain optimal health, and here we find ourselves in a situation in which not many options are available to help those who are severely sick due to covid- [ ] . vocation is a determinant factor for those who decided to study nursing, and the main drive is the opportunity to care for others [ ] . our results support these two ideas in two ways: ( ) they indicate that this attitude towards their professional life is still true in the new generations, with the remarkable fact that all the participants are so committed and wishing to help. ( ) the pandemic has positively re-enforced their wishes to become nurses, obtaining similar results as other authors [ ] . although, the state of alarm decree includes the possible mobilization of students in their last year at university, their mobilization was principally needed in a small scale in madrid and catalonia, the areas greatly affected by covid- [ ] . the fast shift to e-learning education has not ceased to be a continuation of teaching and education through online resources, although it has not been clearly planned and adapted for e-learning [ ] . our results clearly present various relevant ideas related to this. in first place, and related with the clinical training, the health science degrees and more specifically the nursing degree have an essential need to be developed in clinical context. this element clearly cannot be substituted, and is perceived by all the students as being essential. nevertheless, at present, a discussion exists about how high-fidelity clinical simulation could substitute the clinical training in real-world environments [ , ] . this methodology, which facilitates an intermediate learning between the theoretical dimension and the practical dimension, is proposed, aspiring to construct a real environment. however, and despite it being a type of learning established and known by the student body at the university of murcia as well as the granada, it is striking that this type of learning has not been described as an alternative. we interpret this finding as the clinical training being indispensable for the students. also, it forces us to reflect if this is the new reality of health care, and if the future nursing professionals should learn how to navigate in these conditions. the debate regarding the return of the nursing students to clinical environments is open and some recommendation has been provided [ ] . the question now for the universities and nursing educators is that if as soon as the resources are provided and an adequate organization and adaptation occurs, the students should return to the health care services, what is the balance between the potential risk for the students and the importance of the clinical training? in second place, and related with the teaching of theory, the students prefer face-to-face teaching as opposed to the e-learning. they believe that the interaction is higher in quality and learning is greater. at present, another debate is open, as shown by two systematic reviews that do not provide concluding results on the existence of the greater learning linked to e-learning education of health professionals and students, highlighting the poor quality of existing studies and the importance of contextual factors [ , ] . perhaps due to these reasons, the videoconference, distance learning, but synchronous and bi-directional, is the best assessed. another critical aspect is that the change to the online methodology was not chosen by the students, and the expectations they have with respect to their studies have been clearly disrupted. their entire academic life has been marked by a specific style of teaching, and they have become organized to continue with it, but the pandemic has imposed a different one with which they do not feel comfortable yet, thereby creating uncertainty and little security. this worries a great part of the health science academics [ ] . it therefore absolutely necessary to start to work on the adaptation to e-learning that takes into account the previously-mentioned aspects so that the student's uncertainty decreases, especially in light of the evaluations. academics have already expressed awareness of the students' concerns that are centered on their future degree and career progression [ ] . the university counted with a technological infrastructure that has been able to deal with a drastic and fast change to distance teaching. however, the urgency of adapting this type of teaching has highlighted some situations of disadvantage. thus, the older students, as compared to the younger ones, and in great part women and mothers, do not possess the most basic digital competences. this finding is robust, as the older students themselves, as well as the younger ones, are able to point this out in agreement with each other. they also point out that there is a small percentage of students who do not have the electronic resources or a connection to the internet necessary for adequately following the teaching. universities are trying to provide answers to some of these problems. it could be said that the phases of shock and normalization described by the students coincided with the period of reaction and acts of implementation by the institutions. there are activities that allow for fast implementation. for example, the universities of murcia and granada freely loaned laptop computers with software to % of the students who requested them [ ] , with this number being more than students in murcia alone, as well as mobile internet-access devices [ ] . however, the implementation of activities related with the evaluation has required conscientious reflection and consensus that has forced their implementation later in time [ ] . in any case, once this first stage has been overcome, and faced with the absence of permanent solutions for this pandemic in the short term, it is necessary to propose distance learning strategies with a robust design, with the time necessary to create study plans that are well thought-out and durable [ , ] . we should be aware that we are currently undergoing an "emergency" education, a temporary shift of instructional delivery to an alternate delivery mode due to crisis circumstances [ ] . the reality is that this transition to e-learning under these circumstances has nothing to do with a design that takes the maximum advantage and possibilities of the online format. we should reflect on the differences in the rhythm, the student-instructor relationship, pedagogy, the role of the instructor, the role of the student, the synchronicity of online communication, the role of online evaluations, and the source of feedback [ ] . among the limitations of the study, we find that a thorough discussion and comparison with the opinions of other authors has not been possible, given the novel and exceptional situation we are currently living in. on the other hand, we should be aware that the sample studied cannot be representative of the reference population, and this can evidently affect the generalization of the results. after the first week of adaptation to the conditions of confinement and the establishment of new online teaching systems, the students begin a new normality. the imposition of e-learning brings more limitations to students who are older, with work and family responsibilities, living in a rural environment and with limited electronic resources. online teaching has allowed substituting the teaching of theory, although face-to-face teaching is preferred, at the same time it has shown that clinical practices are indispensable for the training of the nursing students. online education goes beyond the online continuation of the classes. the parties responsible should already be working on this for the next academic year, in light of the uncertain future of a short-term control of covid- . acknowledgments: our most sincere thanks to the people who agreed to participate in this research. the authors declare no conflict of interest. th year students -aa what is going to happen? -aa what are you afraid of? -aa what do you think will happen with the practice? -aa what do you think will happen to your degree? -aa if you miss a practicum how good is your training? life expectancy -how does the situation caused by the crisis in the professional field affect your desire to become a nurse? world health organization. who director-general's opening remarks at the media briefing on covid- - covid- and italy: what next? italian public health response to the covid- pandemic: case report from the field, insights and challenges for the department of prevention public health emergency and crisis management: case study of sars-cov- outbreak life in the pandemic: some reflections on nursing in the context of covid- covid- : a potential public health problem for homeless populations impact of the burden of covid- in italy: results of disability-adjusted life years (dalys) and productivity loss unesco & iesalc covid- and higher education: today and tomorrow teaching in times of pandemic nursing education after covid- : same or different? using thematic analysis in psychology qualitative evaluation and research methods the significance of saturation consolidated criteria for reporting qualitative research (coreq): a -item checklist for interviews and focus groups thematic analysis of qualitative data: amee guide no. why did i become a nurse? personality traits and reasons for entering nursing covid- and student nurses: a view from england nursing students are already risking their lives against covid- with precarious contracts [las estudiantes de enfermería ya se juegan la vida contra el covid- con contratos precarios suzie) emerging evidence toward a : clinical to simulation ratio: a study comparing the traditional clinical and simulation settings simulation in nursing education: current regulations and practices pre-registration undergraduate nurses and the covid- pandemic: students or workers? efficacy of adaptive e-learning for health professionals and students: a systematic review and meta-analysis conventional vs. e-learning in nursing education: a systematic review and meta-analysis forced disruption of anatomy education in australia and new zealand: an acute response to the covid- pandemic university of granada , internet connection lines for students who have difficulty connecting líneas de conexión a internet para los estudiantes con dificultades para conectarse what value nursing knowledge in a time of crisis? the difference between emergency remote teaching and online learning what research tells us about whether, when and how key: cord- -kqlra authors: li, dion tik shun; samaranayake, lakshman perera; leung, yiu yan; neelakantan, prasanna title: facial protection in the era of covid‐ : a narrative review date: - - journal: oral dis doi: . /odi. sha: doc_id: cord_uid: kqlra we live in extraordinary times, where covid‐ pandemic has brought the whole world to a screeching halt. tensions and contradictions that surround the pandemic ridden world include the availability, and the lack thereof, various facial protection measures to mitigate the viral spread. here, we comprehensively explore the different type of facial protection measures, including masks, needed both for the pubic and the health care workers (hcw). we discuss the anatomy, the critical issues of disinfection and reusability of masks, the alternative equipment available for the protection of the facial region from airborne diseases, such as face shields and powered air purifying respirators (papr), and the skin‐health impact of prolonged wearing of facial protection by hcw. clearly, facial protection, either in the form of masks or alternates, appears to have mitigated the pandemic as seen from the minimal covid‐ spread in countries where public mask wearing is strictly enforced. on the contrary, the healthcare systems, that appear to have been unprepared for emergencies of this nature, should be appropriately geared to handle the imbalance of supply and demand of personal protective equipment including face masks. these are two crucial lessons we can learn from this tragic experience. the covid- pandemic presents one of the biggest challenges, as we transition into the third decade of the twenty-first century. collapses in the healthcare system in some parts of the world, global setback of the economy, and shortage of general and healthcare supplies are just some of the issues that policy makers have to cope with daily. amidst these challenges lies a critical question that confronts both the healthcare workers and the general public: the use of different types of facial protection. while there is no doubt that wearing different types of facial cover including face masks is an important weapon in the prevention of cross infection in the healthcare setting (meleney fl, ) , the efficacy of a majority of these appears to be yet unproven, and matter of conjecture and controversy. in the current setting of the global shortage of surgical masks, many authorities discourage the use of high efficiency masks in order to reserve them for those at the highest risk of contracting the disease, i.e., healthcare providers in direct contact with infected patients. at the other end of the spectrum is the argument that community-wide mask wearing could play a role in source control, which would likely decrease the rate of transmission. slowing down the speed of spread would "flatten-the-curve" and alleviate the pressure on the healthcare system, thus the quality of health care delivery would not be compromised (kenyon, ) . this is founded on the basis that many carriers of the virus are asymptomatic, and the incubation period or the prodrome can this article is protected by copyright. all rights reserved be lengthy, prior to the appearance of any tangible symptoms. in the absence of personal protection, these `silent carriers` as well as `super spreaders` may spread the virus through their respiratory droplets unawares. moreover, there is a clear lack of consensus on the level of protection required for different specialities of medical and dental professionals who are in contact with potential disease carriers. here, we provide a comprehensive review on the different type of facial covers, including masks, available both for the pubic and the health professionals. notably, we discuss the anatomy, and the critical issues of disinfection and reusability of masks, the alternative equipment available for the protection of the facial region from airborne diseases, such as face shields and powered air purifying respirators (papr). the review concludes with the skin-health impact of prolonged wearing of facial protection, by health care workers. understanding the different types of masks can initially be intimidating due to their diversity and confusing terminology. this is complicated by the regional differences in regulations and standards. nevertheless, most authorities divide masks into three tiers: respirator masks, surgical masks, and single-use face masks. the first tier in the classification of masks comprises the respirator masks. they have the highest filtering capacity of the three tiers. respirator masks are designed to filter over % of virussized pollutant particles in the air, and are tightly fitted onto the face of the wearer. they require fit testing to ensure proper adaptation to the face. in the u.s., respirator masks, so called n masks are certified by the national institute for this article is protected by copyright. all rights reserved currently, the u.s. centres for disease control and prevention (cdc) does not recommend the use of respirator masks for non-healthcare providers, as these are critical supplies that should be reserved for those at the highest risk of infection (u.s. food and drug administration, ). respirator masks are designed for single use only, and ideally should be changed after every patient encounter. because of the tight fit and high filtering capacity, the wearer of respirator masks might experience shortness of breath and discomfort after prolonged use. the next tier in the classification of facial masks is the surgical mask. these are loosely fitted masks that do not require fit testing, and are routinely used in the healthcare setting when the procedures do not generate a significant amount of aerosol, and when the risk of acquisition of airborne transmissible diseases is low to moderate. surgical masks are commonly referred as "face masks". however, not all face masks qualify as surgical masks due to the regulatory guidelines in the u.s., to be considered as surgical masks they have to be certified by the astm international (previously known as american society for testing and materials) standards authority. in europe, the surgical masks are certified using the european standards organisation (en). based on their filtration efficacy, surgical masks are classified into levels , and in the u.s. system. level surgical masks have the highest filtration efficacy compared to their counterparts, with an ability to filter over % of particles of . microns, and a maximum level of fluid resistance. on the other hand, the european system classifies surgical masks into type i-iii, with the filtration capability similar to their us. counterparts. surgical masks offer protection against droplets from direct spatter, but do not effectively filter small particles. surgical masks, unlike respirator masks are not tightly fitted around the face, and due to this loose fit they do not protect against leakage from the lateral aspects of the masks. therefore, the niosh does not recommend that surgical masks be used as particulate respirators (u.s. national institute for occupational safety and health, ). nevertheless, surgical masks might be effective in blocking splashes, sprays, and large respiratory droplets during routine medical or surgical procedures. community-wide use of surgical masks remains a controversial topic in the setting of the ongoing covid- pandemic. on the one hand, the world health organization issued an interim report on april , , stating that the evidence is lacking for the prevention of the acquisition of covid- virus in healthy persons (world health organization, ). however, it is now generally this article is protected by copyright. all rights reserved accepted that universal mask wearing might be beneficial with regards to source control, as they are likely help prevent the direct projectile of virus-containing respiratory droplets and aerosols from infected individuals. in a recent study using model simulations, it was suggested that the broad adoption of masks by the general public could be effective in reducing the community transmission of covid- , thus lessening the burden on the healthcare system (eikenberry et al., ) . the authors concluded that the effect would potentially be greatest when the compliance of mask wearing is high, and when it is combined with other measures such as social distancing. in another study by cheng et al., the authors compared the incidence of covid- in hong kong special administrative region (hksar) where the compliance of face mask usage by the general public was . %, to that of other "non-mask-wearing" countries with similar population density healthcare systems and social distancing measures. it was found that the incidence of covid- within the first days was significantly lower in hksar than that of non-maskwearing regions. the authors concluded that universal mask-wearing might help reduce covid- burden by containing the emission of infected saliva and respiratory droplets from the mildly infected individuals, or those who are asymptomatic (v. c. . single-use face masks do not meet the requirements of surgical masks. the construction of single-use face masks varies, but are typically thin and might consist of only a single layer. single-use face masks are not normally used in the healthcare setting, if the supply of surgical masks is not a concern. although single-use face masks generally cannot filter very small particles, they might still be able to block the emission of large droplets and saliva fairly well. moreover, when the supply of surgical masks and respirator masks are limited even for healthcare workers (hcw), single-use face masks might be a realistic alternative to be used in the community setting. due to the acute shortage of surgical masks and n respirators, some jurisdictions discourage their use by the general public and reserve them for those at the highest risk for viral exposure, such as hcw who are in close contact with infected patients. a recent recommendation by the cdc issued in april encouraged the use of cloth face coverings in public settings to slow the spread of covid- (u.s. centers for disease control and prevention, ). this is a seemingly sensible solution when proper masks are in critical supply. while cloth masks do not protect against aerosols, they might still play a role in minimizing the spread of the virus, especially the other recommendations are practiced, such as staying home, reducing unnecessary travel, and social distancing. cloth masks are increasingly being offered at various online shops, and many do-it-yourself versions have been suggested. a comparison of the various masks is shown in table . this article is protected by copyright. all rights reserved while the construction of unregulated single-use face masks is variable, the anatomy of most surgical masks certified by either the astm or en standards are similar (figures and ). surgical masks are commonly made of three layers, with a filter layer placed between two layers of non-woven fabric (thomasnet, ). the outer layer is usually coloured and is a waterresistant layer, while the inner layer is an absorbent layer and is in contact with the skin of the wearer. the middle filter layer is most commonly made of polypropylene, made through a meltblown technology (thomasnet, ). surgical masks are usually pleated to allow adjustment of fit around the face of the wearer. at the top part of the surgical mask, there is an adjustable nose clip for the wearer to adjust the shape around the nasal bridge. this reduces the gap between the mask and the face and thus prevents excessive leakage from the margins of the mask. the most common means for the surgical mask to be attached to the face of the wearer are through either ear loops on either sides of the mask, or via head ties for the wearer to tie them around the head at the level above the ears and around the neck. while surgical masks with ear loops are more convenient to wear and remove, those with head ties are adjustable and might allow a tighter fit around the face of the wearer. this could mean that the amount of leakage around the margins of the mask is less in surgical masks with head ties than those with ear loops. respirator masks, such as n masks, are usually made of, up to four, multiple layers (thomasnet, ) (figure c ) i) comprising a non-woven layer which filters particles of . microns in diameter, ii) an activated carbon layer which filters chemicals, iii) a cotton layer which filters particles of . microns in diameter, and iv) a second non-woven layer. they might have an optional valve for regulation of breathing. similar to surgical masks, n masks are commonly made by melt-blown technology using polypropylene . respirator masks are then sterilized after they have been manufactured (thomasnet, ). the shortage of facemasks during the covid- pandemic has created fear and panic amongst health care workers (hcw) in particular as this essential piece of ppe has been in major short supply, leading to prolonged and repetitive wear of a single mask, and re-use of disinfected masks. although us cdc has issued guidelines stating that a facemask is considered contaminated when it is worn in managing an infected patient, and the facemask should not be reused (siegel, rhinehart, jackson, chiarello, & health care infection control practices advisory, ) , facemasks shortage, has led to their reuse after decontamination and disinfection in a number of jurisdictions of the world. researchers have therefore investigated the possibilities to this article is protected by copyright. all rights reserved disinfect facemasks to ease the shortage problem. the practicality of the disinfection process of a used facemask depends on the following criteria: i. all pathogens are eliminated, ii. the structure of the facemask is not damaged, iii. the function of the facemask including filter capacity is maintained, iv. no residual disinfectant that could cause health hazard. different methods of disinfection have been suggested and tested, which could be broadly categorized into heat (dry and moist), chemical or radiation treatment (cadnum et al., ; lore, heimbuch, brown, wander, & hinrichs, ) . this article is protected by copyright. all rights reserved based solutions and soaps were detrimental to n- -like fabric respirators. these agents cased degradation of the static charge in the fabric and decreased the filtration efficiency dramatically. facemask disinfection by radiation with microwave, gamma ray or ultraviolet germicidal irradiation (uvgi) have also been tested. microwave has melted the n respirators in one study (viscusi et al., ) , while gamma ray caused significant reduction in the filtering capacity of the masks (de man et al., ). both techniques were therefore not recommended. appropriate frequency ultra violet was found to have no effect on the facemasks filter capacity (viscusi et al., ), but a study found residual viruses in two of the six samples when tested by droplet inoculation of h n viruses (heimbuch et al., ) . what is the best method to disinfect masks? this is a question that lacks clear-cut answers. however, considering a balance between decontamination and potential material damage, it appears that non-chemical approaches are preferable ( the extremely contagious nature of pandemic viral diseases such as covid- mandate precautions with necessary protective equipment, not only for hcw but also the general public. that said, there is also a worldwide shortage of masks, specifically those such as the n filtering facepiece respirators (ffr). this implies resorting to other mask types, especially those with reusable potential. furthermore, the increasing time of usage results on significant resistance to breathing, owing to the build-up of moisture. these caveats raise the question: can masks be reused? if so, the acceptable frequency of repetitive disinfection, and the type of masks that withstand such chemical assault are key questions that need to be resolved. additionally, there is evidence to show that sars-cov and sars-cov- can survive on plastic surfaces for up to hours (van doremalen et al., ) . the exact duration of their survival on ffrs or other conventional masks remains unknown. nevertheless, the possibility of "self- this article is protected by copyright. all rights reserved contamination" through repeated use of masks cannot be overruled. therefore, in terms of masks reusability, the following critical questions must be answered: can these masks be sterilized? what is the optimal mode of sterilization such that it kills the viruses but does not affect the properties of the mask? if so, how many times can they be sterilized? as discussed in the previous section, although research in this area is nascent, much more work regarding disinfection of masks need to be done in order to answer these questions. the next section explores the masks and face shields that are designed to be reusable. as early as , the national academy of sciences, usa suggested that it may be better to stock reusable respirators than n respirators (the national academy of sciences, ) . such reusable respirators contain face pieces that can be cleaned and reused, while the exact nature of reusability of the filter cartridge remains unknown (weiss, weiss, weiss, & weiss, ) . recently the government of hong kong sar distributed reusable face masks (cumask+) to its residents. this six-layered, copper-infused mask is claimed to prevent the colonization/immobilization of bacteria and viruses. this mask, which satisfies the american society for testing and materials (astm) f level standard for particle filtration efficiency (pfe), bacterial filtration efficiency (bfe) and resistance to penetration by synthetic blood. it has also been claimed that this mask was effective up to washes. however, it remains unclear if the efficacy to preventing the novel sars-cov- is retained up to washes. in a recently published proof-of-concept study, the authors proposed in interesting approach towards d printing of custom-made face mask, with discrete manufacturing approaches for the reusable and disposable components (swennen, pottel, & haers, ) . although leakage and virologic testing of these masks have not been performed at the time of publication, d-printed face masks appear to be an interesting solution to the current short supply of ppe. however, the reusability of these protective devices remains unknown, as yet. as mentioned previously, wearing of cloth masks might be an alternative solution when proper masks are in short supply. however, cloth masks wearing is still a controversial topic due to concerns about reusability and proper disinfection. a practical approach to decontamination of cloth masks is to use steam under pressure. such an approach was proposed and is used commonly in taiwan, where, cloth masks are decontaminated using short cycles (about minutes) of heating under pressure in a steam/rice cooker. as discussed above, moist heat disinfection of cloth masks significantly reduces the level of bacteriophage ms and methicillin this article is protected by copyright. all rights reserved resistant staphylococcus aureus (li et al., ) . however, the effects of moist heat on the sars-cov- on cloth masks is still unknown. whether all the mask types can achieve a balance between filtration efficiency and material integrity after repeated use and disinfection remains a conjecture, as yet. considering that we are on the verge of further impending epidemics and pandemics, scientists should be prudent in proactively developing masks that have reusable potential. a face shield, worn as an additional barrier in front of a face mask during medical and surgical procedures, is an adjunctive personal protective equipment (ppe) available to hcws (figure ) . the purpose of a face shield, that usually consists of a clear plastic material, is to protect the mucous membrane of the face (eyes, nose and mouth) from direct splashing, spraying and spatter of blood, saliva, other contaminated bodily fluids and materials, and irrigation fluids during patient treatment. because most face shields do not form a tight seal around the side of the face and chin area, they do not offer protection against aerosols leaking in from the margins of the face shields. also, face shields might be subject to glare and fogging (roberge, ) . in fact, strong evidence is lacking in terms of the effectiveness of face shields against the transmission of viral respiratory diseases (the national academy of sciences, ). considering the above reasons, they are considered an adjunct, and should be used with other ppe, such as masks, and head caps. despite some of the disadvantages of face shields, many authors recommend the use of face shields, especially during the current pandemic, when ppe is in short supply (advani, smith, lewis, anderson, & sexton, ; garcia godoy et al., ; perencevich, diekema, & edmond, ) . face shields are robust, durable, easy to disinfect, and can be reused indefinitely in theory. also, they are easy to manufacture, and no specific materials are required other than a clear material which is easy to acquire. additionally, wearing of face shields does not jeopardize interpersonal communication: lip reading and interpretation of facial expressions are still possible. this is particularly important for those with hearing disabilities. during aerosol generating procedures, the cdc recommends that the care provider should wear either: i) a mask and eye googles, ii) a mask with attached face shield, or iii) a face shield that fully covers the front and sides of the face (centers for disease control and prevention, ). the american dental association (ada) also recommends wearing of face shields by dental this article is protected by copyright. all rights reserved health-care personnel (dhcp) when treating patients (american dental association, ). because it is assumed that even asymptomatic patients can transmit disease, the highest level of ppe available should be used (american dental association, ) . this includes wearing face shields or goggles in addition to the different types of masks (american dental association, ). aerosol-generating procedures (agps) are intrinsic to the routine practice of dentistry. while n respirators manage to filter at least % of particles < m in size, fit tests are required to ensure the masks fit properly on the user by measuring air leakage. occasionally, individuals fail the fit tests and are deemed not suitable for wearing n respirators, or in situations like hcws working long hours and/or when the heavy growth of the facial air (e.g. beards, moustaches) impedes the mask fit and integrity (mcmahon, wada, & dufresne, ) . additionally, prolonged wearing of n respirators are also known to be uncomfortable because of the increased breathing resistance, and heat and moisture build-up (roberts, ) . hence powered air-purifying respirators (papr) have been suggested as a solution to alleviate the foregoing issues. papr is a battery-powered blower that provides positive airflow through a filter, cartridge, or canister to a hood or face piece (figure ) . when compared to most facemasks, papr may offers additional protection. one study has shown that a properly used papr offered up to an assigned protection factor (apf) of when compared to apf of for a n respirator (centers for disease control and prevention, ) . the air is filtered by high-efficiency particulate air (hepa) filter or p filters, which are both effective in filtering . % of particle size . m in diameter (bollinger, ) . papr is considered to be the alternative when an individual fails an n fitting test. it is also suggested to be used in high risk environments like managing patients with airborne diseases or high risks aerosol generating procedures (howard, ) . papr is also more comfortable than wearing n masks especially those working for long hours with physical exertions such as nurses and orthopaedic surgeons (powell, kim, & roberge, ). there are several drawbacks of using papr on top of its higher cost compared to other facial protection equipment. there are specific guidelines in donning and doffing a papr to avoid contamination, which require extra training and time (the national academy of sciences, ). some designs of papr, such as those with a loose-fitting hood, inhibit the use of headlight or this article is protected by copyright. all rights reserved loupes during dental procedures. the constant, noise generated by the air-purifier is also an irritant to the patient as well as the hcws especially in a dental clinic setting. the clinicians and the supporting staff, therefore, need to assess the risks/benefits carefully when deciding the necessity of using papr in the dental clinic. the covid- pandemic has clearly spotlighted the facial skin damage due to the prolonged use dermatological issues are also possible with custom-made d-printed masks, prolonged application of these masks may result in allergic and decubitus lesions at the nasal bridge. this is likely to be specifically amplified in hcw who work in virology units that are humid and warm. while adjustments of non-invasive ventilation devices are fairly easy to perform and hence prevent such ulcerations, such adjustments on protective respirators are not possible. one suggestion to mitigate this problem is to use protective hydrocolloid dressings over the nasal bridge (payne, ). in addition, the routine use of skin unguents may mitigate such damage, although there are no clear guidelines on the frequency of such usage. tensions and contradictions that surround the current pandemic ridden world include the availability, and the lack thereof, various facial protection measures to mitigate the viral spread. here, we comprehensively explore the different type of facial protection measures available to the public and the health care workers. we discuss the anatomy, the critical issues of disinfection and reusability of masks, the alternates available, such as face shields, cloth masks, and powered air purifying respirators (papr), and the skin-health impact of prolonged wearing of facial protection. evidence favor the widespread use of some form of face covering minimizes the community spread of covid- . ideally, surgical masks and n respirators must be discarded after a single this article is protected by copyright. all rights reserved . this article is protected by copyright. all rights reserved showing a snugly fitting, air tight, head piece with a transparent plastic lining in front, connected through a (detachable) plastic tube to the power unit. the power unit has a replaceable air filter, and a motor which creates a positive pressure ventilation system with filtered air. universal masking in hospitals in the covid- era: is it time to consider shielding? interim mask and face shield guidelines niosh respirator selection logic effectiveness of ultraviolet-c light and a high-level disinfection cabinet for decontamination of n centers for disease control and prevention. a guide to air-purifying respirators. dhhs (niosh) publication no the role of community-wide wearing of face mask for control of coronavirus disease (covid- ) epidemic due to sars-cov- disinfection of n respirators by ionized hydrogen peroxide during pandemic coronavirus disease (covid- ) due to sars-cov- sterilization of disposable face masks by means of standardized dry and steam sterilization processes; an alternative in the fight against mask shortages due to covid- to mask or not to mask: modeling the potential for face mask use by the general public to curtail the covid- pandemic national pressure ulcer advisory panel (npuap), pan pacific pressure injury alliance (pppia) facial protection for healthcare workers during pandemics: a scoping review accepted article this article is protected by copyright. all rights reserved powered air-purifying respirator use in healthcare: effects on thermal sensations and comfort face shields for infection control: a review to papr or not to papr? essential microbiology for dentistry guideline for isolation precautions: preventing transmission of infectious agents in health care settings custom-made d-printed face masks in case of pandemic crisis situations with a lack of commercially available ffp / masks the national academy of sciences: board on health sciences policy, institute of medicine. the use and effectiveness of powered air purifying respirators in health care: workshop summary the national academy of sciences: committee on the development of reusable facemasks for use during an influenza pandemic. reusability of face-masks during an influenza pandemic: facing the flu preventing transmission of pandemic influenza and other viral respiratory diseases. personal protective equipment for healthcare workers: update how surgical masks are made how to make n masks? isolation precautions recommendation regarding the use of cloth face coverings, especially in areas of significant community-based transmission accepted article this article is protected by copyright. all rights reserved u.s. food and drug administration respirator trusted-source information: ancillary respirator information aerosol and surface stability of sars-cov- as compared with sars-cov- evaluation of five decontamination methods for filtering facepiece respirators disrupting the transmission of influenza a: face masks and ultraviolet light as control measures advice on the use of masks in the context of covid- . interim guidance this article is protected by copyright. all rights reserved accepted article key: cord- -mj vrxdj authors: patel, viren; mazzaferro, daniel m.; sarwer, david b.; bartlett, scott p. title: beauty and the mask date: - - journal: plast reconstr surg glob open doi: . /gox. sha: doc_id: cord_uid: mj vrxdj nan coronavirus disease has profoundly changed society, culture, commerce, and perhaps most importantly, human interaction. as the citizens of the world followed government-imposed stay-at-home orders, and as the phrase "social distancing" became part of the daily lexicon in a matter of weeks, the public largely adopted the use of face coverings in public places to reduce potential transmission of the virus. the practice of using face coverings for the nose and mouth, whether with homemade fabrics or with surgical masks, undoubtedly has effects on facial perception. although emotions such as intense fear can be communicated with contraction of the muscles of the brow and those around the eyes, communication of genuine happiness requires contraction of the muscles around the mouth, which is unlikely to be seen behind a face covering. additionally, the lower half of the face, and specifically the perioral area, has been shown to be vital for determinations of attractiveness. in the s, dr. leslie farkas, widely recognized as the father of craniofacial anthropometry, sought to define the facial measurements and proportions associated with attractive faces. when comparing attractive and unattractive faces, dr. farkas found that the greatest differences in facial measurements and proportions were centered around the perioral area, including but not limited to a narrow philtrum, a wider oral commissure distance, and a greater protrusion of the upper vermilion. with this in mind, it is interesting to consider how masks concealing the lower half of the face would affect perceived attractiveness, which has been shown to influence judgments of a range of interpersonal characteristics, such as competence and trustworthiness. , , the present study was undertaken to assess whether judgments of attractiveness differ when the lower face is covered by a surgical mask. we anticipated that faces covered with surgical masks would be judged as more attractive than faces not covered by a mask. a racially heterogeneous set of male and female faces was obtained from the chicago face database. the chicago face database is a set of high-resolution images of subjects' faces aged between and years, which is available to researchers as a free resource. the faces were altered to simulate the appearance of wearing a surgical mask, using microsoft powerpoint (microsoft corporation, redmond, wash.) (figs. - ) . the photographs of faces were evaluated by users recruited and compensated through amazon's mechanical turk (mturk) (amazon corp, seattle, wash.), a crowdsourcing platform. samples generated from mturk have been shown to be of superior quality than that of traditional convenience samples, and mturk has been used in both the social science and plastic surgery literatures. [ ] [ ] [ ] raters were randomly assigned to a set of male or female faces. a series of masked and unmasked faces were then randomly presented, and the raters were asked to rate the attractiveness of each face on a scale of (least attractive) to (most attractive). raters were excluded from the study based on built-in attention checks and by the minimum time limit for completion to ensure data validity. the study was determined to be exempt from review by the children's hospital of philadelphia's institutional review board. ratings of unmasked photographs were used to define categories of attractiveness for men and women: "unattractive" (bottom %), "average" ( %- %), and "attractive" (above %). the average of an individual face's unmasked ratings was used to place each face into of these categories. percent improvement of attractiveness from baseline was calculated for each face after application of the mask, and analysis of normal variance was used to compare this between categories. a post hoc analysis was then conducted using scheffe pairwise comparisons. paired t tests were used to determine whether ratings of faces changed significantly after application of a mask. stata version (college station, tex.) was used for data analysis, and standard descriptive statistics were conducted. a total of raters' responses were analyzed. there were significant differences in the average percent improvement for faces in the unattractive, average, and attractive cohorts for both women and men (p < . , p < . , respectively) ( table ) . interestingly, the largest percentage improvements were seen in the unattractive groups, with an approximately % increase in ratings for women and men after the application of a mask. furthermore, in post hoc pairwise comparisons, the unattractive group showed a significantly higher percentage improvement when compared with the average and attractive groups, for both women and men. in contrast, there was no difference in the percentage improvement between the average and the attractive groups, for both genders. when looking at changes in ratings for faces, we found that % of the faces in the unattractive group were rated significantly higher after application of a mask, compared with approximately % of the average faces, for both women and men. interestingly, in the attractive group, male face ( %) and female face ( . %) were rated significantly lower after application of a mask. the present study provides novel information about judgments of attractiveness of persons wearing surgical patel et al. • beauty and the mask masks. individuals who were thought to be average or unattractive at baseline were judged as more attractive when wearing masks, which hid their lower face. this effect was the strongest for faces in the lower third strata of attractiveness. although the eyes and the periorbital region are often cited as the facial regions that define beauty, the results from the study suggest that other facial features also contribute to judgments of attractiveness, corroborating the long-held ideal that beauty is a result of the harmony of various facial aspects. , symmetry of facial features across the midline of the face, as well as the "averageness" in size and shape of discrete features, has been shown to be reliable markers of facial attractiveness. , if disharmonious parts, such as the nose, lips, jaw, and neck, are hidden from view, then perceptions of attractiveness increase. from the perspective of evolutionary biology, symmetry, averageness, and youthfulness of facial features (and bodily features) are markers of physical attractiveness and reproductive potential. , in contrast, individuals who have asymmetrical, nonaverage, or non-youthful features are seen as less attractive. the most profound example of this is seen in persons with facial disfigurement, who are not only seen as less attractive, but also assumed to have less positive personality traits than those who are less or non-disfigured. unfortunately, there is recent evidence to suggest that these responses are truly hardwired into the occipitotemporal cortex and anterior cingulate cortex of the brain. it would be interesting to see whether these areas also respond when the lower half of the face is obscured with a face covering or mask. this study has important implications for medical practice. communication of the universal face expressions-anger, disgust, fear, surprise, happiness, sadness, and contempt-involves the entire face. if the lower face is obscured by a surgical mask or face covering, there is potential for the misinterpretation of the information being conveyed in a conversation. in clinical practice, both providers and patients wearing face coverings or masks run the risk of being misunderstood or misunderstanding one another. as we move to a return to normalcy in health care, as well as daily life, we may wish to consider that the physical distancing that has come with the delivery of health care via electronic platforms may enhance patient-provider communication beyond what can occur in person but with faces partially covered by masks. the results of this study also have important implications for society. first, with facial cues being limited, it is interesting to consider where the gaze will turn to make these judgments of attractiveness. will there be increased emphasis on the orbital complex and the upper face or will the gaze then turn to other body parts like the torso? if the practice of wearing masks endures, it would not be surprising for plastic surgeons to see a rise in patients seeking alterations to the body parts that are still visible, as these will be the only ways to express one's attractiveness. conversely, will the use of fillers and neuromodulators in and around the perioral region decline in popularity, and will surgical procedures such as rhytidectomy and genioplasty be sought less frequently? what will happen to the sales of lipstick and tooth whiteners as well as other applied enhancers and cosmetics? additionally, the mask itself could affect perceptions of an individual's attractiveness. will certain colors, patterns, and designs of masks be viewed as more acceptable than others and will we move to the development of a "see-through" mask that allows some emotions visually based in the perioral region to be expressed? the results of this study bring all these questions to the forefront. regardless, it is clear that there are far greater implications for this practice than meets the eye. universal and cultural differences in facial expressions of emotions anthropometric facial proportions in medicine more than skin deep: judgments of individual with facial disfigurement explaining financial and prosocial biases in favor of attractive people: interdisciplinary perspectives from economics, social psychology, and evolutionary psychology the chicago face database: a free stimulus set of faces and norming data evaluating online labor markets experimental research: amazon.com's mechanical turk public perception of helical rim deformities and their correction with ear molding orthognathic surgery has a significant effect on perceived personality traits and emotional expressions ideal facial relationships and goals judgments of facial attractiveness as a combination of facial parts information over time: social and aesthetic factors body image, cosmetic surgery, and minimally invasive treatments psychology of facial aesthetics behavioural and neural responses to facial disfigurement key: cord- -pgel i y authors: chan, tak kwong title: universal masking for covid- : evidence, ethics and recommendations date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: pgel i y nan ► policy makers must rely on best available evidence rather than awaiting strongest evidence when devising urgent policies that can potentially save human lives. ► there is no shortage of mechanistic evidence and observational studies that affirmed the benefits of wearing a face mask in the community, which should drive urgent public health policy while we await the results of further research. ► there is no valid scientific evidence to support the assertion that the use of a face mask in the community may impose a higher risk of infection on the ground of improper use or false sense of security. ► rationing offers no moral ground to ignore the evidence about the benefits for the users of lower priorities. ► the proper approach to addressing shortage is to formulate stratified recommendations that take full account of the benefits of using face masks in the community and provide viable solutions at different scenarios (see table in the main text). ► i urge the who and policy makers worldwide to consider my stratified recommendations, or adopting measures to a similar effect, particularly as the authorities are contemplating relaxation of other aggressive measures such as border closure, lockdown and social distancing. this commentary echoes the plea from greenhalgh et al to encourage people to wear a disposable surgical mask (face mask) in the community. there is limited clinical evidence that wearing a disposable face mask, enhancing hand hygiene practice or social distancing can reduce transmission of respiratory viral infections in the community, although there is mechanistic basis for these measures to work. for covid- , hand hygiene and social distancing are widely recommended, while universal use of face masks in the community is not widely recommended, especially in some western countries. [ ] [ ] [ ] [ ] some doubted the effectiveness of wearing a face mask in the community. some argued it may foster a false sense of security. some said face masks should be reserved for healthcare workers. inconsistent messages from the experts and policy makers about the rationale for the recommendation has led to confusion in the community. i aim to provide further clarification of the evidence and ethics on this issue (which can provide grounds alternative and/or supplementary to the precautionary principle applied by greenhalgh et al) and make a plea to the world health organisation (who) and policy makers to reformulate current recommendations with a view to enhancing the practice of wearing a face mask in the community. current best available evidence should guide urgent policy while public health decisions should be evidence-based, drawing on randomised controlled trials (rct) as an important source of information, the methodological challenges of evaluating large-scale public health interventions need to be recognised. when there is logistic difficulty in conducting an rct, evidence from other data sources can provide valid support for an urgent public health action. the mechanistic effects of handwashing and wearing a face mask have been demonstrated, thus offering some scientific basis for their benefits in terms of disease control. a recently published article shows turbulent gas cloud can prolong the life of pathogenbearing droplets and allow them to travel a longer distance. the turbulent gas cloud dynamics should offer further scientific basis to recommend the use of face masks for source control and protection of the wearer. healthcare workers are recommended to wear a face mask as part of droplet precautions, which may prevent them from splashes bmj global health of respiratory droplets from sneezing, coughing or talking patients. some experts suggested that while there is a perception that wearing a face mask may help, there is little evidence of any benefit outside the clinical setting. in a recent meta-analysis, six rcts were identified reporting the effect of wearing a face mask with enhanced hand hygiene in reducing laboratory-confirmed influenza in the community. although none of them supported a significant protective effect, all the authors acknowledged that their studies may have underestimated the effect of the intervention (see table for their limitations). [ ] [ ] [ ] [ ] [ ] [ ] their results also may not be generalisable to the universal use of face masks in the community during an actual pandemic which should result in heightened level of public awareness and community efforts. as some authors unequivocally made it clear, due to the inherent limitations, one cannot base on their rcts to conclude that it offers no benefits to wear a face mask in the community during a pandemic. furthermore, an absence of evidence (from rcts in this instance) should be distinguished from evidence of absence. a previous systematic review identified two case controlled observational studies to assess the effectiveness of wearing a face mask in the community. [ ] [ ] [ ] subsequent to that systematic review, one further relevant observational study was published. all these three observational studies concurred with each other, showing a significant protective effect of face masks in the community, although their findings may be limited by misclassification and reporting bias (see table for details). in view of the imperfect data from the rcts, the mechanistic evidence and the observational studies should contribute to the best available evidence guiding the policy. while efforts should be guided for further clinical research, the benefits of wearing a face mask in the community during a pandemic should be affirmed in the interim. put another way, while the strongest evidence from valid rcts is not yet available, and perhaps it will never be available because of the methodology issue, the choice should favour accepting current best available evidence over putting human lives at risk during a pandemic. summing up, i wish to quote greenhalgh et al as saying '… while there are occasions when systematic review (of rcts) is the ideal approach to answering specific forms of questions, the absence of thoughtful, interpretive critical reflection can render such products hollow, misleading and potentially harmful'. face mask wearers are offered added protection rather than put at higher risk of infection the who recommend that in the community only symptomatic patients and caretakers should wear a face mask. but studies have shown that covid- carriers may be asymptomatic and so members of the public may be unaware that they carry the virus. the effective control of disease outbreak relies on the concerted efforts of everyone in the community. as the symptomatic infected are asked to wear a mask to avoid splash onto others, the logic should follow that all healthy individuals should also wear a face mask for two reasons. first, they should avoid a splash from others who may be asymptomatic carriers not wearing a mask. second, they may be an asymptomatic carrier themselves. some experts talked about the downside to wearing a face mask and thereby opposed the idea that the general public should wear a face mask. they said people wearing a face mask may be exposed to a higher risk of getting the infection-if they touch their face more often, if they wear the mask improperly or if they dispose of the mask unsafely. there is a previous study showing that some people may touch their face times a day. it was therefore argued that mask wearers who touch the mask on their face may be exposed to a higher risk of infection. such arguments are flawed in that there is no evidence that people who wear a face mask would touch their face more often than those who do not. indeed, given the splash that one without a face mask may receive on the face during usual contact with other people, people who touch their face often is likely exposed to the similar risk of infection regardless of whether they wear a face mask or not. there were also concerns about the use of a face mask because this may offer a false sense of security. no effective measure would by itself offer % protection. people who wash hands properly and frequently may also have a false sense of security let alone those who do not wash their hands long enough or thoroughly enough. various measures need to be applied in combination to achieve maximal effectiveness. the proper response should be to reinforce the proper way of applying all useful measures in combination through education. a previous study showed that the use of a face mask likely reduces viral exposure and infection risk on a population level in spite of imperfect fit and imperfect adherence. to assert that the use of a face mask in the community may impose a higher risk of infection on the ground of improper use or false sense of security has no support of valid scientific evidence, defies common sense and raises suspicion of an implicit decision not to act or to act on the basis of past practice rather than available evidence. the current available evidence about the benefits of its use should prompt the policy makers to recommend it with no further delay. rationing offers no moral ground to ignore the evidence about the benefits of wearing a face mask in the community it has been suggested that face masks should be reserved for healthcare workers, the sick and caregivers. while this can be a ground for rationing the distribution of face masks to those in greater needs, this by no means offers a reasonable basis to ignore the evidence about its benefits in the community setting. to start with, the authorities bmj global health should have always kept a sufficient amount of protective gears for the healthcare workers and for everyone in the community in preparation of an outbreak. in case of shortage during a pandemic, there is no dispute that those in greater needs such as healthcare workers should be given higher priorities of getting face masks. however, it is also important to protect the public and slow the spread of the infection in the community. the proper approach to addressing shortage is to formulate stratified recommendations that take full account of the benefits of using face masks in the community and provide solutions at different scenarios (see table ). acknowledging the benefits of using face masks in the community does make a big difference. an analogy can be made to patients with end-stage renal disease. even for those who are given lower priorities for renal transplantation, amid severe organ shortage, they deserve to have their needs recognised, to be put on a waiting list and to be given the hope and the chance of receiving the best cure. the rationale is plain. dignity is an essential dimension of human health and even dying patients deserve to have their needs recognised and treated with respect. in a similar vein, during a pandemic, even when the public cannot be allocated sufficient face masks, they deserve to have their needs treated with respect. in case the public are asked to sacrifice their well-being for the overall benefits of the entire community, they need to be told of this and they deserve the credits. those who are given higher priorities for face masks are protected by administrative tools and legal means available to the authorities to ensure adequate supplies to them. on the other hand, manipulating the otherwise legitimate demand from those given lower priorities would unjustly deny the free market a chance to respond to their genuine need with accelerated production of face masks or invention of substitute products. any effort of rationing by means of ignoring the evidence about the benefits for the users of lower priorities does not fit into any current ethical framework and would be counter to maintaining public trust in the public office and the medical profession. herd immunity offers no moral ground to let the infection spread one may even suggest that infection should be allowed to spread to produce herd immunity. herd immunity was recognised when it was observed in the s that the number of new infection subsequently dropped after a significant number of children became immune to measles. nowadays, it can be produced by vaccinating the community. in theory, allowing the infection to spread naturally can also produce herd immunity. given the existing public health tools to slow down the spread of bmj global health infection, however, allowing infection to spread naturally would mean sacrificing human lives with intention. at best, this would be highly controversial and would only be remotely justifiable if and only if there was evidence that sacrificing some human lives at first can save more human lives at the end. there is no such evidence. nor do we have any evidence that people infected with covid- at one time point may develop immunity in the subsequent exposure to the same or slightly mutated virus. we may also remain optimistic that a vaccination may be available in a matter of months or early next year. in the circumstance, the priority should be to protect human lives by all means. when there are measures that potentially can slow down the spread of infection, with wearing a face mask in the community being one of them, they must be actively pursued. we are still in the battle against covid- . while social distancing and hand washing form the main recommendations, there is no shortage of mechanistic evidence and observational studies that affirmed the benefits of wearing a face mask in the community. wearing a face mask is an effective, cheap and easy-to-implement measure. it is more essential when social distancing is less feasible, such as on public transport, when people shop for daily essentials, and for people who cannot work from home. the development of covid- pandemic and the current crisis may in part be attributable to the insufficient protection for the community. while the benefits of the universal use of face masks in the community should have been recognised earlier, it will never be too late to implement what is necessary. there may be a long period that other more aggressive measures such as border closure, lockdown and social distancing need to be relaxed to some extent after the peak of the pandemic but before the pandemic completely subsides. this will be the time the general public will need sufficient protection more than ever. the recommendations can be tailored to different scenarios but the bottom line is that it should remain faithful to the current available evidence. i urge the who and policy makers worldwide to consider my stratified recommendations, or adopting measures to a similar effect (see table ). acknowledgements the author would like to thank ben cowling for helpful comments on an earlier draft. funding the author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. patient consent for publication not required. provenance and peer review not commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc . ) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ . /. orcid id tak kwong chan http:// orcid. org/ - - - face masks for the public during the covid- crisis nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-personal protective and environmental measures nonpharmaceutical measures for pandemic influenza in nonhealthcare settings-social distancing measures a quantitative assessment of the efficacy of surgical and n masks 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