key: cord-0774456-funtrtt3
authors: Faruque Ahmad, Md
title: A Novel Perspective Approach to Explore Pros and Cons of Face Mask in Prevention the Spread of SARS-CoV-2 and other pathogens
date: 2020-12-31
journal: Saudi Pharm J
DOI: 10.1016/j.jsps.2020.12.014
sha: 3f5ba66595f14b2694590fefb0fa3b02c2d6ec25
doc_id: 774456
cord_uid: funtrtt3

Corona virus disease 2019 (COVID-19) outbreak has become a severe community health threat across the world. Covid-19 is a major illness, presently there is no as such any medicine and vaccine those can claim for complete treatment. It is spreading particularly in a feeble immune people and casualties are expanding abruptly and put the health system under strain. Among the strategic measures face mask is one of the most used measures to prevent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Wearing a face mask possibly create a false sense of security lead to decline others measures. Face mask could be risk for the people of under lying medical conditions, old age group, outdoor exercise, acute and chronic respiratory disorders and feeble innate immune. Restrictive airflow due to face mask is the main cause of retention of CO2 called hypercapnia that can lead to respiratory failure with symptoms of tachycardia, flushed skin, dizziness, papilledema, seizure and depression. According to latest updates face shield and social distancing could be better substitute of face mask.

Corona virus disease 2019 (COVID-19) outbreak has been emerged as a serious global public health threat. COVID-19 is an infectious pandemic outbreak caused by SARS-CoV-2 and this novel strain of SARS-CoV-2 belongs to same family of coronaviruses those are responsible for SARS-CoV and MERS-CoV (Fig. 1) . The cases are still rising in haste across the world and infected 235 countries, areas or territories estimated with approximately over 35.35 million people infected with 1.03 million deaths. United State America has highest number of cases 7,341,406 among the all nations with the highest total death 208,433 according to WHO report on October 6, 2020. As of October 6, 2020, cases from WHO region reported 6,337,772 in Europe, 17,176,705 in Americas, 2,503,734 in Eastern Mediterranean, 633,080 in Western Pacific, 7,488,605 in South East Asia and 1,206,767 in Africa (WHO, 2020) .

Strategic measures for COVID-19 prevention in health personnel accentuate on patient isolation and infection control that include steps to be measured during the diagnosis and care of infected patient, contact, droplet, blood and precaution should be adopted during specimen collection and induction. The significant measures for the public to clean hands subsequent to non living and living contacts, use sanitizers, face mask, social distancing etc. Among the various measures applied by the people face mask play an important role to control the spread of SARS-CoV-2 through protecting from infected persons and protecting others from infection and reduce the risk of exposure (Fig. 2) . Despite the fact that strategic measures of face mask exhibits false sense of security and may lead to death in specific group of the people.

Covid-19 is a severe disease which does not currently have a known cure or vaccine. It is a contagious infection which can be transmitted through respiratory droplets. Deaths are rapidly raising and there is a continuous strain on health care systems. To slow the spread of this deadly SARS-CoV-2 policymakers as a precautionary principle have highly recommended to wear face mask along with other social distancing steps (Greenhalgh et al., 2020) . WHO recognizes that the wearing of masks by populace exhibits remarkable effects in severe pandemics as a single partial preventive measure may have a substantial impact on the transmission of infection (Organization, 2019) .

The COVID-19 virus is transmitted mainly through the respiratory droplets and contact routes among peoples. Data indicates that transmission can also occur via fomites around the infected individual in the immediate surrounding environment (Ong et al., 2020) . Studies have suggested the SARS-CoV-2 disease, may also be transmitted through the asymptomatic persons those who don't have symptoms of the disease. Some individuals may test COVID-19 positive result 1-3 days before symptoms develop by testing with polymerase chain reaction (PCR) (Kimball et al., 2020) .

The most important benefit of wearing a mask is the person can limit the spread of the virus to others if someone knows or doesn't know about their infection, especially the asymptomatic person. Although the most effective way to avoid the spread of infections is to take proper hand hygiene steps and to maintain physical distancing but wearing a mask in public may restrict the transmission of COVID-19 by individuals who have the virus.

Organization (WHO) from the beginning integrated face masks into their guidelines to minimise virus transmission. The face mask is very crucial to cover the face, especially in the areas where other social distancing steps are hard to hold (Desai and Aronoff, 2020) . CDC initially encourages the face mask use during the pandemic later on the advice was updated that nose and mouth covering with only cloth face cover when in public can prevent others from infection. But coving the face with cloth cover doesn't mean that one can forget social distancing. CDC guidelines suggest fabric face masks to the public rather than the surgical and N95 masks that healthcare professionals use (How to Protect Yourself & Others | CDC, 2020). However, it was found that there is no claim that the mask is competent enough to spread the transmission of the virus, but carrying a mask could make someone feel safer and remind of a preventive measure.

Country-wise recommendations on face mask use in community settings have been listed in table 1 (Feng et al., 2020) .

There are several reasons to wear a face mask. Firstly it reduces 95% of the respiration that transmits the virus in an area up to 6 feet away, and it minimizes oral/fecal transmission by preventing the virus from getting into persons nose or mouth if the personal touch the infected surface and then their face. Masks, therefore, encourage us to continue to practice physical distancing. Mask reminds people to be compliant with hand hygiene and not to touch the nose and mouth. Mask provides feeling to others in contributing to stopping the further spread and most importantly mask gives protection to front line workers caring for COVID-19 patients.

Infants younger than two years should not wear masks, and people who cannot become unaware of a mask by themselves (Why Face Masks Are Crucial, 2020) . In the studies, it was found that the SARS-CoV-2 is viable in the air for several hours under experimental conditions in aerosol emission, but surgical masks appear to block aerosols in such laboratory experiments (Van Doremalen et al., 2020; Leung et al., 2020) that strongly supports public wearing masks during the COVID-19 pandemic. Presymptomatic individuals tend to be responsible for around 50 percent of infections (Ganyani et al., 2020) , so a marginal decrease in community transmission with mask might make a big difference. Such essential preventive steps may be used to monitor the demand for hospital bed spaces and ventilation systems. Face mask guidelines vary across countries. Many countries enforced compulsory face mask regulations in public places and releases recommendations on face mask use in community settings that are listed in table 1.

There is lack of direct evidences from published data or randomized controlled trials (RCT) on the use of masks as source control for SARS-CoV-2. Efficacy of surgical masks against influenza, rhinovirus as well as seasonal coronavirus was studied and it was reported that mask has significant role in source control for the seasonal coronavirus droplets of all sizes but found less effective at blocking small influenza droplets and of blocking rhinovirus droplets of any size (Leung et al., 2020) . So, efficacy of mask on current SARS-CoV-2 is not yet clearly known.

Vander et al. reported that almost all kind of mask may decrease viral exposure and risk of infection on population regardless of unfitness and poor adherence (Vander et al., 2008) . A case report of china regarding the efficacy of mask on controlled setting of airplane passengers was published. A person onboard was later on found positive for COVID-19 but during the flight from China to Toronto he was wearing the mask and when nearby close seated 25 other passengers along with flight attendants were tested they all found negative (Schwartz et al., 2020) .

Filtering capability of masks depends upon different types of mask, as mask could be made of the various designs and materials. A typical droplet size is 5 μm-10 μm while the particle sizes for speech are on the order of 1 μm (Howard et al., 2020) . Surgical mask are also known as medical mask which have better bacteria filtration and air permeability and can protect from contact with droplets and splashes by reducing exposure to the saliva and respiratory secretions. A surgical mask also filters out large particles in the air and should only be used once.

N95 mask provides more safety and security than a surgical mask. Surgical N95 respirators are most widely used as personal protective equipment in health care environments such as hospitals among healthcare professionals. When the person who wears inhales, it can filter out the big and small both kind of particles. An N95 mask may block 95% of very small particles and when wearer breathes out, it releases unfiltered air (COVID-19, 2020) .

A cloth mask is intended to capture droplets emitted while the user is talking, coughing, or sneezing. Studies reported filtration efficacy of cloth mask as compared to surgical mask.

Cloth mask made up of household materials had filtration rate between 49% to 86% for 0.02 μm exhaled particles while surgical masks filtered 89% of those type particles (Davies et al., 2013) .

Data suggest that a surgical mask was found to filtered 75% of particles between 0.02 μm to 1 μm on the other hand the cloth mask was found to filter 60% (Van der Sande et al., 2008).

Overall, it was concluded face mask exhibit significant role to prevent the speared of SARS-CoV-2.

According Belgium's Federal Public Service for Health use of face mask to prevent infection of coronavirus barely creates sense in hospitals where coronavirus patients are treated and patients specimens are tested (Lifesaver or false protection, 2020). Beijing's Centre for Disease Control and Prevention (CDC) in its guidelines confirmed people can go outdoors without wearing mask to confirm COVID-19 outbreak is under control. CDC also guided that residents must have to compliance rules of social distancing (China: CDC issues new guidelines, 2020).

Wearing a face mask may possibly provide a false sense of safety and lead to decline social distancing and hands washing compliance (Greenhalgh et al., 2020) . Face mask wearers get irritation and feel awkward that lead to touch and adjust mask repeatedly. This irritation leads to infect face, ears and eyes. Exhaled air with wearing face mask get into eyes contact that leads to uneasiness and makes an impulse to finger the eyes, nose and face that could be a cause of infection. Speech of volume and quality gets hampered owing to wearing face mask that lead to involuntarily make closer to each other consequently people be inclined to noncompliance of social distancing. Most of us are new face mask users, so level of mask safety could not achieve by all of us and it leads to noncompliance aspects of its use, reuse and dispose consequentially chances of infections will increase. Wearers have long nose or face deformities cannot fix mask accurate manner and may cause of infection from SARS-CoV-2 and other microbial pathogens.

People ignorance and lack of knowledge how to wear face mask may be cause of infect themselves and infect to others. It is the need of the hour to get proper training under the supervision of expert in each and every concern to maintain hygiene and achieve the optimum benefits of face mask. Complications with face mask can be seen in Fig. 3 .

According to WHO SARS-CoV-2 infects all age groups. Nevertheless, proofs suggest that 2 category of people are vulnerable to COVID-19 infection disease. They are under lying medical conditions that include chronic respiratory disease, diabetes, cardiovascular disease and cancer and other category are over 60 year old age people (Fig. 4) . The possibility of severe disease steadily rises with time starting from approximately 40 years. In Current covid-19 pandemic outbreak US Centers for Disease Control and Prevention recommended some guidelines regarding wearing face masks. Everybody should use a cloth face cover in public place but it should be avoided to be applied on children who are below 2 years or someone who has breathing difficulties, incapacitated or incapable to remove face mask without others assistance (How to Protect Yourself & Others | CDC, 2020). Face mask is used to avoid the infection but it is not advisable to sensitive illness group such as chronic obstructive pulmonary disease (COPD), acute and chronic respiratory infection, asthma, apnea and dyspnea etc. Restrictive airflow owing to face mask is the main reason for secondary complications that may cause of retention of CO2 is called hypercapnia. Furthermore, complications associated with hypercapnia include tachycardia, dyspnea, confusion, flushed skin, dizziness, and headache. Severe hypercapnia can lead to respiratory failure with symptoms of papilledema, seizure and depression (Patel and Majmundar, 2018) . COPD patients wearing mask may lead to hypercapnia and they should be monitored by medical practitioners to avoid critical illness. Restrictive airflow due to face mask creates high concentration of CO2 in body in sensitive groups that exhibits fatal reaction by decreasing pH and leading to respiratory acidosis. The important issue is that CO2 regulates blood pH and high concentration CO2 in blood makes blood acidic and law concentration makes alkaline both conditions either acidic or alkaline could lead to health hazards ( Fig. 5) . Overall, it is concluded that it is better to avoid face mask and maintain social distancing and other measures particularly to sensitive group (Diaz Milian et al., 2019).

The innate immune comprises a rapid response mechanism of first line barrier to avert microbial invasion. The major use of the innate immune reaction is to instantly prevent the spread of foreign pathogens in the body (Chen, Zhou and Min, 2018) . Efficacy of innate immunity is depending on load of virus. Humidity accumulates inside mask due to restricted air flow that is favourable condition for SARS-CoV-2 survival. Particularly children and infant discharge nasal fluid frequently and have lack of sense to maintain hygiene. Hence, children and infant should be monitored by parents and caretakers to avoid moisture and humidity inside face mask by nasal and mouth discharges. That could be the reason of increase viral load or other contamination. Consequentially, viral load and possibility of infection increase and innate immunity decreases in mask wearing people. Present pandemic COVID-19 infection direct depending on immune system of individual. As a consequence, the most of the old age people and underlying health conditions people are more susceptible for SARS-CoV-2 infection. Face mask and gloves sometimes misguide the people that they are fully protected. Wearers believe face mask is enough to protect from infection and with gloved hand touch their body and face while the efficacy of innate immunity reveals on skin surface rather than gloves.

Consequentially, people leave the habits of hand sanitization and increases chances of exposure. University of New Jersey elucidates that for the duration of physical activity carbon dioxide levels increase that lead to more rapid breath and raised heart rate. Mask could trap a little of this CO2 inside and that may cause of fatigue (Is It Safe for My Family to Exercise with Face Masks, 2020). Exercising people with mask can get anaerobic threshold in a short period of time in compare to exercising without wearing mask. People with asthma, hypoxia and high blood pressure, and others underlying health conditions must take advice from healthcare practitioners regarding the use of face mask.

The Sun UK news paper reported that 26 years old jogger died due to running 2 miles with face mask in Wuhan, China. After surgery doctors confirmed collapsed lung was the reason for death and revealed that the runner left lung was compressed by 90%. Moreover, it was also reported that in Hunan province of China 14 years old two boys died due to abruptly collapsed.

They were running in school track during physical education class with face mask. According to death certificate reason for death was sudden cardiac arrest (China: CDC issues new guidelines, 2020).

United States Health care Infection Control Practices Advisory Committee (HICPAC) suggests to health professionals that face and eyes should be fully protected throughout the patient care procedures. Fluids sprays and splashes comprise infectious pathogens that could affect heath care personnel. These fluids droplets can be adhered to mouth, eyes, nose mucous membrane and broken skin surface consequentially patient handlers may get infected. The present HICPAC guidelines clearly recommend wearing face shield during handling patients particularly for SARS-CoV-2 and avian influenza (Siegel et al., 2007) . It has been seen in in vitro study that cloth mask may cause of filtration of natural and anthropogenic aerosols that could be virus and same size of aerosol particles. Face shield decreased 96% instant exposure of virus in simulated health worker in a simulation study. Same study with physical distancing decreased inhaled virus by 92%. (Lindsley et al., 2014; Perencevich et al. 2020) . Face shields exhibit several benefits over face mask. They can be repeatedly use by cleaning them with disinfectants, soap and detergents. Face shield cover complete face, so exposure of infection through nose, mouth and eyes will be reduced. To get entire efficacy, clinical trials should be conducted on broad scale on different parameters to achieve optimum benefits. Number of publications in PubMed by using different searching keywords/phrases it was concluded that research on face mask is desperately needed to know the veracity in community health (Fig. 6 ).

Social distancing is not a novel notion it has been employed to avert the spread of infection through across the world since ancient times. Current pandemic outbreak made it more popular. It minimises the interaction between people either they are healthy or sick by residing at home. Social distancing include strictly avoid contact, stop social gathering and stay home etc. It is a non pharmaceutical self effort to control the spread of infectious disease chiefly current COVID-19. WHO define social distancing in 2009 during flu pandemic to maintain an arm's length distance from others. Furthermore, CDC revised it in pandemic COVID-19 that avoid mass gathering and in practice avoid close proximity to each other and suggest maintaining 6 feet distance. Among various types of infections control social distancing most effective to prevent fomites infection (Interim U.S. Guidance, 2020; Kinlaw et al., 2009) 

COVID-19 outbreak has been appeared globally as a serious public health threat. Even extremely equipped nations are now facing second subsequent wave of this pandemic outbreaks that have obligated for social distancing measures. Application of face mask in the public will be contemplated only as temporary measures for several perceptive groups of people not as a substitute for established precautionary procedures. It is the need of the hour to search alternates that could prove better efficacy than present face mask. Face shield and social distancing could be better substitute of face mask for individual group of people that include COPD, acute and chronic respiratory disease, outdoor exercise, old age, underlying medical conditions and hypercapnia sensitive group but further clinical studies are required to be carried out.

None.

The authors express thanks to every front-line personnel in the fight against COVID-19. healthline.com/health-news/face-masks-importance-battle-with-covid19 (Accessed: 11 August 

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