Contain your Cough: #Masks4All in South Africa

A collaboration of public health and infection prevention doctors of TB Proof and Public Health Action Team started a Masks4All campaign arguing for homemade facemasks as a potentially powerful tool to the fight against COVID-19. Here they explain why.

Homemade facemasks will reduce the chances of you spreading COVID-19 to others, may reduce your risk of contracting the disease, and will keep surgical masks and respirators where they belong – in health facilities. It is important to emphasise that the homemade cloth mask is an addition, not a replacement, to our existing toolkit of public health strategies to “flatten the curve”.

These tools include: Staying at home; Keeping a two meter physical distance from others; Regular hand washing for at least twenty seconds; Avoid touching your face; Sanitising surfaces; and Wide-spread screening, Testing and Intensive contact tracing for COVID-19. A key element has been missing, but hopefully not for long. A growing number of health workers, researchers, activists, civil society organisations and citizens in South Africa are joining the global call for #Masks4All.

A rapidly changing world and rapidly changing research

The COVID-19 pandemic has caught the world and South Africa off guard. What started out as a seemingly mild disease in a distant land, has become a formidable threat to our health system, our economy, our societies and every South African. As the pandemic exponentially changed gears, opinions and evidence about the disease and how to control it have shifted too. This has been complex for decision makers, as ‘evidence-based’ statements made confidently one day, turned out to be less clear or even incorrect the next. This is not due to poor decision-making, but reflects the rapid influx of new and changing information. What usually takes years, is happening in days. Some of the sweeping interventions implemented in South Africa seemed unthinkable just weeks before. Closing borders, restricting movement, closing schools and business and physical distancing have all been instituted based-on expert opinion, learning from other countries, or rapidly developed scientific models.

Public mask use has been a specific bone of contention. Countries like China, Hong-Kong, Korea, Japan and very recently the Czech Republic, are advocating for widespread mask use in the general population, and others have given exactly the opposite advice. Many, like the United States, are at a point where they are reconsidering their recommendation. This has been further complicated by the impact of the general public stockpiling masks, contributing to severe shortages for healthcare workers on the frontline of combating this pandemic.

Health facilities have the greatest need for masks

In health facilities across South Africa, health workers depend on N95 respirators, surgical masks, goggles and gloves to keep them safe at work, not only from COVID-19, but also from diseases like tuberculosis (TB) and HIV. There is a critical global shortage of protective equipment, which means all N95 respirators and surgical masks should be reserved for use in healthcare settings. We are heartened to see organisations and individuals donating any stock they have to their nearest health facility and strongly encourage more people to do the same.

But what about everybody else?

When looking at mask use in public it is important to consider two perspectives. Firstly, as a healthy member of the public, does wearing a mask decrease my risk of becoming infected? Secondly, as somebody who may already be infected (even if I don’t know it), does a mask help me to prevent spreading my infection to others?

Considering the first instance, the research is limited, but masks appear to be helpful if you are in very close contact with someone who is infectious. When the roles are reversed, the evidence is much stronger. Hence the #Masks4All slogan: I protect you, you protect me. Wearing a mask reduces the spread of infectious droplets, especially when someone coughs or sneezes, for diseases like COVID-19, influenza and TB. The WHO and other experts are in agreement, and advise anyone with respiratory symptoms to wear a mask. However, a growing body of evidence suggests that nearly half of people with SARS-CoV-2 (i.e. the virus that causes COVID-19 disease) do not have symptoms. In China and Singapore they have shown between 6.4 – 12.6% of people who developed COVID-19, were infected by someone who did not show any symptoms.

The risk of asymptomatically and unknowingly spreading COVID-19 is the main reason for considering public mask wearing. If we ask South Africans to wear masks in public, they can protect each other. This is in keeping with the principle of physical distancing, where everyone considers themselves infectious and behaves in a manner aimed at reducing the spread of the disease. Masks can help us protect each other, when visiting the grocery store, taking a sick relative for healthcare, collecting a social grant, or using public transport.

Furthermore, masks in South Africa would have added benefits. We are facing a concurrent major health crisis, TB, which is our leading cause of death. The COVID-19 pandemic is predicted to have a very negative impact on TB prevention and care. This may lead to increased deaths, with TB patients, whether cured or currently under treatment, having an increased risk of severe COVID-19 disease. There is evidence that surgical masks help reduce the spread of TB by 56% if worn by somebody with symptoms. We will take any additional help we can get to curb our TB epidemic.

Another potential benefit of encouraging widespread community mask use is that it could destigmatize mask wearing in countries like South Africa, where masks are commonly associated with feared illnesses like drug-resistant TB. This may encourage people who have symptoms of any respiratory illness, to wear a mask in public. This is based on TB Proof’s experience with past #UnmaskStigma campaigns and echoed by global public health experts: “If everyone wears a mask, no stigma is attached.”

We have made the argument that masks are important for health workers and could also help the public to limit symptomatic and asymptomatic spread, but we currently have a global shortage. So, where does this leave us?

Homemade masks as a compromise

Homemade masks have been suggested as a pragmatic alternative to scarce medical masks for members of the public, but what does the evidence say about them? In short – they are not as effective as surgical masks – but cloth masks can protect others by reducing the spread of contagious droplets from infected individuals to uninfected people.

 Studies tested cloth masks in comparison to surgical masks in healthy volunteers to see whether they help to capture infectious droplets. They concluded that:

• “Any type of general mask use is likely to decrease viral exposure and infection risk on a population level, in spite of imperfect fit and imperfect adherence”
• “A hand-fashioned mask can provide a good fit and a measurable level of protection”
• “A homemade mask …would be better than no protection”

Only one randomized control trial (one of the most authoritative forms of evidence) has been done comparing cloth masks to surgical masks and this has found that surgical masks are superior to cloth masks in a healthcare setting to protect healthcare workers. Some experts have pointed to this finding to advise against the use of cloth masks by the public, but this is missing the point. Compared to no masks at all, cloth masks are the better option. This is in a context where the public are being urged to wear masks on public transport. If we want to keep healthcare supplies from being used outside of healthcare facilities where they are essential equipment, we need to provide the public with the best possible alternative. The details around how to make cloth masks safely remain very important. Thankfully there are numerous guides available to help members of the public, including information on designs, safe use and appropriate cleaning.

This is something you can do

Our Minister of Health, Dr Zweli Mkhize, has endorsed the use of masks for people who have a cough, or in situations where physical distancing is difficult. While this is a step in the right direction, it does not highlight the importance of considering everybody as potentially infectious, and the subsequent need for masks for all.

Fortunately an about-face is upon us. TB Proof and PHACT are leading a Position Statement calling on President Ramaphosa to commit to #Masks4All. It has already been signed by twelve leading health and civil society organisations and numerous individuals, committing to help make alternative masks and protect scarce healthcare resources. On 2 April, in response to growing evidence, the Western Cape became the first province to recommend the use of cloth masks for the general public.

We call on South Africa’s National Coronavirus Command Council to:

1. Help mobilise South Africa through publicly encouraging our creative and resourceful citizens to make and share cloth masks on a mass scale.
2. Provide technical guidance on the best materials and designs for making masks at home or places of work or learning.
3. Use existing communication platforms for widespread public education on correct and safe use.
4. Lead by example and appear in public wearing a cloth mask.
5. Take all steps necessary to ensure healthcare settings are safe for all, including uninterrupted access to N95 respirators and surgical masks for health workers.

And we call on all South Africans to join the global #Masks4All movement, because if I protect you, you protect me.

Authored by Dr Helene-Mari van der Westhuizen (TB Proof), Dr Nathan Green (PHACT), Dr Atiya Mosam (PHACT), Dr Dirk von Delft (TB Proof), Dr Jesse L Werner (PHACT) and Dr Arne von Delft (TB Proof)