key: cord-0927982-rj6te7fz authors: Stone, Teresa E.; Kunaviktikul, Wipada; Omura, Mieko; Petrini, Marcia title: Editorial: Facemasks and the Covid 19 pandemic: What advice should health professionals be giving the general public about the wearing of facemasks? date: 2020-04-12 journal: Nurs Health Sci DOI: 10.1111/nhs.12724 sha: 8d24f357a62fed2ba4e71ab115b2e665edac1f4f doc_id: 927982 cord_uid: rj6te7fz nan and a lack of personal protective gear. Hospitals resorted to pleading on social media for more protective equipment (Gan, Thomas, & Culver, 2020) . Medical staff during the height of the crisis in Wuhan, had only one protective suit per day and were forced to wear diapers as they could not change their protective gear for as long as 12 hours. The numbers of health professionals falling ill have obviously led to further shortages and one Wuhan doctor was quoted as saying, "just a very rough estimate, 100 nurses and doctors can look after 100 ordinary beds and 16 ICU beds. If they are sick, not only do they occupy 100 beds, but the staff taking care of 100 beds are gone. That means a hospital loses the capacity of 200 beds." (Ma et al., 2020) . In the light of this, China's National Health Commission's warning to health professionals to make "reasonable use" of protection gear warning against "excessive and disorderly use" (Frias, 2020) seems unreasonably harsh. The same issues are being seen across the globe as the pandemic spreads: over 2000 Italian health workers contracted the disease and there have been many deaths partly as a result of a lack of availablity of personal protective equipment (International Council of Nurses, 2020) . It is a similar story in Spain with over 5400 health workers infected as of the end of March 2020nearly 14% of the total infections in that country (Minder & Peltier, 2020) . Panic buying of masks has resulted in shortages across the world. Over 10,000 people queued up for masks in Hong Kong, with one woman waiting for over 18 hours, and another reported that she had used the same mask for over five days (Huang & Tong, 2020) . A shipment to Hong Kong was deemed so valuable it had an armed escort (Woodhouse, Kuchler, & Liu, 2020) . The World Health Organization's director general, Dr. Tedros Adhanom Ghebreyesus, said that, as a result of the COVID-19 outbreak, demand for personal protective equipment was 100 times higher than average, and prices had risen to 20 times higher resulting in global stocks of masks and respirators being insufficient to meet supply (Boseley, 2020) . He went on to say that there were delays of four to six months in supply and that the shortage was due to "widespread inappropriate use" by those who were not ill or not medical staff. One consequence is that the second-worst hit city in Hubei province faces a shortfall of 24,000 of protective gear, 60,000 masks, as well as 15,000 This article is protected by copyright. All rights reserved. Accepted Article goggles and face shields (Frias, 2020) and there are people in the streets wearing the N95 mask and other professional masks that healthcare workers need. Videos have emerged from Wuhan, the epicenter of COVID-19, of the Chinese government using drones to admonish people for not wearing masks (Pietsch, 2020) and villagers have taken to the same tactics: this clip shows a woman being scolded by a man operating a drone in an Inner Mongolian village https://www.youtube.com/watch?v=--nN7k0Rc9U. Ironically the wearing of masks has hindered efforts to trace suspected carriers because the surveillance technology cannot recognize faces (Chen, 2020) . Despite the advice from the World Health Organization (WHO) (2020) that frequent handwashing with soap and water or use of an alcohol-based hand rub is the primary means of prevention along with respiratory hygiene, maintaining social distance and avoiding touching the eyes, nose and mouth many organizations outside of health are advising mask use. For example, across Japan, hotels, transport, and retail staff wear masks and frequently, this is a company directive. For instance, All Nippon Airways (ANA), Japan Airlines (JAL) and Japan Railways (JR) have explained that staff wears masks "to provide safe services for customers," among other reasons. In some other cases the request to wear masks has come from employees, for example, the Association of Flight Attendants-CWA, which represents flight attendants from Hawaiian and more than a dozen other airlines, is asking airline to allow flight attendants to wear masks on flights to and from Asia (Oliver & Thompson, 2020) . To date, there has been mounting anger as the airlines have refused this request citing the Centers for Disease Control and Prevention (2019) policy that that face masks should only be used by airline crew members when they "are helping sick travelers with respiratory symptoms such as coughing or sneezing." Facemasks are also advised for sick travelers and those sitting near passengers with respiratory conditions. More concerningly, some health professionals and government organizations have misconceptions about mask efficacy: for example, the Thai health minister is strongly This article is protected by copyright. All rights reserved. Accepted Article advocating the use of face masks contrary to WHO advice and health officials in many Asian countries have required the general public to wear masks (Boonbandit, 2020; Tufekci, 2020) . So, is wearing a mask likely to be preventive? Experts tell us that it is less useful than frequently washing hands. The World Health Organization's director general recently pointed out that masks were not always beneficial for the healthy general public, "masks don't necessarily protect you, but they doif you have the diseasestop you from giving it to anybody else" (Boseley, 2020) . Authors of a recent systematic review of ten randomized control trials found limited evidence for face mask effectiveness in preventing influenza virus transmission either when worn by the infected person to avoid transmission or when worn by uninfected people to reduce exposure (Xiao et al., 2020) Summing up evidence Pawlowski (2020) notes that surgical masks are designed for surgeons to wear to prevent the transmission of pathogens from their nose and mouth to the surgical field; they are not intended to avoid viruses being inhaled through the mask. Neither are they designed to be worn for extended periods as many of the general public do. The shortage of masks has led to a range of inappropriate and potentially dangerous ways of covering the nose and mouth. Children and adults in China have used plastic bags to cover themselves and resorted to other desperate measures such as wearing plastic bottles over their heads, ski masks and even sanitary towels. More frequently seen are cloth masks or scarves used as a mask, and there is no compelling evidence to suggest that these are effective. Knowledge about the SARS-CoV-2 virus is rapidly evolving, but it is thought that the virus is transmitted through droplets, direct contact, and by coming into contact with contaminated surfaces and it is not known to be airborne and cannot circulate through the air (United Nations, 2020). The respiratory droplets may travel up to six feet from someone who is sneezing or coughing. Bai (2020) cites Chiu an infectious disease expert who states that "If you have an infected person in the front of the plane, for instance, and you're in the back of the plane, your risk is close to zero simply because the area of exposure is thought to be roughly six feet from the infected person." Authors of a recent systematic review concluded that most viruses from the respiratory tract, such as corona, influenza, or SARS can persist on surfaces for a few days and can thereby be a continuous source of transmission if no regular preventive surface disinfection is performed (Kramer, Schwebke, & Kampf, 2006) . The SARS-CoV-2 virus resembles other human coronaviruses, such as those that cause SARS and MERS and can stay on surfacessuch as metal, glass or plastic This article is protected by copyright. All rights reserved. Accepted Article for as long as nine days but can be efficiently inactivated by surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide or 0.1% sodium hypochlorite within 1 minute (Kampf, Todt, Pfaender, & Steinmann, 2020) . The extensive media reporting and frequent use of pictures of people wearing masks may have had a role in fueling the mask-wearing frenzy, but there have been many articles with sensible, evidence-based advice cautioning against a reliance on masks and instead washing hands frequently in soapy water, using correct etiquette when coughing and sneezing and avoiding touching the face and referencing reliable sources for the information they give (Boseley, 2020; Secon, 2020) . The Director General of the Centers for Disease (CDC) control said: "I think this virus is probably with us beyond this season, beyond this year, and I think the virus eventually will find a foothold and we'll get community-based transmission and you can start to think about it like seasonal flu. The only difference is we don't understand this virus" (Moreno, 2020) . We need to respond appropriately to the threat from this threat knowing that climate change, global interconnectedness, antivaccine sentiment and a myriad of other factors leave us vulnerable to global pandemics and increasing infectious disease outbreaks (Global Preparedness Monitoring, 2019). Along with unknown viruses, we also need to manage the ones we know. In the 2019-2020 season, there have been at least 15 million cases of influenza and 8,200 deaths including 54 children in the United States alone (Guzman, 2020) . As health professionals, we need to be clear about what preventative measures we should take and about the advice we give the public. The primary advice for prevention is effective handwashing with soap and water for at least 20 seconds, rubbing the hands together and avoid touching the mouth, nose and eyes (World Health Organization, 2009). The inappropriate use of masks has become a moral issue leaving frontline health workers without the necessary protective equipment. As health professionals, we have an obligation to model appropriate health behaviors and disseminate accurate health information based on current evidence that the use of surgical facemasks by the general public is not recommended unless they are looking after a sick person in a household setting or are themselves suffering an illness. Far more effective is through handwashing and maintaining a safe distance from other people. how-to-use-masks How to choose and wear a mask safely How the new coronavirus spreads and progresses -and why one test may not be enough Anutin: Farangs who don't wear masks 'should be kicked out WHO warns of global shortage of face masks and protective suits Coronavirus outbreak tests China's surveillance technology Thousands of Chinese doctors volunteered for the frontline of the coronavirus outbreak. 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