Indan Journal of Medical Research Indan Journal of Medical Research Indan Journal of Medical Research
  Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login  
  Home Print this page Email this page Small font sizeDefault font sizeIncrease font size Users Online: 2794       

   Table of Contents      
PERSPECTIVE
Year : 2021  |  Volume : 153  |  Issue : 1  |  Page : 233-237

Face mask - An essential armour in the fight of India against COVID-19


1 ICMR-National AIDS Research Institute, Pune 411 026, Maharashtra; Division of Epidemiology and Communicable Diseases, New Delhi 110 029, India
2 Public Health Foundation of India, New Delhi 110 017, India
3 Public Health Foundation of India, New Delhi 110 017; Indian Council of Medical Research (ICMR), New Delhi 110 029, India
4 Department of Health Research (ICMR), Ministry of Health & Family Welfare, New Delhi 110 001, India

Date of Submission19-Nov-2020
Date of Web Publication26-Mar-2021

Correspondence Address:
Balram Bhargava
Department of Health Research (ICMR), Ministry of Health & Family Welfare, New Delhi 110 001
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_4486_20

Rights and Permissions

How to cite this article:
Panda S, Kaur H, Dandona L, Bhargava B. Face mask - An essential armour in the fight of India against COVID-19. Indian J Med Res 2021;153:233-7

How to cite this URL:
Panda S, Kaur H, Dandona L, Bhargava B. Face mask - An essential armour in the fight of India against COVID-19. Indian J Med Res [serial online] 2021 [cited 2021 Apr 18];153:233-7. Available from: https://www.ijmr.org.in/text.asp?2021/153/1/233/308604

Face masks, in the last year or so, have covered a space in public discussion and political debate, which is larger than ever before. To use or not to use and what is an appropriate situation to use face masks constitute some of these discourses. This renewed focus on face masks has come about with the advent of COVID-19. Respiratory infections occur through the transmission of microorganism-containing droplets (>5-10 μm) and aerosols (≤5 μm) exhaled from infected individuals during breathing, speaking, coughing and sneezing, the risk of which can be reduced by wearing face mask[1].

The use of face masks at the community level for disease prevention can be traced back to the time of the Manchurian plague (1910-1911)[2]. During this epidemic, the team working on the containment of the disease, suspected airborne transmission of this pneumonic plague and encouraged people to wear gauze masks in addition to quarantining the patients[2]. A few years later, during the 1918 influenza pandemic, inappropriately popularized as Spanish flu, the use of multilayered gauge masks was touted as a prevention tool in Western countries. Unfortunately, the subpar quality and to some extent public reluctance towards using masks were responsible for its poor impact[3],[4]. Almost a century later, with new discoveries and advancements in knowledge of infectious diseases, face masks became the first line of defence against severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS) and now the COVID-19 outbreak caused by the novel coronavirus SARS-CoV-2[1],[5],[6].

In the early days of the COVID-19 pandemic, there were many unknowns about the transmission mode of the virus. Despite this, the East Asian countries such as Hong Kong, Taiwan and South Korea swiftly enhanced wearing of face masks in public places[7],[8],[9]. This behaviour stems from their previous encounters with the epidemics of coronaviruses[10]. Contrastingly, in the West, initial hesitation from some of the government officials to implement mask mandates was associated with a relatively rapid spread of SARS-CoV-2[11],[12]. A study in the United States noted that if face masks were nationally mandated for employees on March 14, 2020, perhaps 19,000-47,000 lives could have been saved by the end of May[13]. A study in Canada estimated a reduction of 25 per cent in weekly COVID-19 cases with mask mandates, and a study in Germany suggested a 40 per cent reduction in daily growth rate of COVID-19 cases with masks[14],[15].

In India, early advisories related to travel restrictions following the first detection of COVID-19 on January 30, 2020, measures such as screening at the international airports for travellers coming from abroad, flight restrictions, as well as national lockdown since March 24, prevented the COVID-19 numbers from rising rapidly. Subsequently, the use of face masks was encouraged in public. Worth noting against this background is the national serological survey (second round) conducted by the Indian Council of Medical Research across several States, finding only seven per cent of the adult population with antibodies against COVID-19 by mid-September 2020[16], while a similar survey in May-June 2020 identified 0.7 per cent seroprevalence[17]. This indicated that a large proportion of the population was yet unexposed and susceptible to the virus. A preliminary analysis of data generated by the third round of the national serological survey, completed in early-January 2021, further indicates that the infection has so far not spread beyond one-fourth of the population and therefore we are far from herd immunity at this stage (unpublished data).

In response to the aforementioned evidence, and in order to keep COVID-19 numbers in check in the festive and winter season, the Government of India launched a Jan Andolan campaign to provide targeted nudges via posters and billboards at public places or public service announcements on media platforms. The purpose is to prompt the population towards 'COVID-19 appropriate behaviour'[18]. Promoting mask use behaviour is one of the key components of this public health response.

Wearing a mask is not an alternative to physical distancing and hand hygiene, but it is most valuable in scenarios where physical distancing is challenging. Face masks limit the spread of infectious respiratory droplets into the environment. There are three types of face masks available in the market: (i) COVID-19 - cloth masks, (ii) medical masks, and (iii) respirator masks (N95 and N99). The World Health Organization (WHO) recommends cloth masks for general public use, and medical or respirator masks for people at high risk of COVID-19, those with COVID-19 and healthcare workers[19].

Cloth masks block the exhalation of coarse particles and limit the spread of the smaller particles[20],[21]. The filtration efficacy of multilayered cloth masks is 50-70 per cent for respiratory aerosol particles[22],[23]. Effectiveness of cloth mask depends on various factors such as fabric material, number of layers and the fit of the mask. A multilayered cloth mask with at least three layers and a high thread count is preferred[24]. Cotton blend or other hybrid materials, such as cotton silk or cotton chiffon, are recommended as these have higher filtration than pure cotton[25],[26]. The outer layer of the mask should be of highly hydrophobic material, such as polyester or cotton-polyester blend, to repel the droplets from the environment. The middle layer should also be hydrophobic preferably of non-woven polypropylene fabric, but the inner layer should be hydrophilic to absorb the droplets coming out of the mouth and nose[27]. Medical masks cover the mouth and nose with a three-layered non-woven material. Medical masks without gap can filter 99 per cent particles larger than 0.3 μm and 75 per cent particles smaller than 0.3 μm[26]. N95 and N99 respirator masks are relatively more effective in filtration than the cloth and medical masks. N95 masks without gap can filter 99.9 per cent particles larger than 0.3 μm and 85 per cent particles smaller than 0.3 μm[26].

Strategies to extend the use and reuse of masks depend upon the mask type. Cloth masks are to be washed daily or immediately after use with soap and warm water[6],[28]. Medical masks are generally single use, whereas respirator masks can be cautiously reused after reprocessing during a critical shortage in healthcare facilities. Vaporized hydrogen peroxide is a relatively reliable and efficient method for decontamination in resource constraint settings, but there are other methods also available such as dry heat pasteurization, ultraviolet irradiation and moist heat[29],[30],[31]. Further, a relevant point to consider is that the increased use of disposable masks during the COVID-19 pandemic is leading to environmental challenges due to irresponsible dumping[32].

Poor air quality has been linked with increased risk of COVID-19 cases. Under stable atmospheric conditions, particulate matters agglomerate with SARS-CoV-2 increasing its permanence and contagiousness in the environment as it travels longer distances[33]. A few preliminary studies have reported that people with long-term exposure to air pollution are at risk for higher severity and mortality from COVID-19[34],[35],[36],[37]. This is worrisome in the Indian context. The India State-Level Disease Burden Initiative has reported high ambient pollution levels across India, with the annual mean particulate matter <2.5 μm in size levels more than three times the recommended limit of

40 μg/m[3] in several States in north India [Figure 1][38]. Cloth or medical masks are not adequate to protect against air pollution; neither do these provide protection against edge-seal leakage[39]. N95 or N99 respirator masks are more effective for protection against air pollution[40], and the associated higher risk of COVID-19. Caution is however, necessary to ensure the quality of face masks if these have to serve their intended purpose well.
Figure 1. Annual mean ambient particulate matter <2.5 μm in size concentration levels in the States of India, 2019. Source: Adapted in part from Ref. 38 in accordance with the Creative Commons License (https://s100.copyright.com/AppDispatchServlet?publisherName=ELS&contentID=S2542519620302989&orderBeanReset=true&orderSource=Phoenix).

Click here to view


It is important to ensure the appropriate use of face mask for it to be effective. A recent survey noted that only 44 per cent of Indians were wearing it properly in compliance with the guidelines. Discomfort and difficulty in breathing were the commonly reported barriers against the use of face mask[41]. There are ways to improve the comfort of the wearer and mechanisms to avoid breathing difficulty, which could be shared with the public more broadly using appropriate mass communication strategies[42]. A face mask of adequate quality can be used while exercising in places with risk of transmission of respiratory organisms, without any drop in oxygen saturation of the blood[43]. It is also important to note that mask use is not recommended in children under two years, in individuals with disabilities such as cerebral palsy and in those not able to remove the mask without assistance[44].

In conclusion, it is important to appreciate that diligent face mask use is a crucial component of the set of public health interventions, components of which together build multiple layers of barriers between individuals infected with SARS-CoV-2 and those who are susceptible. Widespread use of face masks coupled with hand hygiene and physical distancing has been found to increase the odds of SARS-CoV-2 transmission control. However, self-reported face mask use has been reported to have increased in some parts of the world separate from government mandates, indicating that supplemental public health interventions are needed to maximize this behavioural change[45]. In addition to limiting the spread of infectious respiratory droplets into the environment, face masks are affordable, easy to use and practical where physical distancing appears difficult. A local train or a public bus commuting with daily office-goers within and between cities on a typical day in India is the case in consideration here. In situations of mass religious gatherings such Kumbh mela or Haj transit stations, wearing face masks would be very useful, but this could be challenging to implement so other preventive measures such as vaccination should also be emphasized in these situations. In addition, face masks also reduce the transmission of other respiratory infections such as influenza and tuberculosis. However, using them is the key. Masks on faces could serve as reminders for others, especially in the current environment when people are experiencing prevention fatigue. People wearing masks thus could not only help in generating peer pressure but also serving as the agents for social change. It would therefore be ideal if every person living in India attempts to wear a proper face mask diligently in public places for now. Face masks are here to stay for some time, as even with the recent introduction of COVID-19 vaccines, the development of vaccine-induced herd immunity is going to take some time. Finally, it is important to recognize that although vaccinated individuals would have less risk of getting symptomatic SARS-CoV-2 disease, they may still be able to spread the virus to others and should therefore use face mask.

Conflicts of Interest: None.

 
   References Top

1.
Prather KA, Wang CC, Schooley RT. Reducing transmission of SARS-CoV-2. Science 2020; 368 : 1422-4.  Back to cited text no. 1
    
2.
Kool JL, Weinstein RA. Risk of person-to-person transmission of pneumonic plague. Clin Infect Dis 2005; 40 : 1166-72.  Back to cited text no. 2
    
3.
Kellogg WH, Macmillan G. An experimental study of the efficacy of gauze face masks. Am J Public Health (N Y) 1920; 10 : 34-42.  Back to cited text no. 3
    
4.
Vaughan WT. Influenza: An epidemiologic study. Available from: http://hdl.handle.net/2027/nnc2.ark:/13960/t6qz30017, accessed on December 5, 2020.  Back to cited text no. 4
    
5.
Cunha CB, Opal SM. Middle East respiratory syndrome (MERS). Virulence 2014; 5 : 650-4.  Back to cited text no. 5
    
6.
World Health Organization. Coronavirus disease (COVID-19): Masks. Available from: https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-masks, accessed on November 2, 2020.  Back to cited text no. 6
    
7.
Cheng VC, Wong SC, Chuang VW, So SY, Chen JH, Sridhar S, et al. The role of community-wide wearing of face mask for control of coronavirus disease 2019 (COVID-19) epidemic due to SARS-CoV-2. J Infect 2020; 81 : 107-14.  Back to cited text no. 7
    
8.
Penn M. How some Asian countries beat back COVID-19. Available from: https://globalhealth.duke.edu/news/how-some-asian-countries-beat-back-covid-19, accessed on November 4, 2020.  Back to cited text no. 8
    
9.
Jennings R. How cultural differences help Asian countries beat COVID-19, while US struggles. Available from: https://www.voanews.com/covid-19-pandemic/how-cultural-differences-help-asian-countries-beat-covid-19-while-us-struggles, accessed on November 4, 2020.  Back to cited text no. 9
    
10.
Mills M, Rahal C, Akimova E. Face masks and coverings for the general public. The Royal Society and British Academy; 2020. Available from: https://royalsociety.org/-/media/policy/projects/set-c/set-c-facemasks.pdf?la=en-GB&hash=A22A87CB28F7D6AD9BD93BBCBFC2BB24, accessed on November 4, 2020.  Back to cited text no. 10
    
11.
Cheung H. Coronavirus: Why attitudes to masks have changed around the world. BBC News; 13 July, 2020. Available from: https://www.bbc.com/news/world-53394525, accessed on November 4, 2020.  Back to cited text no. 11
    
12.
Leffler CT, Ing E, Lykins JD, Hogan MC, McKeown CA, Grzybowski A. Association of country-wide coronavirus mortality with demographics, testing, lockdowns, and public wearing of masks. Am J Trop Med Hyg 2020; 103 : 2400-11.  Back to cited text no. 12
    
13.
Chernozhukov V, Kasahara H, Schrimpf P. Causal impact of masks, policies, behavior on early COVID-19 pandemic in the U.S. J Econom 2021; 220 : 23-62.  Back to cited text no. 13
    
14.
Karaivanov A, Lu SE, Shigeoka H, Chen C, Pamplona S. Face masks, public policies and slowing the spread of COVID-19: Evidence from Canada. medRxiv 2020. doi: 10.1101/2020.09.24.20201178.  Back to cited text no. 14
    
15.
Mitze T, Kosfeld R, Rode J, Wälde K. Face masks considerably reduce COVID-19 cases in Germany: A synthetic control method approach. Bonn (Germany): Institute of Labor Economics; 2020. Available from: http://ftp.iza.org/dp13319.pdf, accessed on December 5, 2020.  Back to cited text no. 15
    
16.
Murhekar MV, Bhatnagar T, Selvaraju S, Kumar VS, Saravanakumar V, Vivian Thangaraj JW, Shah N, et al. SARS-CoV-2 antibody seroprevalence in India, August-September, 2020: Findings from the second nationwide household serosurvey. Lancet Glob Health 2021. doi: 10.1016/S2214-109X(20)30544-1.  Back to cited text no. 16
    
17.
Murhekar MV, Bhatnagar T, Selvaraju S, Rade K, Saravanakumar V, Vivian Thangaraj JW, et al. Prevalence of SARS-CoV-2 infection in India: Findings from the national serosurvey, May-June 2020. Indian J Med Res 2020; 152 : 48-60.  Back to cited text no. 17
    
18.
Press Information Bureau. Hon'ble Prime Minister to launch Jan Andolan for COVID-19 appropriate behaviour. Available from: http://Pib.gov.in/Pressreleaseshare.aspx?PRID=1662449, accessed on November 4, 2020.  Back to cited text no. 18
    
19.
World Health Organization. Mask use in the context of COVID-19: Interim guidance, 1 December, 2020. Geneva: WHO; 2020.  Back to cited text no. 19
    
20.
Bandiera L, Pavar G, Pisetta G, Otomo S, Mangano E, Seckl JR, et al. Face coverings and respiratory tract droplet dispersion. R Soc Open Sci 2020; 7 : 201663.  Back to cited text no. 20
    
21.
Bahl P, Bhattacharjee S, de Silva C, Chughtai AA, Doolan C, MacIntyre CR. Face coverings and mask to minimise droplet dispersion and aerosolisation: A video case study. Thorax 2020; 75 : 1024-5.  Back to cited text no. 21
    
22.
Lindsley WG, Blachere FM, Law BF, Beezhold DH, Noti JD. Efficacy of face masks, neck gaiters and face shields for reducing the expulsion of simulated cough-generated aerosols. Aerosol Sci Technol 2021. doi: 10.1080/02786826.2020.1862409.  Back to cited text no. 22
    
23.
Ueki H, Furusawa Y, Iwatsuki-Horimoto K, Imai M, Kabata H, Nishimura H, et al. Effectiveness of face masks in preventing airborne transmission of SARS-CoV-2. mSphere 2020; 5 : e00637-20.  Back to cited text no. 23
    
24.
Zangmeister CD, Radney JG, Vicenzi EP, Weaver JL. Filtration efficiencies of nanoscale aerosol by cloth mask materials used to slow the spread of SARS-CoV-2. ACS Nano 2020; 14 : 9188-200.  Back to cited text no. 24
    
25.
Aydin O, Emon B, Cheng S, Hong L, Chamorro LP, Saif MTA. Performance of fabrics for home-made masks against the spread of COVID-19 through droplets: A quantitative mechanistic study. Extreme Mech Lett 2020; 40 : 100924.  Back to cited text no. 25
    
26.
Konda A, Prakash A, Moss GA, Schmoldt M, Grant GD, Guha S. Aerosol filtration efficiency of common fabrics used in respiratory cloth masks. ACS Nano 2020; 14 : 6339-47.  Back to cited text no. 26
    
27.
Rawal A. Multi-layered masks to combat COVID-19. Indian J Med Res 2020; 152 : 9-11.  Back to cited text no. 27
    
28.
MacIntyre CR, Dung TC, Chughtai AA, Seale H, Rahman B. Contamination and washing of cloth masks and risk of infection among hospital health workers in Vietnam: A post hoc analysis of a randomised controlled trial. BMJ Open 2020; 10 : e042045.  Back to cited text no. 28
    
29.
World Health Organization. Rational use of personal protective equipment for COVID-19 and considerations during severe shortages; 2020. Available from: https://apps.who.int/iris/bitstream/handle/10665/338033/WHO-2019-nCoV-IPC_PPE_use-2020.4-eng.pdf, accessed on December 24, 2020.  Back to cited text no. 29
    
30.
Mackenzie D. Reuse of N95 Masks. Engineering (Beijing) 2020; 6 : 593-6.  Back to cited text no. 30
    
31.
Saini V, Sikri K, Batra SD, Kalra P, Gautam K. Development of a highly effective low-cost vaporized hydrogen peroxide-based method for disinfection of personal protective equipment for their selective reuse during pandemics. Gut Pathog 2020; 12 : 29.  Back to cited text no. 31
    
32.
Sangkham S. Face mask and medical waste disposal during the novel COVID-19 pandemic in Asia. Case Stud Chem Environ Eng 2020; 2 : 100052.  Back to cited text no. 32
    
33.
Tung NT, Cheng PC, Chi KH, Hsiao TC, Jones T, BéruBé K, et al. Particulate matter and SARS-CoV-2: A possible model of COVID-19 transmission. Sci Total Environ 2021; 750 : 141532.  Back to cited text no. 33
    
34.
Comunian S, Dongo D, Milani C, Palestini P. Air Pollution and COVID-19: The Role of Particulate Matter in the Spread and Increase of COVID-19's Morbidity and Mortality. Int J Environ Res Public Health 2020; 17 : 4487.  Back to cited text no. 34
    
35.
Coker ES, Cavalli L, Fabrizi E, Guastella G, Lippo E, Parisi ML, et al. The effects of air pollution on COVID-19 related mortality in Northern Italy. Environ Resour Econ (Dordr) 2020; 76 : 611-34.  Back to cited text no. 35
    
36.
Wu X, Nethery RC, Sabath BM, Braun D, Dominici F. Exposure to air pollution and COVID-19 mortality in the United States: A nationwide cross-sectional study. medRxiv 2020. doi: 10.1101/2020.04.05.20054502.  Back to cited text no. 36
    
37.
Yao Y, Pan J, Liu Z, Meng X, Wang W, Kan H, et al. Temporal association between particulate matter pollution and case fatality rate of COVID-19 in Wuhan. Environ Res 2020; 189 : 109941.  Back to cited text no. 37
    
38.
India State-Level Disease Burden Initiative Air Pollution Collaborators. Health and economic impact of air pollution in the states of India: The Global Burden of Disease Study 2019. Lancet Planet Health 2021; 5 : e25-38.  Back to cited text no. 38
    
39.
Cherrie JW, Apsley A, Cowie H, Steinle S, Mueller W, Lin C, et al. Effectiveness of face masks used to protect Beijing residents against particulate air pollution. Occup Environ Med 2018; 75 : 446-52.  Back to cited text no. 39
    
40.
Shakya KM, Noyes A, Kallin R, Peltier RE. Evaluating the efficacy of cloth facemasks in reducing particulate matter exposure. J Expo Sci Environ Epidemiol 2017; 27 : 352-7.  Back to cited text no. 40
    
41.
The Hindu. Only 44% wear mask correctly, shows survey; 15 September, 2020. Available from: https://www.thehindu.com/news/national/karnataka/only-44-wear-mask-correctly-shows-survey/article32614925.ece, accessed on December 5, 2020.  Back to cited text no. 41
    
42.
Harvard Health. Coping with face mask discomfort. Available from: https://www.health.harvard.edu/staying-healthy/coping-with-face-mask-discomfort, accessed on December 5, 2020.  Back to cited text no. 42
    
43.
Chan NC, Li K, Hirsh J. Peripheral oxygen saturation in older persons wearing nonmedical face masks in community settings. JAMA 2020; 324 : 2323-4.  Back to cited text no. 43
    
44.
Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). Available from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html, accessed on December 18, 2020.  Back to cited text no. 44
    
45.
Rader B, White LF, Burns MR, Chen J, Brilliant J, Cohen J, et al. Mask-wearing and control of SARS-CoV-2 transmission in the USA: A cross-sectional study. Lancet Digit Health 2021; S2589-7500(20)30293-4.  Back to cited text no. 45
    


    Figures

  [Figure 1]



 

Top
 
 
  Search
 
    Similar in PUBMED
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed840    
    Printed57    
    Emailed0    
    PDF Downloaded151    
    Comments [Add]    

Recommend this journal