key: cord-1001594-tvfgfv1m authors: Picard, Jérémy; Cornec, Gwenael; Baron, Raoul; Saliou, Philippe title: Wearing of face masks by healthcare workers during covid-19 lockdown: what did the public observe through the French media? date: 2020-08-13 journal: Journal of Hospital Infection DOI: 10.1016/j.jhin.2020.08.009 sha: 434edfac457107fc09b96eef877547f74dd6c76c doc_id: 1001594 cord_uid: tvfgfv1m Summary Wearing a face mask is a major issue in the fight against Covid-19 pandemic spreading. The French general population widely started to wear this individual protection equipment usually dedicated to healthcare workers, without being educated to its correct use. People base their behavior on what they see in the media. However, we observed that masks wearing of healthcare workers published in the media during the pandemic was only conform on 70.8% of the photographs collected on some of the main French information websites. Health authorities should communicate widely about the good practices for mask wearing in general population. To deal with the Covid-19 pandemic, the systematic wearing of masks has gradually become widespread among all healthcare workers [1] . Indeed, the SARS-Cov-2 virus is now considered as mainly transmitted by droplets and masks are an effective barrier to fight the virus spreading [2] . This information was quickly relayed by the media and the demand for masks skyrocketed in patients and general population [3, 4] . Even if the usefulness of wearing a mask among the general population has come to be widely accepted, the French government has long opposed its systematic use. In normal times, professionals may already be confused by the variety of masks and its indications. In addition, many institutions are facing a shortage that forces learned societies to review the indications and methods of use [5] . Operational hygiene teams are used to train healthcare workers in the proper use of masks. These training courses are unfortunately infrequent in normal times and only concern healthcare professionals [6] . The general public is constantly exposed to images of masking through the various media [7] . Their behaviour may be induced by this exposition. This is also the case for caregivers who are exposed to these representations daily. However, the pictures disseminated do not always comply with good practice. The aim of this study is to assess the wearing of masks appropriateness observed in the images broadcast by the main French media during this lockdown period. We conducted a prospective study from March 30, 2020 to May 11, 2020, during the public lockdown period decided by the French government following the spread of confirmed Covid-19 cases and Intensive Care Units saturation. We reviewed some of the main French information media websites: Le Monde, Le Figaro, Libération, L'Obs, Le Point, L'Express, BFM TV and CNews, and one regional newspaper website: Le Télégramme. We daily collected photographs presented on the home page, or on the dedicated Covid-19 page, where a face mask worn by a French healthcare worker could be seen. We then evaluated its compliance with good practices. Le Monde is a generalist daily national journal with about 323,000 subscribers in 2020, whose website received more than 210 million visits in April 2020. Le Figaro is a daily journal with 326,000 subscribers and a website consulted more than 210 million times in April 2020. Le Point and L'Express are weekly magazines respectively distributed to 290 million people and 201 million people, and their websites have been consulted respectively 53 million times and 39 million times in April 2020. BFMTV and CNews are the main continuous 24/7 news channels accessible from every TV posts, and BFMTV website have been consulted 180 million times. Finally, Le Telegramme is the local journal distributed at Brest Hospital, it's delivered to more than 180,000 people every day and its website received 18 million visits in April 2020 [8] . In France, there are commonly two types of face masks for medical use. The first one is the anti-projection mask or surgical mask and the second one is a respiratory protection device or filtering face piece, usually class 2 (FFP2), the latter being equivalent to an N95 facemask. Surgical mask wearing is recommended for healthcare workers in contact with a person presenting signs of respiratory infection, and in the absence of invasive procedures on the J o u r n a l P r e -p r o o f respiratory tract. On the contrary, FFP2 should be reserved for healthcare workers performing invasive medical procedures on the respiratory sphere that may generate an aerosol, such as non-invasive ventilation, nasopharyngeal sampling, endotracheal aspiration, functional respiratory explorations... [1] Compliance was assessed on the basis of several criteria: • Only one face mask must be worn • The face mask must cover the nose and mouth, it must not be worn under the chin or on the hair • Two ties or elastics must be placed for the mask to be well positioned (surgical mask and FFP2) and to maintain airtightness (FFP2) • The face must be hairless under a FFP2 to maintain the airtightness • The face mask must not be touched or manipulated • A FFP2 mask must be worn if the picture was taken during an invasive procedure • Tissue masks or other barrier masks are not recommended for healthcare workers during cares. Mask wearing was considered as non-compliant if one of the above criteria was not respected. Compliance was assessed by two hygienist doctors independently. In case of disagreement, the photographs were reviewed and a collegial decision was taken. We collected 120 different photographs after exclusion of foreign ones. We also paid attention to exclude general public photographs. In case of doubt concerning the occupation of the subject or its nationality, the file was excluded. A total of 238 healthcare workers were represented wearing masks. The number of photographs collected by website is presented in table I. Finally, 85 photographs (70.8%) were classified as compliant, and 35 (29.2%) as noncompliant. As several healthcare workers could be seen in a picture, we also classified 38 (16%) mask wearing as non-compliant, out of a total of 238 (Table I) . Among non-compliant photographs, 18 showed healthcare workers wearing a mask under the chin, 3 of them showed 2 different masks worn at the same time, 12 masks were not well placed or could not have been airtight because of mispositioned elastics, 1 FFP2 was worn on a beard, 2 were touched by the professional, and 1 surgical mask was worn during an aspiration which is an aerosol-generating procedure. Some of the photographs presented more than one non-compliant criterion. Furthermore, 26 were taken during direct care to patients, whereas 9 represented healthcare workers, some of them being key opinion leaders, during an interview (Table II) . Mask wearing is a useful barrier to protect healthcare workers against droplet-transmitted virus such as SARS-CoV2, responsible for Covid-19. However, to be effective, masks must be used in accordance with good practice recommendations. Surgical face masks, FFP2 or N95 face masks are single-use products. They should be thrown away after handling and should not be kept around the neck between two treatments. Our study demonstrated an However, the general population is not trained in the use of masks even if there are recommendations published by WHO [9] . They therefore tend to copy what they observe in the media and may base their behaviour on the professionals they see in action. Knowledge on recommended carrying times and fragility of these devices is not well spread. Moreover, mistakes in mask positioning are frequently observed in the general public: for example, masks not covering entirely the nose or the mouth, and thus ineffective. Media websites are a huge way of disseminating information, reaching a large audience. Mass media campaigns can change human health behaviours [10] . One can hypothesize that information disseminated through media may impact the population behaviour on mask wearing. This can be especially true when the observed behaviour is the key opinion leader's one. We have unfortunately observed that several portraits staged in the press concern medical professors who wore their surgical mask as a bib, which is also a frequent mistake in the general population. In France, the errors observed could be also linked to divergent speeches made by the government concerning the value of the mask. During the lockdown period the mask wearing in the general population was not recommended for asymptomatic persons. When people observed that all healthcare workers systematically wore a mask to prevent Covid-19, they felt the need to wear one themselves. Healthcare establishments were quickly faced with shortages of masks which forced institutions and learned societies to review its use indications. This has resulted in an increased mask wearing time and restrictions on the use of FFP2 masks. The French Hygiène society, SF2H, allowed caregivers to keep the same FFP2 mask up to 8 hours maximum and to keep the same surgical anti-projection mask for up to 4 hours maximum [5] . Moreover, the nursing staff had to use very different materials throughout the epidemic. To cope with the shortage of masks, establishments had to order J o u r n a l P r e -p r o o f many different brands of masks and they found themselves using equipment of very uneven quality. The scale of the epidemic has led to the saturation of healthcare services. Healthcare workers were sometimes overwhelmed by care and had little or no available time to attend training on the use of personal protective equipment. In addition, hospital hygiene teams are often small and have had to cope with a very large demand for training in the field. The equipment usually used for care was no longer available and it was complicated to train the entire hospital to use the new equipments. We did not observe the use of fabric masks in a care situation. The use of this kind of mask which does not provide a sufficient level of protection is not recommended by learned societies [5] . However, their use is widespread in the general population, especially since the end of confinement in France. Even if its wearing rules are not as strict as those of surgical masks or FFP2, its use cannot be improvised. The general population has never been trained in their use and therefore may copy behaviors observed in the media. Some of these masks made at home have no effectiveness in terms of protection because their level of filtration is not sufficient. Others, available in shops, meet AFNOR standards but must be used in accordance with the recommendations to be effective. The systematic wearing of the mask in public space is not compulsory but some municipalities have attempted to impose it by municipal decrees. It is however compulsory in public transport in large cities like Paris. Masks are certainly an effective protection in these conditions to prevent the spread of the Covid-19 epidemic. Our study has some limitations. The websites of the main French newspapers are not the only media where the wearing of masks is visible. Television news and report magazines expose the general public to this style of image extremely frequently. We could not assess the compliance of mask wearing in the reports broadcast in videos by lack of means. We felt that the websites were a representative sample of what can be seen in news magazines. These are very popular sites that reach a relatively large audience. It would be interesting to conduct this type of study in other countries, and to assess mask wearing in television programs. Health authorities should communicate widely about the good practices for mask wearing in general population. J o u r n a l P r e -p r o o f What face mask for what use in the context of COVID-19 pandemic? The French guidelines Infection prevention and control and preparedness for COVID-19 in healthcare settings -third update Wearing face masks in the community during the COVID-19 pandemic: altruism and solidarity The role of community-wide wearing of face mask for control of coronavirus disease 2019 (COVID-19) epidemic due to SARS-CoV-2 COVID-19-associated shortage of alcohol-based hand rubs, face masks, medical gloves and gowns -proposal for a risk-adapted approach to ensure patient and healthcare worker safety Influence of risk assessment inspection on the prevention of nosocomial infection Mass masking in the COVID-19 epidemic: people need guidance Alliance pour les Chiffres de la Presse et des Médias (ACPM). Fréquentation internet. Synthèse des classements Avril 2020. 2020. /Les-chiffres/Frequentationinternet/Synthese-des-classements2 World Health Organization (WHO). When and how to use masks 2020 Use of mass media campaigns to change health behaviour En Italie, plus de 150 médecins sont morts du coronavirus Est-il si difficile en médecine de dire "je ne sais pas" ?». Libération qui critique des méthodes de Didier Raoult, est-elle en «conflit d'intérêt» avec les laboratoires concurrents ? Libération Coronavirus : les portraits de soignants au front à l'hôpital Georges-Pompidou à Paris. Le Figaro J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f https://www.bfmtv.com/international/en-italie-plus-de-150-medecins-sont-morts-du-coronavirus_AN-202004270261.html [11] A healthcare worker phoning with a maskLiberation.fr https://www.liberation.fr/france/2020/04/30/est-il-sidifficile-en-medecine-de-dire-je-ne-sais-pas_1786919 [12] Masks worn as a bib by key opinion leadersLiberation.fr https://www.liberation.fr/checknews/2020/03/26/cetteprofesseur-critique-des-methodes-de-didier-raoultest-elle-en-conflit-d-interet-avec-les-labor_1782911 [13] Masks worn as a bib by key opinion leadersLefigaro.fr https://www.lefigaro.fr/actualite-france/coronavirusles-portraits-de-soignants-au-front-a-l-hopitalgeorges-pompidou-a-paris-20200404 [14] J o u r n a l P r e -p r o o f