Should healthcare workers wear masks even for routine engagements with patients? And should the wider population also wear masks in order to suppress the spread of coronavirus?
These are questions that refuse to go away, despite official guidance, in Ireland and internationally, that masks are of limited benefit away from specialised health settings and could even be counterproductive.
The debate is complicated by the worldwide shortage of protective equipment, which means priority needs to be given to healthcare workers and vulnerable patients.
The World Health Organisation advises people should wear a mask only if they are ill with Covid-19 symptoms, especially coughing, or looking after a person with the virus.
“If you are not ill or looking after someone who is ill, then you are wasting a mask,” its guidance bluntly states.
More than 650 Irish healthcare workers have so far been infected, with transmission occurring between staff and patients responsible in about one-quarter of these cases.
Understandably, the risk of infection for healthcare workers is a huge worry for staff and a considerable manpower challenge for the system.
Here in Ireland, HSE lead for infectious diseases Prof Martin Cormican recently reviewed guidelines on mask-wearing for hospital staff and came to the conclusion that there was no evidence to support the wearing of surgical masks by healthcare workers for close patient encounters and staff meetings.
Citing WHO advice, Prof Cormican suggested mask-wearing by people with no symptoms could create unnecessary cost and create “a false sense of security”.
Infectious droplets
He acknowledged there was “some uncertainty” about how much asymptomatic people could disperse infectious droplets, but said this was likely to be “very much less” than among people with symptoms.
“Even if the hypothesis that transmission from truly asymptomatic healthcare workers in the healthcare setting is significant is accepted, there is no evidence the universal use of surgical masks is effective in reducing this beyond what is achieved by standard precautions [hand hygiene, respiratory hygiene and cough etiquette and environmental cleaning] and minimising interpersonal interaction.”
Prof Cormican’s updated guidance was sparked by a decision by St James’s Hospital to issue protective equipment more widely to staff working outside intensive care situations where the risk of infection is highest.
The hospital’s advice that staff should wear surgical masks for all patient encounters and meetings between staff where social distancing of at least two metres cannot be maintained has been followed by other hospitals where the workforce had expressed concerns.
The indications are that hospitals are continuing to go their own way. Occupational health advice provided within the RCSI Hospital Group, seen by The Irish Times, states: "It doesn't matter what national guidelines say – if it's wrong in reality, it's wrong and will not work . . . they are guidelines and not proscriptive or dogma. The duty is to find solutions that work."
RCSI guidelines recommend staff wear masks, along with disposable aprons and gloves, even for “minimal contact activities” such as cleaning, taking a temperature or feeding a patient.
Unreliable
In the community, basic homemade or surgical masks are notoriously unreliable when used by untrained people. Aside from the gaps at the side, the act of handling the mask can increase the risk of infection rather than reducing it.
Yet, given the lack of definitive knowledge about how coronavirus is spread, many experts now argue that something is better than nothing, and that masks can play a role, alongside social distancing and hand hygiene, in further reducing the rate of transmission.
Regulators in the US are said to be mulling a change of guidelines in relation to masks, while countries such as Austria and the Czech Republic have made the wearing of masks compulsory in public.
One hospital in Naples has reportedly managed to avoid any staff infections through strict demarcation between Covid-19 and non-Covid-19 patients and the use of gas mask-like protective gear.
Dr Cillian de Gascun, head of the expert group advising the Government, said the issue was under discussion and would be kept under review.
“We are aware of anxiety among healthcare workers. There really isn’t any evidence there to recommend the wearing of face masks for asymptomatic individuals.”
Whatever the official advice, many more people are choosing to make their own masks or have donned surgical masks, despite their limited use outdoors.
Eventually, supply issues may ease, and it is likely that masks will play an even bigger role as Ireland and other countries attempt to ease their way out of this crisis.