The COVID-19 pandemic is now a major threat to global health and economy, the full impact of which is yet unknown. The case load and deaths are gradually mounting in India too, especially over these past weeks. These figures may have been substantially higher if the Government of India had not put in such stringent, pre-emptive containment measures. There is also a clear variation in how different states are handling the crisis, and that difference shows in the numbers of new cases and deaths occurring.
But this pandemic cannot be controlled by governments alone. It needs the participation and passion of all the people of India; and it needs clear, feasible measures that ordinary citizens can undertake to help reduce transmission. The lockdown has probably played a great role in flattening the epidemic curve thus far, but it cannot go on forever. It remains an experimental intervention not just for India, but for other countries as well.
Lack of clarity
With a lack of clarity on what the ultimate benefits would be, and what the implications will be when the lockdown is revoked. Any degree of relaxation could result in increase in the transmission, unless the epidemic weakens substantially, but there is no indication yet of the same. It is therefore important to explore sustainable methods of reducing community transmission.
Along with the well-accepted measures of physical distancing and frequent hand washing, the use of face masks or face covering is now emerging as a third pillar in community action — doable and low-cost.
The tide has turned since the beginning of epidemic, and even the CDC (USA) changed its position and has issued an updated set of guidelines advising the members of the general public to wear non-medical face covering outside their homes, whether or not they're sick.
Would a mass movement by the people of India to take this up on a large scale serve to actually reduce transmission pressure in the community?
Before understanding the role of masks in the spread of infection, it is important to understand the transmission dynamics of COVID-19 infection. Similar to influenza and other respiratory infections, the infection can be transmitted through droplets of different sizes, mostly 5-10 m in diameter.
Droplet transmission occurs when a person is in close contact (within 1 m) with someone who has respiratory symptoms (e.g., coughing, sneezing or even speaking), most commonly by inhalation.
Transmission could also occur through fomites in the immediate environment around the infected person. A fomite is an inanimate object that, when contaminated with or exposed to infectious agents (such as disease causing bacteria, virus or fungi), can transfer disease to another person. Fomites include door knobs, switches, computer keyboards etc. At hospitals, it could be stethoscopes, neck ties, IV drips and other hospital equipment. Fomite transmission could be important as the virus may remain viable, depending on the surface, for hours and in some cases, days. Frequent hand washing and cleaning schedules are ways to reduce fomite transmission. But the inhalation route remains the predominant mode of spread.
Most people think that wearing a mask is for self-protection, and that is partially true. But the main benefit of all people wearing masks is that in infected persons, the mask will help prevent these droplets from getting into the air and infecting others. They are thus reducing the spread of infection to others.
Lingering presence
This assumes even more significance as there are reports coming in suggesting that the virus can live in droplets in the air for up to three hours after release from an infected individual, lingering even much after the person has left the area.
Furthermore, one in four to five individuals infected with COVID-19 virus are not symptomatic and they may have started releasing viruses before they developed symptoms.
This is a key factor in the ability of this virus to spread, and the infected don’t even know they are infecting others.
Evidence has been mounting on the value of masks in reducing community spread. In Mainland China, extreme forms of social distancing and compulsory face mask wearing in public places appears to have successful in reducing the incidence after the initial outbreak in Hubei Province. Mask wearing also reduced community transmission in other provinces after five million people left Wuhan before the Chinese New Year. In Hong Kong, although the government only advised the people to stay at home, they voluntarily started wearing masks in public places. Following this, the labs in Hong Kong reported a significant drop in the detection of influenza and other respiratory viruses from patient samples, strongly suggesting that there was reduction in spread of these viruses.
During the present outbreak of COVID-19, one patient from Chongqing, China, transmitted the COVID-19 infection to 5 people in one vehicle when he didn’t wear a face mask, while no one was infected later in the second vehicle he took when he wore a face mask. This indicates the importance of wearing face masks for everyone in a closed space.
Wearing face masks therefore protects the user and also the others around. Use of face masks in social spaces is therefore likely to play a vital role in mitigating disease spread. We feel that the use of the face masks should become mandatory when people step out of their homes to any area where social distancing is not practical. This is a sustainable and an affordable intervention.
One reason why CDC and WHO initially recommended that the public do not use disposable masks is because the public started purchasing the medical masks (surgical or even N-95 masks) meant for use by the health care workers. The latter is not even meant for all health care workers, but only for those performing or assisting with high-infection-risk aerosol-generating procedures. Consequently there was an acute shortage of these personal protection equipment for hospitals and the prices have also shot up substantially. It would be foolish to continue this practice. For the public, cloth masks are probably effective and sufficient for this purpose.
In fact, some years ago, before disposable masks became easily available in India, most surgeons used washable cloth masks successfully during operations. These masks are simple to make and instructions are available on social media for making them.
Recently, respiratory disease experts advocated in a medical journal the use of traditional cloth coverings such as dupatta and saree, towels, turban and even handkerchief as face cover. Communities could be taught to use these to cover their mouth and nose when they cough or sneeze and when they are in places such as markets community gatherings where social distancing may be impractical. The wearing of the masks or any face cover could provide a barrier for transmission to and from the user. However cloth mask would serve the purpose better as it is a specifically designed cover.
A show of success
For instance, the ‘mask for all campaign’ in a rural community in south Odisha, the Bissamcuttack initiative is a show of success. Bissamcuttack is a small town in Rayagada District of Odisha, 200 km from the nearest ICU and 400 km from the nearest COVID-testing facility. Dr John Oommen, Community Health physician at the Christian Hospital, Bissamcuttack (CHB), recognised that if the COVID-19 epidemic reached a tribal region like this, it would be a disaster.
From the technical discussions, it was clear that everything depended on the proportion of the population getting infected in a short time. If the predictions of experts of 50 % of the population eventually contracting the infection comes true, or even if half the number is affected, the damage would be very heavy. The key therefore lay in getting the people to do whatever is possible to reduce the transmission in the community. With social distancing and hand washing already being well communicated by the government and other agencies, the CHB team felt a Mask For All Campaign could be a possible value addition. Support was found from the Azim Premji Philanthropic Initiatives, Bangalore.
Discussions were held with members of a local club, AFSA of Bissamcuttack, and they quickly warmed up to the idea. Dilip Kumar, Gourishankar Patra and other youth agreed to take it on with guidance from CHB. And on 30th March, work began to stimulate the movement. They organised 27 local tailors including professionals, stay-at-home mothers and SHG members, to take up the task of stitching 10,000 cloth masks, CHB provided the instructions, the cloth and a nominal sum of sum of Rs 5 per mask stitched. The AFSA team took on the distribution of the masks to every individual in every family in the Bissamcuttack Panchayat, with instructions on its use. Staff of CHB’s Mitra team took the initiative out to another 54 villages of the block.
By April 15, over 25,000 cloth masks had been stitched by 63 tailors and over 22,000 distributed to people. From 6th of April, the hospital (CHB) made it compulsory for anybody entering the hospital campus to wash their hands and wear a mask – creating one level of protection for the health personnel who would be treating them. Cloth masks are made available at the entrance for Rs 10 apiece. On the 9th of April, the Government of Odisha, which has been very pro-active and organised in its COVID-19 management strategy, made the wearing of face masks compulsory across the state, with a fine for non-compliance.
A simplified explanation
Volunteers handing out the masks at each home explain the logic in simple language. For infected people, the virus has two Exit Gates from the body – the nose and the mouth. For uninfected people, the virus has three Entry Gates into the body; mouth, nose and eyes.
The connection between one person’s exit gate and another’s entry gates is usually air (if you are close to each other) or hands (that pick it up by touching things). We do not know who is infected and who isn’t. So covering the exit and the entry gates of our body makes it safe for us and for others, thus decreasing the chance of spread of the virus in the community.
The following instructions are given for the use of the masks :
Get a cloth mask or make one; write your name on it, so that it doesn’t get mixed up with other family members. You can wash and re-use the mask for months ; don’t throw it away. Wash it before you use it the first time.
Wear a mask for as much time as you can, but compulsorily if you have a cough or fever – even while inside the house; and compulsorily if you step out of your house.
Your mask should cover your nose, mouth and chin – for it to do the job. Don’t just hang it around your neck. Take the mask off only to eat, drink, bathe etc.
Once you put on your mask, handle your mask only by the strings. Do not touch the front of the mask or the inside surface. If you do, then wash your hands.
At night, wash your mask with soap and water. If you have an iron at home, iron the masks; the heat will kill the virus if any. Or else, dry the mask in the sun. Make two masks for each family member if possible, so that you can use them on alternate days.
Try to maintain 6 feet distance from others as much as possible; avoid crowding.
Wash your hands with soap and water as many times a day as possible, especially when you enter your house or leave it, or after touching things.
Conclusion
The Prime Minister in his address to the nation on the 14th of April said : "Completely adhere to the ‘Lakshman Rekha’ of Lockdown and Social Distancing. Please also use homemade face-covers and masks without fail". We endorse this call and request all the people of India to help their neighbourhoods reduce the risk of community transmission by taking this up as a mass movement.
The proposition is that a community intervention comprising of the 3 pillars - physical distancing, frequent hand-washing and masks-wearing, if taken up on a mass scale as a people’s movement, can possibly reduce the community transmission of Covid-19. For this to work, it has to be functional and running well before the lockdown ends. It is a cost-effective, participatory approach that can channelize pent-up energy of youth into a positive community activity, for the greater common good. And anybody with a sewing machine can contribute, working from home, and earning some income in the process. A win-win idea for all of us!
