key: cord-0813220-8nilrsts
authors: MacIntyre, C. Raina; Chughtai, Abrar A.
title: Respiratory protection during the COVID-19 pandemic – the evidence shows it works: Author's response to Mandal et al, 2020.
date: 2020-07-18
journal: Int J Nurs Stud
DOI: 10.1016/j.ijnurstu.2020.103717
sha: 7c24ebcb6a030b972c1d41a9102032c1e897e918
doc_id: 813220
cord_uid: 8nilrsts

nan

In response to the letter by Mandal et al, 2020 , we note three main points made by the authors. Firstly, they believe that masks may be sufficient for healthcare workers; secondly, that wearing a mask may reduce compliance with other hygiene measures and result in increased spread of COVID-19; and that re-use of disposable products may be unsafe; and thirdly that universal face mask use in the community may be beneficial.

The purpose of our systematic review (MacIntyre & Chughtai, 2020) was to evaluate the available data from randomised clinical trials (RCTs) for other respiratory viruses, given there are no RCTs yet published specific to COVID-19, and it may not be ethical to do such RCTs in the midst of a pandemic, when evidence of protection of respirators is available and where health care workers are dying of COVID-19. (CDC COVID-19 Response Team 2020, Godlee 2020, Li, Zhang et al. 2020) A recent meta-analysis of mask use for the beta-coronaviruses SARS, MERS CoV and SARS-CoV-2 confirmed that N95 respirators (96% protection) are more effective than surgical masks (67% protection). (Chu, Akl et al.) This is the best current evidence, and healthcare workers should be afforded the best available protection. (MacIntyre and Wang 2020). Whilst surgical masks do provide protection, and some health workers may be forced to wear them while working with COVID-19 patients during shortages, the precautionary principle should be used (MacIntyre 2014) and the best available protection provided.

The authors also cite Leung et al, as evidence of efficacy of surgical masks. We included this study in our review of masks as source control, and need to clarify that the Leung study is evidence of efficacy of source control (wearing of a mask by a sick person), not of protection of well people. (Leung et al. 2020) Health workers are not disposable assets, and replacing those who are ill, quarantined or dead cannot be done by scaling up production as we can for drugs, ventilators, masks or respirators. From the perspective of the occupational health and safety of health workers and also of maintaining the capacity of the health workforce, it is unreasonable to expect them to work in sub-standard personal protective equipment. Countries should take responsibility for scaling up procurement or manufacturing of disposable respirators, or look at alternatives like re-usable elastomeric respirators for health workers. (Greenhalgh, Schmid et al. , MacIntyre and Wang 2020) This is not a difficult or expensive proposition compared to other investments made by governments, most of whom have failed to adequately stockpile for a pandemic. It requires political will and recognition of the importance of protecting health workers during a pandemic, which will never change if we continue to accept or advocate for lesser protection for health workers. Cloth masks are not a suitable option for health workers. The only RCT of cloth masks published at the time of the pandemic showed a higher risk of respiratory infection for health workers using a cloth mask. (MacIntyre, Seale et al. 2015) However, these findings are specific for the 2-layered cotton mask used in the trial, and do not preclude the design of a safer cloth mask for use by community members, who face a lower risk than health workers. (MacIntyre 2020, MacIntyre 2020). We agree there is little evidence on the safety of decontamination methods for re-use of disposable products, but this was not a focus of our review.

On the point that wearing a mask or respirator will encourage risky behaviour and actually increase infection risk, this is not supported by any evidence. In fact, the best available real-world evidence shows exactly the oppositethat masks and respirators offer significant protection in both health care and community settings. (Chu, Akl et al.) The same type of arguments against accepted public health measures, such as that "HPV vaccine will encourage young people to become promiscuous" have also been proven wrong. (Brouwer, Delinger et al. 2019 ) Health agencies should avoid using non-evidence based arguments against a cheap, low risk and effective intervention such as a mask or respirator in the midst of the worst pandemic of our lifetimessuch negative and inconsistent messaging does not add to clarity, but creates more confusion and loss of trust in health agencies. (Chan 2020) Instead of presenting the few available non-pharmaceutical interventions against COVID-19 as competing options, it would be of best if health agencies provide clear and positive guidance to community members of wearing masks and the principles of good design of a home-made mask. We agree that universal face mask use is a sensible and likely effective policy in settings of high transmission or potential transmission.

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