key: cord-298693-x25r0gtt
authors: Advani, Sonali D.; Yarrington, Michael E.; Smith, Becky A.; Anderson, Deverick J.; Sexton, Daniel J.
title: Are we forgetting the “universal” in universal masking? Current challenges and future solutions
date: 2020-07-16
journal: Infection control and hospital epidemiology
DOI: 10.1017/ice.2020.333
sha: 
doc_id: 298693
cord_uid: x25r0gtt

nan

Overall, HCP compliance with protective measures such as universal masking often correlates with the level of risk they perceive. Individuals are more likely to comply with recommended prevention measures if they perceive themselves to be at higher risk of harm in a particular situation or setting. 5 HCPs commonly perceive their risk of contracting COVID-19 from an infected patient to be higher than the risk of exposure to an asymptomatic coworker. Ironically, HCPs spend more time in close proximity to their coworkers than infected patients. A recent study demonstrated that <5% of exposed HCPs tested positive for SARS-CoV-2 despite exposure to an infected patient without adequate personal protective equipment (PPE), although most HCP attribute greater risk to this type of exposure. 6 The propensity among HCPs to perform inaccurate risk assessments has been seen with other basic infection prevention measures such as hand hygiene. 7

Earlier this year, public health authorities pointed out a lack of evidence related to the use of universal masking by the general public to prevent acquisition of SARS-CoV-2. Later, a member of the World Health Organization (WHO) stated in June 2020 that asymptomatic spread of SARS-CoV-2 is 'very rare.' The WHO quickly modified and clarified this statement by stating that asymptomatic spread is incompletely understood even though it actually occurs, contributing to ongoing confusion. Furthermore, a few high-ranking political leaders and millions of citizens routinely ignore the current recommendation to use face coverings in indoor settings and when in close proximity with others. Inconsistent, contradictory and unclear advice from public health authorities has contributed to widespread confusion about the utility of universal masking in preventing the spread of SARS-COV-2 (response efficacy). 5 The CDC recently updated their exposure guidelines and issued a new "frequently asked question" on May 29, 2019, recommending the use of eye protection when caring for patients in areas of "moderate to substantial community transmission [of SARS-Cov-2]," even if COVID-19 is not suspected. 8, 9 In our opinion, this guidance is confusing and adds an unnecessary emphasis on the use of additional PPE by HCPs when in direct contact with patients and does not place emphasis on the need for universal masking of patients when staff are in close proximity to patients.

COVID-19 fatigue, a term that describes drift in following preventative measures as this pandemic goes on, is an important cause of poor compliance with policies related to universal masking. 10 This "fatigue" among HCPs may be potentially related to their long work hours, required interactions with other team members throughout the day, the burden of wearing additional eye protection and uncomfortable or poor-quality masks.

For effective behavioral change, wearing a mask must become a habit for HCPs in all shared spaces inside and outside the workplace, outside of their immediate household and when appropriate physical distancing is not possible. 11 We need to work closely with HCPs to better understand the root causes for poor masking compliance and to identify and remove barriers to doing the right thing. Simple solutions such as educational campaigns on the rationale for masking, creation of a mask committee comprised of key stakeholders from various worker types to serve as champions, making physical changes to the environment to facilitate distancing, offering better quality masks, as well as suitable and accessable alternate locations that allow for physical separation to occur while HCPs are unmasked during breaks, will likely lead to improved compliance.

Finally, we need clear, simple, and consistent messaging from public health authorities for successful implementation of universal masking policies. Our goal should be to focus on the simple message of universal masking to prevent the transmission of SARS-CoV-2. Healthcare epidemiologists and public health professionals need to learn the art of salesmanship during these times because the message itself, though important, is only as good as the leader that presents it to the public. 12 

Universal masking in hospitals in the COVID-19 era: Is it time to consider shielding?

Pandemic planning resources

Universal masking in hospitals in the COVID-19 era

Universal masking is an effective strategy to flatten the SARS-2-CoV healthcare worker epidemiologic curve

Overcoming COVID-19: addressing the perception of risk and transitioning protective behaviors to habits

COVID-19 infections among HCWs exposed to a patient with a delayed diagnosis of COVID-19

Observing and improving hand hygiene compliance: implementation and refinement of an electronicassisted direct-observer hand hygiene audit program

Practice and technique of using face mask amongst adults in the community: a cross-sectional descriptive study

An intervention designed to investigate habit formation in a novel health behaviour

Hospital epidemiologists and the art of salesmanship

Acknowledgments. None.Financial support. No financial support was provided relevant to this article.

All authors report no conflicts of interest relevant to this article.
