The systematic review portion of this paper did not find any research studies that investigated the effectiveness of face mask use in tackling this specific virus in this specific population. This finding questions the basis of contradicting and varying public health recommendations that have been provided by public health and health professionals on face mask use around the world since the beginning of COVID–19 outbreak. The concerns around current public health recommendations in the context of this finding is discussed below.
Evidence-based public health recommendations
One of the important requirements for further research on this subject is the need for evidence-based public health recommendations. Practicing evidence-based approaches in public health increases the availability of higher quality information, likelihood of successful prevention programs and policies, and efficiency in the use of resources. [10] [11] [12] [13] [14] Current literature states that public health professionals should always integrate scientific evidence when planning and implementing programs, developing policies and evaluating progress, which also applies to when providing public recommendations. [14] [15] Therefore, it is best that recommendations are based on best available scientific evidence whether the recommendation is to wear or not to wear face masks in community settings among different types of sample populations. Recommendations that are not supported by scientific evidence can create controversy and confuse the public as well as health authorities around the world, creating contradicting and inconsistent recommendations. Such recommendations not only create confusion and controversy but also increase the risk of unnecessary spread of the infection.
As an example, in a situation where an asymptomatic, pre-symptomatic or symptomatic individual with COVID–19 who has not yet been medically diagnosed, who is not wearing a face mask, coughs or sneezes without covering their face, they could be releasing respiratory droplets. WHO states that “people can also catch COVID–19 if they breathe in droplets from a person with COVID–19 who coughs out or exhales droplets. This is why it is important to stay more than 1 meter (3 feet) away from a person who is sick.” [16] If these individuals are not wearing a face mask, the risk of spreading the infection through coughing or sneezing out droplets is higher. On the other hand, if healthy individuals in close proximity are not wearing face masks, they may be at a higher risk of contracting COVID–19 through respiratory droplets. [16] This kind of transmission is not rare especially in public transit during rush hour in any part of the world.
By providing recommendations against the use of face mask in the above situation, health authorities may be implying that wearing a face mask is not effective in protecting a healthy individual in this situation. [1] [2] [3] Health officials in countries like the Philippines have brought attention to the possibility of this kind of transmission and recommended the use of face masks. [5] Since the beginning of the outbreak, the WHO provides a recommendation stating that “relatives or caregivers to individuals with suspected 2019-nCoV infection with mild respiratory symptoms should wear a medical mask when in the same room with the affected individual” suggesting that wearing a medical mask is useful in preventing the transmission of COVID–19 to those who are not medically diagnosed with the virus in some scenarios. [17] This recommendation has likely been provided to err on the side of caution by public health entities. However, it is questionable why the same recommendation does not apply to those who have not yet been exposed to the virus and are not relatives of an individual suspected with COVID–19, who can still be exposed to an infected individual in public spaces such as in the above public transit scenario. If face masks recommended above are effective in keeping out droplets between a sick family member and healthy family member, why are the same face masks ineffective in public spaces where there might be infected individuals who are not wearing face masks? Does wearing a face mask protect healthy individuals in close proximity in public spaces at least to some extent? Is not wearing a face mask at all in public spaces beneficial than wearing one? These are questions that the general population likely have and should have clear answers to.
Currently, there is no known effective approach to prevent such type of transmission to healthy individuals other than to assume that asymptomatic, pre-symptomatic or symptomatic individuals who have not yet been medically diagnosed follow recommended precautionary methods such as hand hygiene, cough and sneeze etiquette, and wearing a face mask. It is important to note here that asymptomatic, pre-symptomatic or symptomatic individuals who have not been medically diagnosed are impossible to distinguish from one another in terms of whether they carry COVID–19 and a risk of spreading the virus in public spaces. To be unsure of how to prevent the above type of transmission is dangerous during an outbreak like COVID–19.
As demonstrated in the above information, the evidence behind recommendations provided regarding face mask use to those who are not medically diagnosed with COVID–19 is unclear and inconsistent, bringing uncertainty around the current recommendations. Further scientific research on face mask use is imperative to answer the above questions and concerns to resolve the controversy and lack of clarity around face mask use and to provide evidence-based public health recommendations on whether to wear or not to wear face masks among different populations amid a fast-spreading outbreak like COVID–19.
Providing public health recommendations on the use of face masks in the absence of evidence
When providing public health recommendations relating to a novel virus in the absence of evidence, there are important things to keep in mind. To answer the concerns associated with the use of face masks, public health and health professionals must question if the potential risks associated with wearing face masks incorrectly outweigh the potential benefits of wearing face masks correctly when followed by other precautionary practices. Potential risks of face mask use as identified by public health and health professionals include: increased possibility of spreading germs due to the misuse of face masks such as touching the outside of the face masks and retouching underneath the face mask to touch the face; increased likelihood of people touching their own faces because of the face masks, for example to adjust the masks; establishment of a false sense of security among those who wear face masks; and ineffectiveness due to unfitting of face masks especially among children and those with facial hair. [17] [1] [2] [3] [9] [18] In the case where potential benefits of wearing face masks appropriately cannot be outweighed against the risks of wearing face masks, taking actions to eliminate potential risks associated with wearing face masks may be a safer approach rather than recommending the public not to wear a face mask at all.
Furthermore, when providing recommendations to the public about the use of face masks to limit the transmission of COVID–19, it is important to give special consideration to vulnerable populations and those who are often around these vulnerable populations such as individuals in the community who have immunocompromised family members. People with pre-existing conditions such as cancer, diabetes, heart disease and renal or chronic lung disease appear to be more vulnerable to becoming severely ill with COVID–19 directly or through a family member. [19] [20] It may be best to err on the side of caution when making recommendations to the public regarding face mask use in the absence of evidence to reduce the risk of potential transmission to the most vulnerable populations.
Evidence and knowledge transparency of public health recommendations with the public
Transparency during a health emergency is extremely important because information plays an important role in maintaining core public health objectives. [21] During a situation where the public is at risk of a real or potential health threat, there might be delays in obtaining treatment options, interventions may be lengthy and there may be limited resources available. [21] Public recommendations and guidelines, therefore, is the most important tool available in managing a risk during an outbreak. [21] According to public health professionals, providing proactive guidelines and having transparency is an organizational responsibility and it is also the most successful method to grasp a control of public discourse, media reports and customer relations related to the situation. [21] Scholars in the field of Public Health Ethics and Pandemic Influenza Planning have also emphasized the importance of transparency in managing infectious disease outbreaks. [21][22] During an infectious disease outbreak, transparency provides the right information needed to survive the emergency. [21] [23] [24] Transparency is also an important component of procedural fairness in decision-making and priority setting during an outbreak. [21] [23] [24] Scholars state that “transparency is also a necessary, if not sufficient, condition for accountable decision-making and for the promotion of public trust.” [21] Transparency about the unknown and the known are both equally important to build and promote public trust. [21]
Therefore, in the case of the COVID–19 outbreak, whether recommendations are provided in the absence of evidence or whether they are evidence-based must be transparent to the public. Where there is evidence transparency, the public is more likely to understand what scientific evidence recommendations are based on and therefore, be more confident in adhering to recommendations. For example, in the case of medical professionals’ request to halt the hoarding of face masks among the public, merely saying “masks do not help” has not been helpful in preventing the public from continuing to buy face masks, perhaps unnecessarily. [25] [26] With scientific evidence of their ineffectiveness in limiting the spread of COVID–19 among those who are not medically diagnosed with COVID–19, public health and health professionals can be consistent and confident when recommending the public not to buy face masks and as a result avoid situations such as running out of face masks for healthcare workers.
Some of the recommendations provided to the public suggest that the incorrect use of face masks may have potential risks as discussed earlier. These potential risks can be minimized by educating the public about the risks and how to correctly use face masks to prevent the risks. A common concern brought up in current recommendations is about the false sense of security that face masks may bring to those who use them. [17] [2] [3] A false sense of security is the feeling of being safer than one really is. [27] In the context of COVID–19 and face mask use, a false sense of security means that the individuals may feel that they are safe from contracting COVID–19 because they are wearing face masks while that may not be the case. In the case of such concern, the public must be educated about the “false sense of security” that wearing a face mask may bring to individuals and how it may contribute to the increased risks associated with wearing face masks or neglecting other precautionary actions. Some recommendations emphasize that other precautionary methods are more important than wearing a face mask while some suggest face masks are only effective in combination with other precautionary practices. [2] [9] All of the above information must be shared effectively with the public through reliable media when making public health recommendations. It is imperative to be transparent with the public about the current evidence and knowledge public health recommendations are based on in order to successfully achieve the goals behind the recommendations.
Global alignment on public health recommendations
Public health recommendations must align globally. Varying recommendations can have a negative effect on countries around the world, especially in developing countries. In some developing countries, there is a severe lack of dissemination of credible information to the public as well as a concerning lack of knowledge among the general population to be able to identify and distinguish credible information from noncredible information. In these populations, most people tend to trust what is typically seen on social media or other online platforms. For example, a consult physician in Sri Lanka says that, “containing the panic and dissemination of misinformation has proved tougher than fighting the actual disease [COVID–19].” [28] [29]
In the case of face mask use, when people in developing countries observe on online platforms, a wide use of face masks to limit the spread of COVID–19 or recommendations advising the use of face masks, they may be likely to follow these recommendations without questioning the evidence behind the practices or recommendations. This may be the case especially when recommendations are coming from sources from developed countries. Some people may assume that the practices are evidence-based because they are coming from developed countries. Influenced by what they see on online platforms, the public of countries around the world may assume that merely wearing face masks will protect them from contracting COVID–19. Similarly, if there are recommendations to not wear face masks, those recommendations might also be followed without taking into consideration other advice that should follow along such as practicing hand hygiene and respiratory hygiene.
In developing countries with less advanced health care systems, confusion due to varying recommendations can lead to having a worse negative impact on their population as well as healthcare systems. Considering these factors, global alignment on public health recommendations and decisions among public health professionals and entities is crucial when proving recommendations amid an outbreak such as COVID–19.
Future research on face mask use
Further investigation into the effectiveness of face mask use among those who are not medically diagnosed with COVID–19 is important and timely for many reasons. If currently available face masks are not effective in limiting the spread of COVID–19 among this specific population or have significant limitations to its effectiveness, with advanced technology and innovations, further research can investigate novel approaches to invent and improve the efficiency of face masks to prevent the transmission of COVID–19 and other coronaviruses. While investigating into the effectiveness of face masks will be beneficial in limiting the spread of COVID–19, further research can open doors to investigating, understanding, and designing more advanced personal protective equipment (PPE) for situations where PPE may be required in community settings. Additional research can help identify and distinguish between the types of face masks that are best for different populations, and address possible stigma and existing cultural differences associated with face mask use. Moreover, information about the effectiveness of face masks will provide health professionals insight into whether there is a need to advise global manufacturers to increase the production of face masks, which addresses growing concerns such as face mask hoarding by the public, limited availability of face masks for healthcare workers, and the need for mandatory control over supply and price of face masks through legislation in countries that recommend the use of face masks to limit the spread of COVID–19. [30] [31] [32]
Although COVID–19 has not been declared as a pandemic yet (as of 25 Feb 2020), in case of a pandemic, knowing the effectiveness of masks ahead of time of the crisis would be extremely useful. While research surrounding the biology, epidemiology and behaviour of the new virus is extremely important and a priority at the moment, studying every method of prevention is equally important as prevention will not only provide the public with knowledge and instructions that they can rely on and confidently practice, but also save lives and reduce suffering and the expenditure of healthcare resources. This research is important, especially today because there is an immense use of face masks among the public around the world despite the uncertainty around the effectiveness of face masks. Such popular practices must be given immediate attention and studied thoroughly.
Limitations
The author had to use information outside of academic literature such as information from media outlets and newspapers (all cited) due to the lack of specific information in academic literature, such as public health recommendations provided to those who are not medically diagnosed with COVID–19 regarding face mask use. While this may be a limitation, sometimes it is imperative to use available information to bring attention to public health concerns. The systematic review search being limited to the English language is a limitation of this review. It is a possibility that there are research studies published in other languages that have not been translated to English and therefore, are not included in this review. This review being conducted by one reviewer might be a limitation as well, as having more than one reviewer may be advantageous.