Letter to the editors of the IJTLD encouraging the use of traditional cloth face covers to reduce transmission of COVID-19 in the absence of surgical masks.
To ensure that scientific research of immediate concern is shared as rapidly as possible, The Union is fast-tracking accepted articles from the International Journal of Tuberculosis and Lung Disease (IJTLD) and publishing them in full on our website, prior to their publication in the Journal. Find out more about submitting to the IJTLD.
This article was submitted on 3 April 2020 and accepted for publication on 9 April. Read the full text for more information, including the acknowledgments and citations.
Authors: S K. Jindal, A N. Aggarwal, DJ Christopher, R. Dhar, A. Jindal
We read with great interest a recent article in the Journal on the importance of wearing masks. Fortunately, the spread of COVID-19 in India has been limited to date, and although this could be partly attributed to a low testing rate, there are no reports of increased deaths in the community. As a high mortality rate is associated with COVID-19, it is safe to presume that the spread is not yet substantive.
One of the important factors responsible for this containment is the package of early and pre-emptive actions taken by the Government of India. In this article, we focus on cloth face covers as an important measure to prevent disease spread. With reference to COVID-19, a recent report from China revealed that a patient had infected five others while travelling in a vehicle without a face mask, whereas no one was infected in a second vehicle in which the patient travelled while wearing a mask. In countries such as mainland China and Hong Kong, mass masking by the community is considered an important step in preventing the spread of the virus. Use of face masks in both health care and public settings has been found to be useful and hence recommended. Mass masking in Hong Kong is reported to have caused a significant drop in the laboratory detection of influenza and all other respiratory viruses from respiratory specimens since early February.
While people in the community wear masks or other face coverings in the hope of protecting themselves, they also inadvertently reduce the spread of infection to others (at present, masks are recommended for the protection of others and not for self-protection). Masks prevent the release of the virus into the environment through coughing or sneezing by an infected person who has not been yet diagnosed, or is asymptomatic. The virus is detectable in respiratory specimens 1–2 days before people develop symptoms. There is some emerging evidence to suggest that the virus can remain airborne, and it is therefore important to contain their release. Mask wearing is now recommended by the US Centre for Disease Control.
A shortage of surgical masks has added to the health care burden in the midst of a pandemic. Fortunately, the filtration power of cloth masks has been shown to be almost comparable to surgical masks in protecting against viral or bacterial infections that may spread through larger cough droplets. Use of cloth masks by people in the community helps by redirecting the supply of disposable masks for use in healthcare settings. People in India have similar concerns to those elsewhere in the world, but in different countries and regions different forms of prevention are being adopted.
In this context, we would like to share the Indian perspective on the use of protective barriers (see Figure). Traditionally, middle age and elderly women in India tend to carry a loose piece of cloth, commonly called a ‘dupatta’, on their shoulders. Similarly, a saree is worn by a large number of women (especially by higher-risk elderly women) to cover the face against dust and microbes. The vast majority of men in rural areas also routinely wear turbans or shoulder cloths. The loose ends of these are used to cover the face whenever they enter a dusty environment. We now see people routinely using these types of protective clothing in the streets of India. Some even use their handkerchiefs as makeshift face masks. If the use of these items is reinforced as important infection control measures, and standards of cleanliness (including regular washing with detergents or soaps) could be taught as facilitating good health, this is likely to become an acceptable practice in the community.
It is difficult at present to comment upon the effectiveness of the use of face barriers. However, given the scarcity of N-95 and surgical masks (which should be spared for use by health care personnel who are at high-risk), the use of cloth masks or any alternate cover by the general public seems a practical health intervention. It is also a sustainable measure in support of the steps already undertaken by the government. This article is intended as a reminder to the community to use traditional face coverings for infection control in crowded places (such as markets, airports, railway stations, community congregations and during visits to health care settings). In effect, this is repurposing a traditional practice for a public health benefit. Nevertheless, it is important to stress that the effectiveness of such masking remains suboptimal for smaller particles like viruses. It should not instil a false sense of security and people should continue to practice other prevention strategies – remaining indoors, social distancing and hand hygiene.