








key: cord-292201-e7k7gn9q
authors: Fodjo, Joseph Nelson Siewe; Pengpid, Supa; Villela, Edlaine Faria de Moura; Van, Thang Vo; Ahmed, Mohammed; Ditekemena, John; Crespo, Bernardo Vega; Wanyenze, Rhoda K; Dula, Janeth; Watanabe, Takashi; Delgado-Ratto, Christopher; Driessche, Koen Vanden; Van den Bergh, Rafael; Colebunders, Robert
title: Mass masking as a way to contain COVID-19 and exit lockdown in low- and middle-income countries
date: 2020-07-17
journal: J Infect
DOI: 10.1016/j.jinf.2020.07.015
sha: 
doc_id: 292201
cord_uid: e7k7gn9q

In new guidelines published on June 5(th) 2020, the World Health Organization (WHO) recommends that in areas with ongoing COVID-19 community transmission, governments should encourage the general public to wear face masks in specific situations and settings as part of a comprehensive approach to suppress COVID-19 transmission. Recent online surveys in 206,729 persons residing in nine low- and middle-income countries showed that 32.7%-99.7% of respondents used face masks with significantly differences across age groups and sexes. Targeted health promotion strategies and government support are required to increase mask use by the general population.

In new guidelines published on June 5 th 2020, the World Health Organization (WHO) recommends that in areas with ongoing COVID-19 community transmission, governments should encourage the general public to wear face masks in specific situations and settings as part of a comprehensive approach to suppress COVID-19 transmission. Recent online surveys in 206,729 persons residing in nine low-and middle-income countries showed that 32.7%-99.7% of respondents used face masks with significantly differences across age groups and sexes. Targeted health promotion strategies and government support are required to increase mask use by the general population.

We read with interest the research work of Cheng and collaborators on community-wide mask use for Coronavirus Disease 2019 (COVID-19) control. 1 Indeed, face masks are now recommended by the World Health Organization (WHO) to prevent COVID-19 transmission, according to new guidelines published on June 5 th 2020. 2 The new recommendations state that in areas with ongoing COVID-19 community transmission, governments should encourage the general public to wear masks in specific situations and settings where physical distancing cannot be achieved, as part of a comprehensive approach to suppress COVID-19 transmission. 2 Long before the issuance of these guidelines, many Asian countries were already using face masks and this potentially contributed to the rapid containment of COVID-19 in these countries. 1, 3 Outside of Asia, routine use of masks by the general population is rare. Most European countries were applying previous WHO recommendations whereby face masks were reserved for COVID-19 patients, carers or healthcare workers. Moreover, there were fears that promoting mass masking could aggravate the shortage of face masks among healthcare workers, especially as cloth (fabric) masks were not initially considered useful for COVID-19 prevention in Europe. 3 The Director-General of the Chinese Center for Disease Control and Prevention went as far as warning Europe and the United States of America (USA) regarding the risks of not enforcing routine wearing of face masks by the general public. 4 Most low-and middle-income countries (LMIC) outside of Asia also initially deprioritised masks and focused on lockdown strategies in an attempt to "flatten the curve". However, lockdowns are associated with major socio-economic losses, which may further exacerbate the precarious conditions in resource-limited settings, and thus compliance to such strategies is implausible (particularly among populations who depend on daily labour for their income). Furthermore, in highly congested settings such as urban slums or refugee camp settings, lockdowns and/or measures of physical distancing are not feasible. The benefits of isolation-based strategies are also limited, given that pre-and asymptomatic individuals are potentially contagious for COVID-19. 5 We thus welcome the WHO recommendations to use face masks in the general population, as an important component of strategies to stop the epidemic and/or exit the lockdowns, particularly in LMIC. Recent evidence supports a predominantly airborne transmission route for COVID-19, and strongly encourages face mask use in public to prevent inter-human transmission. 6 Modelling studies estimate that the COVID-19 pandemic can be brought to an end if 80% of the population would wear a surgical mask. 7 Moreover, mass masking could also alleviate fears that prevent people from seeking medical care for non-COVID-19 conditions, limiting the collateral damage of the COVID-19 pandemic. On the downside, improper mask use may inadvertently increase COVID-19 transmission via indirect contact routes with the mask serving as a fomite. Mass making may also produce a false sense of security leading to reduced adherence to other preventive measures such as hand hygiene. 3 Finally, surgical masks pose an environmental threat if discarded inappropriately due to their plastic content. 8 It is therefore paramount to monitor both compliance and user practices in ensuring the effectiveness of masks in COVID-19 control.

Between March and June 2020, an international consortium (www.ICPCovid.com) organised online surveys in LMIC to monitor adherence to COVID-19 preventive measures, including face mask use. Only data of consenting respondents who were at least 18 years old and who self-identified as either male or female were analysed 8 In countries where masking was mandatory or highly encouraged by the government during the early phases of the COVID-19 outbreak, adherence rates were >90%. In Brazil, the initial low adherence to face mask use together in combination with little or no confinement measures may have contributed to the high COVID-19 mortality in this country. Where data were available on the type of mask used, reusable cloth masks (more cost-beneficial and environmentally friendly than surgical masks) were the most frequent accounting for 4,413/8,636 (51.1%) of all mask types. Our study shows that even in countries where no pre-existing culture of mask use existed, high uptake of mass masking was feasible. The differential rate of uptake between sexes and age groups, as shown in Table 2 , suggests that targeted health promotion strategies to (further) stimulate mask use may need to be developed, and that COVID-19 prevention strategies need to be contextualized to each setting/population. As there is currently no effective vaccine or treatment against COVID-19, the mass masking policy of the WHO is a prudent move for COVID-19 prevention. We therefore urge the public health and scientific communities to invest in strategies to promote mask use among all tiers of the population, and to further build the evidence-base for optimal COVID-19 prevention strategies.

The authors declare no conflicts of interest. RC receives funding from the European Research Council (grant number 671055). All participants provided an informed e-consent (checkbox) before submitting their data anonymously.

RC conceived the surveys and drafted the initial manuscript; JNSF cleaned and analysed the data, and edited the initial draft; All authors participated in data collection, critical review and approval of the final manuscript. 

The role of community-wide wearing of face mask for control of coronavirus disease 2019 (COVID-19) epidemic due to SARS-CoV-2

Advice on the use of masks in the context of COVID-19: interim guidance

Rational use of face masks in the COVID-19 pandemic. The Lancet Respiratory Medicine

Not wearing masks to protect against coronavirus is a 'big mistake,' top Chinese scientist says

Temporal dynamics in viral shedding and transmissibility of COVID-19

Identifying airborne transmission as the dominant route for the spread of COVID-19

Mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel Coronavirus

Discarded Covid 19 gear: A looming threat

Hand Hygiene, and Influenza among Young Adults: A Randomized Intervention

Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. The Lancet

We thank the following ICPcovid research team members in the different countries who were involved in the local organisation of the surveys: 

