Face masks in the covid-19 crisis: caveats, limits, and priorities

The ‘COVID-19 Pandemic’ continues to excite limitless ‘Discourse Possibilities’ related to different aspects of the ‘Coronavirus (SARS-CoV-2)’, ‘Coronavirus Disease 2019 (COVID-19)’ and numerous relevant enlarging ‘Matters’ occasioned by the emergence of the ‘Unprecedented Devastating and Ravaging 21st Century Storm’ that mandates ‘Global Weathering Through’ [1]! With the ‘COVID-19 Pandemic Information and Biomedical Literature’ increasingly transmuting by the day, and with increasingly much less known with confidence and certainty about the ‘Pandemic’, much more can only be expected and ‘Contributed’ to the ‘Extant COVID-19 Pandemic Face Masks Use Conversation’ as a ‘Daily Given and Taken’! Several ‘COVID-19 Pandemic Matters’ have been disposed at various times by various Authors and Authorities relating to different aspects of the ‘COVID-19 Pandemic’ and include the ‘Science, Politics and Controversies’ concerning, but not limited to, the Coronavirus Origin, Coronavirus Nomenclature, Coronavirus Disease Nomenclature, Appropriateness and Timeliness of the Pandemic Declaration etc! Others are the Pandemic Analytics-Diagnostics-Therapeutics-Holistics, Proactive and Reactive Interventions, Havoc Wreaked and Potential Benefits etc!!

This ‘Communication’ focuses on ‘Face Masks Use’ as part of the ‘Non-Pharmaceutical Interventions (NPIs)’ and is necessitated by a recent Article on ‘COVID-19 Face Mask Use’ [2]! The ‘Non-Pharmaceutical Interventions (NPIs)’ are the ‘Interventions that Work’ with certainty in the ‘Global Fight’ against the ‘COVID-19 Pandemic’ and the ‘Invisible Enemy’ and include, but not limited to: Social Distancing, Social Solidarity, Self-Isolation, Economic Shutdown, Mass Gatherings Restrictions, Schools Shutdown, Public Worship Prohibition, Travel Lockdown, Country Shutdown and Universal and Specific Precautionary Measures. The ‘Global Precautionary Measures’ include, among numerous others: Appropriate Hand-washing Techniques/ Hand Hygiene/ Proper Hand Sanitizer Use, Good Respiratory Hygiene, Avoiding and Frequently Cleaning Surfaces that are Frequently Touched, Avoiding Touching Eyes, Nose and Mouth! Ironically, it is these ‘Non-Pharmaceutical Interventions (NPIs)’ that are proven to be effective that are minimally ‘Researched’ to harvest ‘Evidence-based Data/ Information’ to assure the desired ‘Populace Compliance’ for effectively addressing the ‘Ravaging Pandemic’ [3,4]!! Incidentally also, the NPIs are the ‘Pandemic Interventions’ that are ‘Programmatically Poorly Funded’ with bothersome ‘Disproportionate Resource Allocation’ to the ‘Questionable Interventions’: Anti-COVID-19 Drugs, Antibodies Formulations, Vaccines/ Vaccines in Clinical Trials, Emergency Critical Care Facilities etc; This has been regarded as ‘Interventional Inequity’ [5]! It has also been argued that this, in fact, is a veritable amplification of the ‘Inverse Equity Hypothesis’ [6]!! Therefore, the ‘COVID-19 Pandemic Literature’ is bereft of ‘Quality Research Data’ on ‘COVID-19 Pandemic and Face Masks Use’!!!

The questionable ‘Role’ or ‘Relevance’ of ‘Face Masks Use’ in the ‘COVID-19 Pandemic’ stems from the ‘SARS-CoV-2 Aerosolization Controversy’ and, indeed, the place of ‘Aerosols/ Airborne Transmission’ in the ‘Pandemic Transmission Equation’ [7-9]! The ‘Global Health Authorities’ had an ‘Unconvincing Position and Pronouncement’ on ‘COVID-19 Pandemic and Airborne Transmission’ at the outset and, therefore, the ‘Convincing Role’ of ‘Face Masks Use’ as a ‘Non-Pharmaceutical Intervention (NPI)’ in the ‘Global Fight’ against ‘COVID-19 Pandemic’ was in a flux!! Several ‘Raging Face Masks Use Conversations’, and perhaps ‘Controversies’, are related to, among others: Who should use the Masks, When the Masks should be used, Type of Masks to be used, How the Masks should be used, Where the Masks should be used, Why the Masks should be used etc! The ‘Face Masks Medical Technicalities and Specifications/ Specifics’ re: Ratings/ Standards and Specifications, Oil Resistance, Filtration Effectiveness, Valved/ Non-Valved, Intermediate Melt-blown Fabric, the Country Rating/Standard (N95, 99, 100 in America, FFP1, 2, 3 in Europe, KN95, 99, 100 in China) etc also require critical discourse [7-10]!! The ‘Global Politics’, beyond the Science, Facts and Evidence of ‘Face Masks Use’ is another ‘Matter’ not ventilated in this ‘Focused Communication’! The distinction between ‘Masks’ and ‘Respirators’ disposes yet another discourse for yet some other auspicious time!!

In the absence of convincing ‘Evidence-based Disposition’, ‘Precaution and Pragmatism’ have been advised by the Association of Schools of Public Health in the European Region in its Report launched on the 24th April 20202, [11]. The ‘Non-Medical Grade ‘Social’ Mask’ MUST be used ONLY as one of other ‘Non-Pharmaceutical Interventions (NPIs)’. The ‘Non-Medical Face Masks’ are only advised for ‘General Public Use’ to avoid ‘Critical Shortages’ among ‘Frontline Health Workforce’ in the ‘Global Fight’ against the ‘COVID-19 Pandemic’ [12]! Globally, ‘Critical Care Capacities’ and the ‘Available Functional and Effective Personal Protective Equipment (PPEs)’ are reportedly overwhelmed by the ‘Raging and Ravaging Devastating Pandemic’ and, therefore, ONLY ‘Non-Medical Face Masks’ should be made available for ‘General Public Use’!! The ‘Role’ of the ‘Non-Medical Face Masks Use’ has also been rationalized for the ‘Different Phases’ of the ‘COVID-19 Epidemic Curve’: Before Community Transmission, Epidemic Growth Phase, End of Sustained Transmission, Gradual Easing of Country Lockdown, Return to Economic Activities with dangerous ‘Social Mixing’ etc2!! There is limited ‘Quality COVID-19 Research’ on ‘Face Masks Use’ [3,4] but what is even more disturbing are the ‘Questionable Research Questions’ in some of the ‘Available Studies’: ‘Protection of Mask User’ or ‘The Exposed Public’ [13]! The ‘Role’ and ‘Relevance’ of ‘Face Masks Use’ still need to be further investigated in the ‘Unresolved COVID-19 Pandemic Issues’: Pre-Symptomatic and Asymptomatic Transmissions, Prolonged Viral Excretion Before, During and After Illness and Possible Re-Infection/ Re-Activation [14]!!

The ‘COVID-19 Infodemic’ is another ‘Ravaging Phenomenon’ that MUST be addressed in the ‘Extant Face Masks Use Conversation’. There is a dearth of ‘Quality Researched Data/ Information’ on ‘Non-Pharmaceutical Interventions (NPIs)’, including ‘Face Masks Use’, and since ‘Nature Abhors Vacuum’, there will be an intervening ‘Avalanche/ Deluge of Destructive or Dangerous Information’ with resultant ‘Infodemic’: Misinformation, Disinformation, Myths, Memes, Rumours, Unscientific Claims, Misleading Communication, Inappropriately Contextualized Concepts, Politically-influenced Information, ‘Conspiracy Theories’, Information Toxicity, Downplayed Information etc!! This will continue to influence ‘Effective Face Masks Use’!!

This ‘Communication’ is a ‘Contribution’ to the extant ‘Face Masks Use Conversation’ which is, thus far, part of the ‘Poorly Researched’ useful reliable ‘Interventions that Work’: ‘Non-Pharmaceutical Interventions (NPIs)’! There is so much ‘Unknown and Uncertain’ with ‘Face Masks Use’ in the ‘Global Fight’ against ‘COVID-19 Pandemic’ as there is, in fact, increasingly much more that is ‘Rapidly Dynamically Transmuting and Unknown’ about the ‘Pandemic’!!

REFERENCES
1. Godlee F. COVID-19: Weathering the storm. BMJ 2020; 368:m1199 of 26th March 2020
2. Middleton JD, Lopes H. Face masks in the covid-19 crisis: caveats, limits and priorities. BMJ 2020; 369:m2030
3. Clinical Trials.gov. History of changes for study. NCT04280705, 1 May 2020. https://clinicaltrials.gov/ct2/history/NCT04280705?A=10&B=15&C=Side-by-S.... Clinical Trials.gov. History of changes for study. NCT04280705, 1 May 2020. https://clinicaltrials.gov/ct2/history/NCT04280705?A=10&B=15&C=Side-by-S....
4. Glasziou PP, Sanders S, Hoffmann T. Waste in covid-19 research. BMJ 2020; 369:m1847
5. Eregie C.O. Obesity as a Public Health Emergency: A look at the ‘Pre-FOAD Hypothesis’ as a Panacea for the ‘Interventional Inequity. https://www.bmj.com/content/366/bmj.l5463/rr-0 of 4th October 2019
6. Eregie CO. COVID-19 Pandemic: The multifaceted picture of compromised COVID-19 research and the COVID Phenomenon’. https://www.bmj.com/content/369/bmj.m1847/rr-12 of 10th June 2020
7. Wetsman N. CDC recommends people wear cloth masks to block the spread of COVID-19. The Verge of 3rd April 2020
8. Eregie C.O. COVID-19 Pandemic: Further perspectives on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-16 of 5th April 2020
9. WebMD. Coronavirus Face Masks: What You Should Know. https://www.webmd.com/lung/coronavirus-face-masks of 18th May 2020
10. Krstic Z. Coronavirus and Face Masks: Everything You Need to Know This Summer. https://www.goodhousekeeping.com/health/a32703820/coronavirus-face-mask-... of 10th June 2020
11. Association of Schools of Public Health in the European Region. Strategic use of masks as an element of non-pharmaceutical measures set for a pandemic. 24 Apr 2020. https://www.aspher.org/download/412/strategic_use_of_masks_as_an_element...
12. Centers for Disease Control and Prevention. Use of cloth face coverings to help slow the spread of covid-19. https://cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-fac...
13. Nuki P. Face masks: have we been asking the wrong questions all along? Daily Telegraph 2020 Apr 16. https://www.telegraph.co.uk/global-health/science-and-disease/face-masks...
14. Day M. Covid-19: four fifths of cases are asymptomatic, China figures indicate. BMJ 2020; 369:m1375

Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria.
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria.
*No Competing Interests.