Face Mask Use and Control of Respiratory Virus Transmission in Households

Impacts of the COVID-19 pandemic on healthcare utilization among Home Care Aides in Washington, U.S

This study assesses the impacts of the COVID-19 pandemic on healthcare access for Washington State Home Care Aides (HCAs). Analyzing 62 months of medical claims data from over 35,000 HCAs, the research reveals significant healthcare disruptions during the early pandemic, especially in outpatient settings. However, healthcare utilization rebounded swiftly, surpassing pre-COVID levels as new variants emerged. Furthermore, the analysis indicated significant decreases in healthcare utilization for respiratory conditions in later stages of the pandemic, suggesting that the implementation of non-pharmaceutical and pharmaceutical interventions played a crucial role in preventing the transmission of respiratory diseases. Notably, behavioral health-related utilization among HCAs increased significantly throughout most pandemic phases, underscoring the importance of enhancing behavioral health support during public health crises. This research represents the first comprehensive study unveiling the effects of the COVID-19 pandemic on HCAs' healthcare access and opening avenues for further research and policy development to support this essential workforce.

Colonization of bacterial and viral respiratory pathogens among healthcare workers in China during COVID-19 pandemic

Background

Healthcare settings may amplify transmission of respiratory pathogens, however empirical evidence is lacking. We aimed to describe the spectrum and distribution of respiratory pathogens among healthcare workers in eastern China.

Methods

Healthcare workers were recruited from October 2020 to November 2021 in Jiangsu province. Participants were interviewed regarding demographic and hospital-based protective measures. Thirty-seven common respiratory pathogens were tested using real-time PCR/RT-PCR (Probe qPCR). The role of demographic and hospital-based protective measures on pathogens colonization using multivariable logistic regression models.

Results

Among 316 enrolled healthcare workers, a total of 21 pathogens were detected. In total, 212 (67.1%) healthcare workers had at least one respiratory pathogen; 195 (61.7%) and 70 (22.2%) with a bacterial and viral pathogen. The most commonly detected pathogen was streptococcus pneumoniae (47.5%) followed by Haemophilus influenzae (21.2%). One hundred and five (33.2%) healthcare workers with copathogens had at least two respiratory pathogens. Both bacterial and viral colonization were more common in 2020 compared to 2021. A decreased risk of colonization was seen in participants with infection prevention and control training and suitable hand hygiene.

Conclusions

Colonization of respiratory pathogens in healthcare workers from eastern China was high. Differential risk was impacted only by hospital-based protective measures and not demographic factors.

Masks and respirators for prevention of respiratory infections: a state of the science review

SUMMARYThis narrative review and meta-analysis summarizes a broad evidence base on the benefits-and also the practicalities, disbenefits, harms and personal, sociocultural and environmental impacts-of masks and masking. Our synthesis of evidence from over 100 published reviews and selected primary studies, including re-analyzing contested meta-analyses of key clinical trials, produced seven key findings. First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community transmission of respiratory pathogens. Fifth, masks are important sociocultural symbols; non-adherence to masking is sometimes linked to political and ideological beliefs and to widely circulated mis- or disinformation. Sixth, while there is much evidence that masks are not generally harmful to the general population, masking may be relatively contraindicated in individuals with certain medical conditions, who may require exemption. Furthermore, certain groups (notably D/deaf people) are disadvantaged when others are masked. Finally, there are risks to the environment from single-use masks and respirators. We propose an agenda for future research, including improved characterization of the situations in which masking should be recommended or mandated; attention to comfort and acceptability; generalized and disability-focused communication support in settings where masks are worn; and development and testing of novel materials and designs for improved filtration, breathability, and environmental impact.

Examining factors influencing public knowledge and practice of proper face mask usage during the COVID-19 pandemic: a cross-sectional study

Background

The COVID-19 pandemic had an enormous impact on people's quality of life worldwide. Appropriate use of facemasks is an important checkpoint in containing the spread of infection, which was believed to provide the desired level of protection and preserve the community. Given the relative novelty of facemask use in the general population, it is imperative to prioritize the promotion of appropriate facemask utilization and identify factors that may contribute to poor adherence.

Aim

This study assessed the factors that determined facemask use among the public.

Methods

A cross-sectional questionnaire-based study was conducted among the residents of the Kingdom of Saudi Arabia between November 2020 and January 2021. The current study explored the factors such as demographic characteristics influencing the knowledge and practice of proper use of facemasks. The study included a total of 198 participants. The results were derived through binomial logistic regression analysis to determine the relationship between the demographic characteristics and responses.

Results

The key findings of the study which are crucial in developing targeted intervention strategies to enhance the responsible use and disposal of facemasks are gender, income and employment. A significant difference was found between male and female participants regarding a positive approach to using facemasks, such as washing their hands (P = 0.042). In addition, homemakers differed significantly from students, regarding the correct usage of facemasks (P = 0.026). The study participants were aware that hand hygiene is essential when putting on and removing facemasks. Despite wearing facemasks properly, adult participants possessed less knowledge about the hazards of reusing facemasks and appropriate disposal (OR = 0.202, 95% CI [0.032-1.298]).

Conclusion

The present research identified gender, income, and employment as the primary attributes that play a pivotal role in the formulation of focused intervention tactics aimed at improving the cautious use and appropriate disposal of facemasks. It is essential to implement nationwide awareness activities, such as information campaigns, to enhance knowledge. Health authorities should establish a functional infrastructure for the collection and disposal of used facemasks by the general public, starting with the dissemination of knowledge. Moreover, the results of the present study have significant implications for health preventive programs aimed at preparing for future pandemics, since they highlight the specific demographic groups that should be prioritized in the development of such policies. Furthermore, it is advisable to integrate these interventional initiatives with national health polices to promote preparedness for handling future pandemics.

Transmissibility of severe acute respiratory syndrome coronavirus 2 among household contacts of coronavirus disease 2019-positive patients: A community-based study in India

BACKGROUND

This study identified the risk factors for severe acute respiratory syndrome coronavirus 2 infection among household contacts of index patients and determined the incubation period (IP), serial interval, and estimates of secondary infection rate in Kerala, India.

METHODS

We conducted a cohort study in three districts of Kerala among the inhabitants of households of reverse transcriptase polymerase chain reaction-positive coronavirus disease 2019 patients between January and July 2021. About 147 index patients and 362 household contacts were followed up for 28 days to determine reverse transcriptase polymerase chain reaction positivity and the presence of total antibodies against SARS-CoV-2 on days 1, 7, 14, and 28.

RESULTS

The mean IP, serial interval, and generation time were 1.6, 3, and 3.9 days, respectively. The secondary infection rate at 14 days was 43.0%. According to multivariable regression analysis persons who worked outside the home were protected (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.24-0.85), whereas those who had kissed the coronavirus disease 2019-positive patients during illness were more than twice at risk of infection (aOR, 2.23; 95% CI, 1.01-5.2) than those who had not kissed the patients. Sharing a toilet with the index patient increased the risk by more than twice (aOR, 2.5; 95% CI, 1.42-4.64) than not sharing a toilet. However, the contacts who reported using masks (aOR, 2.5; 95% CI, 1.4-4.4) were at a higher risk of infection in household settings.

CONCLUSIONS

Household settings have a high secondary infection rate and the changing transmissibility dynamics such as IP, serial interval should be considered in the prevention and control of SARS-CoV-2.

Association of face mask use with self-reported cardiovascular symptoms during the COVID-19 pandemic

Introduction

Countries are mandating the use of face masks to stem the spread of coronavirus disease 2019 (COVID-19). Face mask use has been associated with discomfort due to its effects on thermoregulation, breathing and oxygenation. We evaluated the prevalence and severity of self-reported cardiovascular symptoms before and during face mask use.

Methods

This was a cross-sectional study of 1,001 participants residing in Singapore, who participated in a self-administered questionnaire between 25 April 2020 and 4 May 2020. Symptom severity before and during mask use, and health-seeking behaviour information were collected. The study outcome was self-reported worsening of cardiovascular symptoms and its association with the type of mask worn, duration of mask worn per day, and intensity of physical activities during mask use.

Results

The most common symptom reported during mask use was dyspnoea. Independent predictors for self-reported cardiovascular symptoms during mask use were moderate-high physical activity during mask use (odds ratio [OR] 1.634, 95% confidence interval [CI] 1.176-2.270, P = 0.003), duration of mask use for ≥3 h (OR 1.672, 95% CI 1.189-2.352, P = 0.003) and type of mask used, after adjusting for age, sex, healthcare-based worker status and presence of comorbidities. N95 mask was associated with worse symptoms when compared to surgical mask. Participants with ≥3 worsening symptoms or worsening dyspnoea, palpitations, fatigue and dizziness were more likely to seek medical help.

Conclusion

Face mask use has been proven to be an effective way in curbing COVID-19 transmission. However, participants in this study had concerns regarding its use and these concerns should be urgently addressed to enable mask use policies to be enacted.

Lagging effects and prediction of pollutants and their interaction modifiers on influenza in northeastern China

BACKGROUND

Previous studies have typically explored the daily lagged relations between influenza and meteorology, but few have explored seasonally the monthly lagged relationship, interaction and multiple prediction between influenza and pollution. Our specific objectives are to evaluate the lagged and interaction effects of pollution factors and construct models for estimating influenza incidence in a hierarchical manner.

METHODS

Our researchers collect influenza case data from 2005 to 2018 with meteorological and contaminative factors in Northeast China. We develop a generalized additive model with up to 6 months of maximum lag to analyze the impact of pollution factors on influenza cases and their interaction effects. We employ LASSO regression to identify the most significant environmental factors and conduct multiple complex regression analysis. In addition, quantile regression is taken to model the relation between influenza morbidity and specific percentiles (or quantiles) of meteorological factors.

RESULTS

The influenza epidemic in Northeast China has shown an upward trend year by year. The excessive incidence of influenza in Northeast China may be attributed to the suspected primary air pollutant, NO2, which has been observed to have overall low levels during January, March, and June. The Age 15-24 group shows an increase in the relative risk of influenza with an increase in PM2.5 concentration, with a lag of 0-6 months (ERR 1.08, 95% CI 0.10-2.07). In the quantitative analysis of the interaction model, PM10 at the level of 100-120 μg/m3, PM2.5 at the level of 60-80 μg/m3, and NO2 at the level of 60 μg/m3 or more have the greatest effect on the onset of influenza. The GPR model behaves better among prediction models.

CONCLUSIONS

Exposure to the air pollutant NO2 is associated with an increased risk of influenza with a cumulative lag effect. Prioritizing winter and spring pollution monitoring and influenza prediction modeling should be our focus.

Using the Health Belief Model to assess COVID-19 perceptions and behaviours among a group of Egyptian adults: a cross-sectional study

BACKGROUND

It is crucial to study the public's perceptions and behaviour during a pandemic as this will be the driving force for practicing recommended precautions. The current study aimed to identify perceptions of a group of Egyptian adults to COVID-19 using the Health Belief Model (HBM), to measure self-reported practice of preventive behaviours and to identify influencing factors.

METHODS

Cross sectional study was used, including Egyptian adults aged 18 + years. A structured anonymous online questionnaire was used including: a demographic section, the modified MERS- CoV Health Belief Model scale after addition of questions related to COVID-19 and questions on preventive behaviours to COVID-19.

RESULTS

Of the 532 study participants, 28.6% were males, age ranges (18 to 74 years). There was a statistically significant positive correlation between total practice score and all COVID-19 Health Belief Model constructs total scores except for perceived barriers score showing negative correlation (P value < 0.05). Linear regression analysis showed that older age, male gender and living inside Cairo were associated with lower practice score (P value < 0.01).

CONCLUSIONS

Increased perceived susceptibility, perceived benefits, cues to action and perceived self-efficacy scores were associated with higher practice score in the current study. Additionally, results revealed that social media and websites can play an important role in shaping risk perception in the community. Stressing risk perception and efficacy beliefs prevention message can drive people to practice preventive behaviors.

Effect of COVID-19 pandemic on the incidence of acute diarrheal disease and pneumonia among under 5 children in Ethiopia- A database study

COVID-19 has had a devastating impact on preventable and treatable pediatric diseases in Ethiopia. This study looks at the impact of COVID-19 on pneumonia and acute diarrheal diseases in the country, as well as the differences between administrative regions. In Ethiopia, we conducted a retrospective pre-post study to assess the impact of COVID-19 on children under the age of five who had acute diarrhea and pneumonia and were treated in health facilities during the pre-COVID-19 era (March 2019 to February 2020) and the COVID-19 era (March 2020 to February 2021). From the National Health Management District Health Information System (DHIS2, HMIS), we retrieved data on total acute diarrheal disease and pneumonia, along with their regional and monthly distribution. We calculated incidence rate ratios comparing the rates of acute diarrhea and pneumonia during the pre-and post-COVID-19 eras and adjusted for the year, using Poisson regression. The number of under-five children treated for acute pneumonia decreased from 2,448,882 before COVID-19 to 2,089,542 ((14.7% reduction (95%CI;8.72-21.28), p<0.001)) during COVID-19. Similarly, the number of under-five children treated for acute diarrheal disease decreased from 3,287,850 in pre-COVID-19 to, 2,961,771((9.91% reduction (95%CI;6.3-17.6%),p<0.001)) during COVID-19. In the majority of the administrative regions studied, pneumonia and acute diarrhea diseases decreased during COVID-19, but they increased in Gambella, Somalia, and Afar. During the COVID-19 period, the greatest reduction of children with pneumonia (54%) and diarrhea disease (37.3%) was found in Addis Ababa (p<0.001). The majority of administrative regions included in this study have seen a decrease in pneumonia and acute diarrheal diseases among children under the age of five, while three regions namely, Somalia, Gambela, and Afar saw an increase in cases during the pandemic. This emphasizes the importance of using tailored approaches in mitigating the impact of infectious diseases such as diarrhea and pneumonia during situations of a pandemic such as COVID-19.

Nonpharmaceutical interventions for managing SARS-CoV-2

PURPOSE OF REVIEW

Initial response strategies to the COVID-19 pandemic were heavily reliant on nonpharmaceutical interventions (NPIs), a set of measures implemented to slow or even stop the spread of infection. Here, we reviewed key measures used during the COVID-19 pandemic.

RECENT FINDINGS

Some NPIs were successful in reducing the transmission of SARS-CoV-2. Personal protective measures such as face masks were widely used, and likely had some effect on transmission. The development and production of rapid antigen tests allowed self-diagnosis in the community, informing isolation and quarantine measures. Community-wide measures such as school closures, workplace closures and complete stay-at-home orders were able to reduce contacts and prevent transmission. They were widely used in the pandemic and contributed to reduce transmission in the community; however, there were also negative unintended consequences in the society and economy.

SUMMARY

NPIs slowed the spread of SARS-CoV-2 and are essential for pandemic preparedness and response. Understanding which measures are more effective at reducing transmission with lower costs is imperative.

Possible toxicity of chronic carbon dioxide exposure associated with face mask use, particularly in pregnant women, children and adolescents - A scoping review

Introduction

During the SARS-CoV-2-pandemic, face masks have become one of the most important ubiquitous factors affecting human breathing. It increases the resistance and dead space volume leading to a re-breathing of CO2. So far, this phenomenon and possible implications on early life has not been evaluated in depth.

Method

As part of a scoping review, literature was systematically reviewed regarding CO2 exposure and facemask use.

Results

Fresh air has around 0.04% CO2, while wearing masks more than 5 min bears a possible chronic exposure to carbon dioxide of 1.41% to 3.2% of the inhaled air. Although the buildup is usually within the short-term exposure limits, long-term exceedances and consequences must be considered due to experimental data. US Navy toxicity experts set the exposure limits for submarines carrying a female crew to 0.8% CO2 based on animal studies which indicated an increased risk for stillbirths. Additionally, mammals who were chronically exposed to 0.3% CO2 the experimental data demonstrate a teratogenicity with irreversible neuron damage in the offspring, reduced spatial learning caused by brainstem neuron apoptosis and reduced circulating levels of the insulin-like growth factor-1. With significant impact on three readout parameters (morphological, functional, marker) this chronic 0.3% CO2 exposure has to be defined as being toxic. Additional data exists on the exposure of chronic 0.3% CO2 in adolescent mammals causing neuron destruction, which includes less activity, increased anxiety and impaired learning and memory. There is also data indicating testicular toxicity in adolescents at CO2 inhalation concentrations above 0.5%.

Discussion

There is a possible negative impact risk by imposing extended mask mandates especially for vulnerable subgroups. Circumstantial evidence exists that extended mask use may be related to current observations of stillbirths and to reduced verbal motor and overall cognitive performance in children born during the pandemic. A need exists to reconsider mask mandates.

Response to COVID-19 recommended preventive behavioral messages among Guraghe zone communities, South Ethiopia: using constructs of the Extended Parallel Process Model (EPPM)

INTRODUCTION

The World Health Organization declared COVID-19 is a pandemic disease. Countries should take standard measures and responses to battle the effects of the viruses. However, little is known in Ethiopia regarding the recommended preventive behavioral messages responses. Therefore, the study aimed to assess the response to COVID-19 recommended preventive behavioral messages.

METHODS

Community-based cross-sectional study design was carried out from 1 to 20, July 2020. We recruited 634 respondents by using a systematic sampling method. Data were analyzed using Statistical Package Software for Social Sciences version 23. Association between variables were explored using a bivariable and multi variable logistic regression model. The strength of the association is presented using odds ratio and regression coefficient with 95% confidence interval. A p-value of less than 0.05 was declared statistically significant.

RESULTS

Three hundred thirty-six (53.1%) of respondents had good response to recommended preventive behavioral messages. The general precise rate of the knowledge questionnaire was 92.21%. The study showed that merchant was 1.86 (p ≈ 0.01) times more likely respond to COVID-19 recommended preventive behavioral messages than government-employed. Respondents who scored one unit increase for self-efficacy and response-efficacy, the odds of responding to COVID-19 recommended preventive behavioral messages were increased by 1.22 (p < 0.001), and 1.05 times (p = 0.002) respectively. Respondents who scored one unit increase to cues to action, the odds of responding to COVID-19 recommended preventive behavioral messages were 43% (p < 0.001) less likely.

CONCLUSION

Even though respondents were highly knowledgeable about COVID-19, there is a lower level of applying response to recommended preventive behavioral messages. Merchant, self-efficacy, response efficacy, and cues to action were significantly associated with response to recommended preventive behavioral messages. Like merchants, government employer should be applying preventive behavioral messages and also, participants' self and response efficacy should be strengthened to improve the response. In addition, we should be changed or modified the way how-to deliver relevant information, promoting awareness, and also using appropriate reminder systems to preventive behavioral messages.

Spread of viruses, which measures are the most apt to control COVID-19?

The persistent debate about the modes of transmission of SARS-CoV2 and preventive measures has illustrated the limits of our knowledge regarding the measures to be implemented in the face of viral risk. Past and present (pandemic-related) scientific data underline the complexity of the phenomenon and its variability over time. Several factors contribute to the risk of transmission, starting with incidence in the general population (i.e., colonization pressure) and herd immunity. Other major factors include intensity of symptoms, interactions with the reservoir (proximity and duration of contact), the specific characteristics of the virus(es) involved, and a number of unpredictable elements (humidity, temperature, ventilation…). In this review, we will emphasize the difficulty of "standardizing" the situations that might explain the discrepancies found in the literature. We will show that the airborne route remains the main mode of transmission. Regarding preventive measures of prevention, while vaccination remains the cornerstone of the fight against viral outbreaks, we will remind the reader that wearing a mask is the main barrier measure and that the choice of type of mask depends on the risk situations. Finally, we believe that the recent pandemic should induce us in the future to modify our recommendations by adapting our measures in hospitals, not to the pathogen concerned, which is currently the case, but rather to the type of at-risk situation.

The Spread of Exhaled Air and Aerosols during Physical Exercise

Physical exercise demonstrates a special case of aerosol emission due to its associated elevated breathing rate. This can lead to a faster spread of airborne viruses and respiratory diseases. Therefore, this study investigates cross-infection risk during training. Twelve human subjects exercised on a cycle ergometer under three mask scenarios: no mask, surgical mask, and FFP2 mask. The emitted aerosols were measured in a grey room with a measurement setup equipped with an optical particle sensor. The spread of expired air was qualitatively and quantitatively assessed using schlieren imaging. Moreover, user satisfaction surveys were conducted to evaluate the comfort of wearing face masks during training. The results indicated that both surgical and FFP2 masks significantly reduced particles emission with a reduction efficiency of 87.1% and 91.3% of all particle sizes, respectively. However, compared to surgical masks, FFP2 masks provided a nearly tenfold greater reduction of the particle size range with long residence time in the air (0.3-0.5 μm). Furthermore, the investigated masks reduced exhalation spreading distances to less than 0.15 m and 0.1 m in the case of the surgical mask and FFP2 mask, respectively. User satisfaction solely differed with respect to perceived dyspnea between no mask and FFP2 mask conditions.

Overview of tight fit and infection prevention benefits of respirators (filtering face pieces)

Regulations for measures to protect against SARS-CoV-2 transmission vary widely around the world, with very strict regulations in Germany where respirators (filtering face piece FFP2 or comparable) are often mandatory. The efficiency of respirators, however, depends essentially on the tight facial fit avoiding the bypass of contaminated air via gaps between mask and wearer's face. The facial fit can be verified in a fit test. The aim of this review was to describe the quantitative fit test results depending on the respirator designs. A literature search revealed 29 suitable studies. Of all respirators with circumferential head straps, three-panel folded dome-shaped respirators showed the best fit (80.8% of 4625 fit tests passed), followed by rigid-dome-shaped respirators (72.4% of 8234 fit tests passed), duckbill-shaped respirators (31.6% of 2120 fit tests passed), and coffee-filter-shaped respirators (30.9% of 3392 fit tests passed). Respirators with ear loops showed very poor tight fit (3.6% of 222 fit tests passed). In four randomized control trials, single-use respirators were not shown to be superior to surgical masks for the prevention of laboratory-confirmed viral respiratory infections, even when adjusted with a fit test. Therefore, we consider the mandatory use of respirators to be disproportionate and not supported by evidence. Further evidence should be generated, in which scenarios respirators might provide an effective benefit as part of occupational health and safety. For situations with confirmed benefits, only high-quality disposable respirators with head straps or respiratory protective equipment of higher protective levels should be used.

Physical interventions to interrupt or reduce the spread of respiratory viruses

BACKGROUND

Viral epidemics or pandemics of acute respiratory infections (ARIs) pose a global threat. Examples are influenza (H1N1) caused by the H1N1pdm09 virus in 2009, severe acute respiratory syndrome (SARS) in 2003, and coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 in 2019. Antiviral drugs and vaccines may be insufficient to prevent their spread. This is an update of a Cochrane Review last published in 2020. We include results from studies from the current COVID-19 pandemic.

OBJECTIVES

To assess the effectiveness of physical interventions to interrupt or reduce the spread of acute respiratory viruses.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, CINAHL, and two trials registers in October 2022, with backwards and forwards citation analysis on the new studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs investigating physical interventions (screening at entry ports, isolation, quarantine, physical distancing, personal protection, hand hygiene, face masks, glasses, and gargling) to prevent respiratory virus transmission.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 11 new RCTs and cluster-RCTs (610,872 participants) in this update, bringing the total number of RCTs to 78. Six of the new trials were conducted during the COVID-19 pandemic; two from Mexico, and one each from Denmark, Bangladesh, England, and Norway. We identified four ongoing studies, of which one is completed, but unreported, evaluating masks concurrent with the COVID-19 pandemic. Many studies were conducted during non-epidemic influenza periods. Several were conducted during the 2009 H1N1 influenza pandemic, and others in epidemic influenza seasons up to 2016. Therefore, many studies were conducted in the context of lower respiratory viral circulation and transmission compared to COVID-19. The included studies were conducted in heterogeneous settings, ranging from suburban schools to hospital wards in high-income countries; crowded inner city settings in low-income countries; and an immigrant neighbourhood in a high-income country. Adherence with interventions was low in many studies. The risk of bias for the RCTs and cluster-RCTs was mostly high or unclear. Medical/surgical masks compared to no masks We included 12 trials (10 cluster-RCTs) comparing medical/surgical masks versus no masks to prevent the spread of viral respiratory illness (two trials with healthcare workers and 10 in the community). Wearing masks in the community probably makes little or no difference to the outcome of influenza-like illness (ILI)/COVID-19 like illness compared to not wearing masks (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.84 to 1.09; 9 trials, 276,917 participants; moderate-certainty evidence. Wearing masks in the community probably makes little or no difference to the outcome of laboratory-confirmed influenza/SARS-CoV-2 compared to not wearing masks (RR 1.01, 95% CI 0.72 to 1.42; 6 trials, 13,919 participants; moderate-certainty evidence). Harms were rarely measured and poorly reported (very low-certainty evidence). N95/P2 respirators compared to medical/surgical masks We pooled trials comparing N95/P2 respirators with medical/surgical masks (four in healthcare settings and one in a household setting). We are very uncertain on the effects of N95/P2 respirators compared with medical/surgical masks on the outcome of clinical respiratory illness (RR 0.70, 95% CI 0.45 to 1.10; 3 trials, 7779 participants; very low-certainty evidence). N95/P2 respirators compared with medical/surgical masks may be effective for ILI (RR 0.82, 95% CI 0.66 to 1.03; 5 trials, 8407 participants; low-certainty evidence). Evidence is limited by imprecision and heterogeneity for these subjective outcomes. The use of a N95/P2 respirators compared to medical/surgical masks probably makes little or no difference for the objective and more precise outcome of laboratory-confirmed influenza infection (RR 1.10, 95% CI 0.90 to 1.34; 5 trials, 8407 participants; moderate-certainty evidence). Restricting pooling to healthcare workers made no difference to the overall findings. Harms were poorly measured and reported, but discomfort wearing medical/surgical masks or N95/P2 respirators was mentioned in several studies (very low-certainty evidence).  One previously reported ongoing RCT has now been published and observed that medical/surgical masks were non-inferior to N95 respirators in a large study of 1009 healthcare workers in four countries providing direct care to COVID-19 patients.  Hand hygiene compared to control Nineteen trials compared hand hygiene interventions with controls with sufficient data to include in meta-analyses. Settings included schools, childcare centres and homes. Comparing hand hygiene interventions with controls (i.e. no intervention), there was a 14% relative reduction in the number of people with ARIs in the hand hygiene group (RR 0.86, 95% CI 0.81 to 0.90; 9 trials, 52,105 participants; moderate-certainty evidence), suggesting a probable benefit. In absolute terms this benefit would result in a reduction from 380 events per 1000 people to 327 per 1000 people (95% CI 308 to 342). When considering the more strictly defined outcomes of ILI and laboratory-confirmed influenza, the estimates of effect for ILI (RR 0.94, 95% CI 0.81 to 1.09; 11 trials, 34,503 participants; low-certainty evidence), and laboratory-confirmed influenza (RR 0.91, 95% CI 0.63 to 1.30; 8 trials, 8332 participants; low-certainty evidence), suggest the intervention made little or no difference. We pooled 19 trials (71, 210 participants) for the composite outcome of ARI or ILI or influenza, with each study only contributing once and the most comprehensive outcome reported. Pooled data showed that hand hygiene may be beneficial with an 11% relative reduction of respiratory illness (RR 0.89, 95% CI 0.83 to 0.94; low-certainty evidence), but with high heterogeneity. In absolute terms this benefit would result in a reduction from 200 events per 1000 people to 178 per 1000 people (95% CI 166 to 188). Few trials measured and reported harms (very low-certainty evidence). We found no RCTs on gowns and gloves, face shields, or screening at entry ports.

AUTHORS' CONCLUSIONS

The high risk of bias in the trials, variation in outcome measurement, and relatively low adherence with the interventions during the studies hampers drawing firm conclusions. There were additional RCTs during the pandemic related to physical interventions but a relative paucity given the importance of the question of masking and its relative effectiveness and the concomitant measures of mask adherence which would be highly relevant to the measurement of effectiveness, especially in the elderly and in young children. There is uncertainty about the effects of face masks. The low to moderate certainty of evidence means our confidence in the effect estimate is limited, and that the true effect may be different from the observed estimate of the effect. The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness, and although this effect was also present when ILI and laboratory-confirmed influenza were analysed separately, it was not found to be a significant difference for the latter two outcomes. Harms associated with physical interventions were under-investigated. There is a need for large, well-designed RCTs addressing the effectiveness of many of these interventions in multiple settings and populations, as well as the impact of adherence on effectiveness, especially in those most at risk of ARIs.

Filter Masks during the Second Phase of SARS-CoV-2: Study on Population

During the SARS-CoV-2 pandemic, the most common countermeasure are the use of masks, which are supposed to filter inhaled and exhaled air to reduce the spread of the virus. The masks, which are medical devices, must be used by providing appropriate instructions for correct use. This study, which examined the population during the advanced stage of the pandemic, highlighted a substantial improvement in the management and choice of masks, even though the information disseminated to the population probably should be even more detailed and precise in order to avoid incorrect behavior that could compromise the effectiveness of these devices; in fact a high percentage of subjects had behaviors that can facilitate the spread of the virus, such as the continuous attempts to correct the incorrect positioning of the mask on the face or the need to move it because it is annoying.

Vaccine or Garlic-Is It a Choice? Awareness of Medical Personnel on Prevention of Influenza Infections

BACKGROUND

Preventing the spread of the influenza virus is one of the primary health policy challenges of many countries worldwide. One of the more effective ways to prevent infection is influenza vaccination, and the people who enjoy the most public confidence in preventive health care are health workers (HWs). For this reason, it is crucial to study the attitudes of HWs toward influenza vaccination.

METHODS

The survey was conducted among 950 medical (physicians and nurses) and administrative staff in three academic hospitals. Respondents to the survey were selected on a random-target basis to represent hospital employees in the study best. The survey was conducted using the PAPI method between August and September 2020.

RESULTS

Respondents considered hand washing (52.8%) and avoiding contact with sick people (49.3%) the most effective ways to prevent influenza infection. Three in ten respondents considered wearing a protective mask (30.1%) and getting vaccinated against influenza (29.9%) is fully effective in preventing influenza. Influenza vaccination as effective in preventing influenza virus infection was chosen more often by those who worked in a pediatric hospital. Nurses were twice less likely than physicians to declare that influenza vaccination prevents infection (42.4% for nurses vs. 84.0% for physicians). At the same time, 20.4% of nurses believed that eating garlic effectively prevented influenza infection, and 28.1% declared daily vitamin C helpful.

CONCLUSIONS

The study pointed to significant educational gaps regarding the role and effectiveness of influenza vaccination in the process of influenza virus infection and indicated a firm belief in medical myths, especially in the nursing community, related to protection against influenza virus infection.

Deciphering the transmission dynamics of COVID-19 in India: optimal control and cost effective analysis

In this paper we assess the effectiveness of different non-pharmaceutical interventions (NPIs) against COVID-19 utilizing a compartmental model. The local asymptotic stability of equilibria (disease-free and endemic) in terms of the basic reproduction number have been determined. We find that the system undergoes a backward bifurcation in the case of imperfect quarantine. The parameters of the model have been estimated from the total confirmed cases of COVID-19 in India. Sensitivity analysis of the basic reproduction number has been performed. The findings also suggest that effectiveness of face masks plays a significant role in reducing the COVID-19 prevalence in India. Optimal control problem with several control strategies has been investigated. We find that the intervention strategies including implementation of lockdown, social distancing, and awareness only, has the highest cost-effectiveness in controlling the infection. This combined strategy also has the least value of average cost-effectiveness ratio (ACER) and associated cost.

Face masks to prevent transmission of respiratory infections: Systematic review and meta-analysis of randomized controlled trials on face mask use

OBJECTIVES

To examine the use of face mask intervention in mitigating the risk of spreading respiratory infections and whether the effect of face mask intervention differs in different exposure settings and age groups.

DESIGN

Systematic review and meta-analysis. We evaluated the risk of bias using the Cochrane Risk of Bias 2 tool (ROB2).

DATA SOURCES

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched for randomized controlled trials investigating the effect of face masks on respiratory infections published between 1981 and February 9, 2022. We followed the PRISMA 2020 guidelines.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included randomized controlled trials investigating the use of face mask intervention in mitigating the risk of spreading respiratory infections across different exposure settings.

RESULTS

We identified 2,400 articles for screening. 18 articles passed the inclusion criteria for both evidence synthesis and meta-analysis. There were N = 189,145 individuals in the face mask intervention arm and N = 173,536 in the control arm, and the follow-up times ranged from 4 days to 19 months. Our results showed between-study heterogeneity (p < 0.0001). While there was no statistically significant association over all studies when the covariate unadjusted intervention effect estimates were used (RR = 0.977 [0.858-1.113], p = 0.728), our subgroup analyses revealed that a face mask intervention reduced respiratory infections in the adult subgroup (RR = 0.8795 [0.7861-0.9839], p = 0.0249) and in a community setting (RR = 0.890 [0.812-0.975], p = 0.0125). Furthermore, our leave-one-out analysis found that one study biased the results towards a null effect. Consequently, when using covariate adjusted odds ratio estimates to have a more precise effect estimates of the intervention effect to account for differences at the baseline, the results showed that a face mask intervention did reduce respiratory infections when the biasing study was excluded from the analysis (OR = 0.8892 [0.8061-0.9810], p = 0.0192).

CONCLUSION

Our findings support the use of face masks particularly in a community setting and for adults. We also observed substantial between-study heterogeneity and varying adherence to protocol. Notably, many studies were subject to contamination bias thus affecting the efficacy of the intervention, that is when also some controls used masks or when the intervention group did not comply with mask use leading to a downward biased effect of treatment receipt and efficacy.

TRIAL REGISTRATION

PROSPERO registration number CRD42020205523.

A review on the effectiveness of various masks in protection against COVID-19

As of June1st 2021, more than 17 crore people have been infected with COVID-19 across the globe, and almost 3 crore people have been infected in India. The virus can spread through even normal actions like talking with particle emission rates inversely correlating with word frequency and volume, which can be reduced by covering the mouth. However, there is debate concerning the effectiveness of the various face mask types in preventing respiratory infections. Many have reported that wearing a mask is uncomfortable, especially when worn for long hours and while performing strenuous activities. Another disease that has raised its head is mucormycosis. However, COVID-19 can be a serious infection in many, with many fatalities. It is not yet clear how much protection vaccines give, and in a hugely populated country like India, it may be very difficult to vaccinate the whole population. Moreover, the vaccination for pediatric groups has just started. So, it is imperative to wear masks that can be protective against infection. However, some people believe that a straightforward cotton mask is insufficient. We set out to analyze the efficacy of masks through this investigation. According to the results of this systematic review, there are no studies that give conclusive evidence that using face masks as recommended by current public health guidelines will stop this condition. This is a significant discovery that should be communicated to the scientific community and calls into question the rationale for inconsistent and differing public health recommendations.

A Review of the Fabrication Methods, Testing, and Performance of Face Masks

Improvement in the performance and compatibility of face masks has remained the focus of researchers in recent years, especially after the emergence of the COVID pandemic. Although a lot of progress in the design, tolerability, and comfort of the mask has been reported, there are certain limitations, requiring further improvement. The present review aims to highlight the filtration efficacy, comfort, and associated characteristic of various types of face masks and respirators as a function of their design and structure. In addition, the air pollutants, their adverse effects on health, certified respirators, and face masks are also discussed. The present review also provides an insight into different types of commercially available face masks in terms of their materials, filtration efficiency, and limitations. The role of emerging trends (such as nanotechnology and high-performance polymers) in the improvement and development of face masks and respirators is also discussed.

Lessons from the health policies for children during the pandemic in Japan

It is everyone's desire to seek the sound growth of children through food education and there is a critical need for fostering an environment for this purpose. Health policies are important for this support. To the present, the Japanese society has been greatly disrupted by COVID-19 pandemic. "Stay at home", "mokusyoku (silent eating)", and mask wearing were encouraged in nationwide campaigns as public health measures to combat COVID-19. There are some papers reporting negative effects of "stay at home" and lockdowns such as weight gain, decrease in physical activities and change in eating habits. In Japan, while benefits and advantages of food education during mealtime were previously well studied, the "mokusyoku" rule may directly run counter to this food education. Moreover, there are several reports showing that nutrients might contribute to prevention of infectious diseases. Japanese children were also encouraged to wear masks all day long. The results of the clinical research, especially randomized control trials, show limited protective effect of masks. On the other hand, negative outcomes of the masks were reported in various scenes. This review focuses on these topics and arousing reconsideration for a better environment for children.

Bacterial and fungal isolation from face masks under the COVID-19 pandemic

The COVID-19 pandemic has led people to wear face masks daily in public. Although the effectiveness of face masks against viral transmission has been extensively studied, there have been few reports on potential hygiene issues due to bacteria and fungi attached to the face masks. We aimed to (1) quantify and identify the bacteria and fungi attaching to the masks, and (2) investigate whether the mask-attached microbes could be associated with the types and usage of the masks and individual lifestyles. We surveyed 109 volunteers on their mask usage and lifestyles, and cultured bacteria and fungi from either the face-side or outer-side of their masks. The bacterial colony numbers were greater on the face-side than the outer-side; the fungal colony numbers were fewer on the face-side than the outer-side. A longer mask usage significantly increased the fungal colony numbers but not the bacterial colony numbers. Although most identified microbes were non-pathogenic in humans; Staphylococcus epidermidis, Staphylococcus aureus, and Cladosporium, we found several pathogenic microbes; Bacillus cereus, Staphylococcus saprophyticus, Aspergillus, and Microsporum. We also found no associations of mask-attached microbes with the transportation methods or gargling. We propose that immunocompromised people should avoid repeated use of masks to prevent microbial infection.

Assessment of Cardio-Respiratory Function in Overweight and Obese Children Wearing Face Masks during the COVID-19 Pandemic

Objective: To evaluate whether the use of a surgical and N95 mask for overweight and obese children was associated with respiratory distress. Methods: We enrolled 15 healthy and 14 overweight or obese children. We performed two sessions: one wearing a surgical, the other an N95 mask. We tracked changes in partial pressure of end-tidal carbon dioxide (PETCO2), oxygen saturation (SaO2), pulse rate (PR), and respiratory rate (RR) during a 72 min test: 30 min without a mask, 30 min wearing a mask, and then during a 12 min walking test. Results: In healthy children, there was no significant change in SaO2 and PETCO2 during the study; there was a significant increase in PR and RR after the walking test with both the masks. In overweight or obese children, there was no significant change in SaO2 during the study period; there was a significant increase in PETCO2 as fast as wearing the mask and an increase in PETCO2, PR, and RR after walking test. After the walking test, we showed a significant correlation between PETCO2 and body mass index. Conclusion: Overweight or Obese children who wear a mask are more prone to developing respiratory distress, which causes them to remove it frequently. In a crowded environment, they are at greater risk of infection. For this reason, it is desirable that they attend environments where everyone uses a mask.

Investigation of the Role of Face Shape on the Flow Dynamics and Effectiveness of Face Masks

Due to the COVID-19 pandemic, face masks have been used extensively in society. The effectiveness of face masks depends on their material, design, and fit. With much research being focused on quantifying the role of the material, the design and fit of masks have been an afterthought at most. Recent studies, on the other hand, have shown that the mask fit is a significant factor to consider when specifying the effectiveness of the face mask. Moreover, the fit is highly dependent on face topology. Differences in face types and anthropometrics lead to different face mask fit. Here, computational fluid dynamics simulations employing a novel model for porous membranes (i.e., masks) are used to study the leakage pattern of a cough through a face mask on different faces. The three faces studied (female, male, and child) are characteristic faces identified in a previous population study. The female face is observed to have the most leakage through the periphery of the mask, which results in the lowest fitted filtration efficiency of the three faces. The male and child faces had similar gap profiles, leakage and fitted filtration efficiencies. However, the flow of the three faces differs significantly. The effect of the porosity of the mask was also studied. While all faces showed the same general trend with changing porosity, the effect on the child’s face was more significant.

Association of Trends in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Seroprevalence and State-Issued Nonpharmaceutical Interventions: United States, 1 August 2020 to 30 March 2021

BACKGROUND

We assess if state-issued nonpharmaceutical interventions (NPIs) are associated with reduced rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as measured through anti-nucleocapsid (anti-N) seroprevalence, a proxy for cumulative prior infection that distinguishes seropositivity from vaccination.

METHODS

Monthly anti-N seroprevalence during 1 August 2020 to 30 March 2021 was estimated using a nationwide blood donor serosurvey. Using multivariable logistic regression models, we measured the association of seropositivity and state-issued, county-specific NPIs for mask mandates, gathering bans, and bar closures.

RESULTS

Compared with individuals living in a county with all three NPIs in place, the odds of having anti-N antibodies were 2.2 (95% confidence interval [CI]: 2.0-2.3) times higher for people living in a county that did not have any of the 3 NPIs, 1.6 (95% CI: 1.5-1.7) times higher for people living in a county that only had a mask mandate and gathering ban policy, and 1.4 (95% CI: 1.3-1.5) times higher for people living in a county that had only a mask mandate.

CONCLUSIONS

Consistent with studies assessing NPIs relative to COVID-19 incidence and mortality, the presence of NPIs were associated with lower SARS-CoV-2 seroprevalence indicating lower rates of cumulative infections. Multiple NPIs are likely more effective than single NPIs.

Effect of Wearing Surgical Face Masks on Gas Detection from Respiration Using Photoacoustic Spectroscopy

Wearing surgical face masks is among the measures taken to mitigate coronavirus disease (COVID-19) transmission and deaths. Lately, concern was expressed about the possibility that gases from respiration could build up in the mask over time, causing medical issues related to the respiratory system. In this research study, the carbon dioxide concentration and ethylene in the breathing zone were measured before and immediately after wearing surgical face masks using the photoacoustic spectroscopy method. From the determinations of this study, the C₂H₄ was established to be increased by 1.5% after one hour of wearing the surgical face mask, while CO₂ was established to be at a higher concentration of 1.2% after one hour of wearing the surgical face mask, when the values were correlated with the baseline (control).

Face masks to fight against COVID-19 pandemics: A comprehensive review of materials, design, technology and product development

The outbreak of COVID-19 has created renewed attention on research and large scale manufacturing of face masks. In the last two decades, usage of face masks for respiratory protection has gained increased importance as a measure to control the maladies and fatalities due to exposure to particulate pollutants and toxic pathogens. Numerous variants of surgical and high-performance respirator masks are available in the market, and yet the fibrous materials science researchers, manufacturers and public health agencies are making concerted efforts towards improvising them with respect to self-sterilisability, facial fit, thermo-physiological comfort, reusability and biodegradability, while maintaining or rather enhancing the filtration efficiency. This review article presents a compendium of materials, design and performance standards of existing face masks, as well as elaborates on developments made for their performance enhancement. The criticality of inculcation of good hygiene habits and earnest compliance to correct mask donning and doffing practices has also been highlighted. This review is expected to make valuable contributions in the present COVID-19 scenario when donning a face mask has become mandatory.

Novel sustainable filter for virus filtration and inactivation

The COVID-19 pandemic has caused a multi-scale impact on the world population that started from a nano-scale respiratory virus and led to the shutdown of macro-scale economies. Direct transmission of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) and its variants through aerosolized droplets is a major contributor towards increasing cases of this infection. To curb the spread, one of the best engineered solutions is the use of face masks to prevent the passage of infectious saliva micro-droplets from an infected person to a healthy person. The commercially available masks are single use, passive face-piece filters. These become difficult to breathe in during strenuous activities. Also, they need to be disposed regularly due to accumulation of unwanted particulate and pathogens over time. Frequent disposal of these masks is unsustainable for the environment. In this study, we have proposed a novel design for a filter for enhanced virus filtration, better breathability, and virus inactivation over time. The filter is called Hy–Cu named after its (Hy) drophobic properties and another significant layer comprises of copper (Cu). The breathability (pressure drop across filter) of Hy–Cu is tested and compared with widely used surgical masks and KN95 masks, both experimentally and numerically. The results show that the Hy–Cu filter offers at least 10% less air resistance as compared to commercially available masks. The experimental results on virus filtration and inactivation tests using MS2 bacteriophage (a similar protein structure as SARS-CoV-2) show that the novel filter has 90% filtering efficiency and 99% virus inactivation over a period of 2 h. This makes the Hy–Cu filter reusable and a judicious substitute to the single use masks.

Penetration and aerosolization of cough droplet spray through face masks: A unique pathway of transmission of infection

The advent of the COVID-19 pandemic has necessitated the use of face masks, making them an integral part of the daily routine. Face masks occlude the infectious droplets during any respiratory event contributing to source control. In the current study, spray impingement experiments were conducted on porous surfaces like masks having a different porosity, pore size, and thickness. The spray mimics actual cough or a mild sneeze with respect to the droplet size distribution (20–500 μm) and velocity scale (0–14 m/s), which makes the experimental findings physiologically realistic. The penetration dynamics through the mask showed that droplets of all sizes beyond a critical velocity penetrate through the mask fabric and atomize into daughter droplets in the aerosolization range, leading to harmful effects due to the extended airborne lifetime of aerosols. By incorporating spray characteristics along with surface tension and viscous dissipation of the fluid passing through the mask, multi-step penetration criteria have been formulated. The daughter droplet size and velocity distribution after atomizing through multi-layered masks and its effects have been discussed. Moreover, the virus-emulating particle-laden surrogate respiratory droplets are used in impingement experiments to study the filtration and entrapment of virus-like nanoparticles in the mask. Furthermore, the efficacy of the mask from the perspective of a susceptible person has been investigated.

A Simple Method to Quantify Outward Leakage of Medical Face Masks and Barrier Face Coverings: Implication for the Overall Filtration Efficiency

Face masking proved essential to reduce transmission of COVID-19 and other respiratory infections in indoor environments, but standards and literature do not provide simple quantitative methods for quantifying air leakage at the face seal. This study reports an original method to quantify outward leakage and how wearing style impacts on leaks and filtration efficiency. The amount of air leakage was evaluated on four medical masks and four barrier face coverings, exploiting a theoretical model and an instrumented dummy head in a range of airflows between 30 and 160 L/min. The fraction of air leaking at the face seal of the medical masks and barrier face coverings ranged from 43% to 95% of exhaled air at 30 L/min and reduced to 10-85% at 160 L/min. Filter breathability was the main driver affecting both leak fraction and total filtration efficiency that varied from 5% to 53% and from 15% to 84% at 30 and 160 L/min, respectively. Minor changes were related to wearing style, supporting indications on the correct mask use. The fraction of air leaking from medical masks and barrier face coverings during exhalation is relevant and varies according to design and wearing style. The use of highly breathable filter materials reduces air leaks and improve total filtration efficiency.

Reusability of P3 Facial Filter in a Pandemic Emergency: A 3D Analysis of Filter Microstructure with X-ray Microtomography Images after Dry Heat and UV Sterilization Procedures

Objective: Our goal is to evaluate the effects of heat and ultraviolet (UV) irradiation on P3 facial respirator microstructure. Intervention: P3 facial filters were exposed to dry heat and UV sterilization procedures. Methods: P3 facial filter samples underwent a standardized sterilization process based on dry heat and UV irradiation techniques. We analyzed critical parameters of internal microstructure, such as fiber thickness and porosity, before and after sterilization, using 3D data obtained with synchrotron radiation-based X-ray computed microtomography (micro-CT). The analyzed filter has two inner layers called the “finer” and “coarser” layers. The “finer” layer consists of a dense fiber network, while the “coarser” layer has a less compact fiber network. Results: Analysis of 3D images showed no statistically significant differences between the P3 filter of the controls and the dry heat/UV sterilized samples. In particular, averages fiber thickness in the finer layer of the control and the 60° dry heated and UV-irradiated sample groups was almost identical. Average fiber thickness for the coarser layer of the control and the 60° dry heated and UV-irradiated sample groups was very similar, measuring 19.33 µm (±0.47), 18.33 µm (±0.47), and 18.66 µm (±0.47), respectively. There was no substantial difference in maximum fiber thickness in the finer layers and coarser layers. For the control group samples, maximum thickness was on average 11.43 µm (±1.24) in the finer layer and 59.33 µm (±6.79) in the coarser layer. Similarly, the 60° dry heated group samples were thickened 12.2 µm (±0.21) in the finer layer and 57.33 µm (±1.24) in the coarser layer, while for the UV-irradiated group, the mean max thickness was 12.23 µm (±0.90) in the finer layer and 58.00 µm (±6.68) in the coarser layer. Theoretical porosity analysis resulted in 74% and 88% for the finer and coarser layers. The finer layers’ theoretical porosity tended to decrease in dry heat and UV-irradiated samples compared with the respective control samples. Conclusions: Dry heat and UV sterilization processes do not substantially alter the morphometry of the P3 filter samples’ internal microstructure, as studied with micro-CT. The current study suggests that safe P3 filter facepiece reusability is theoretically feasible and should be further investigated.

Adherence to facemask use in public places during the autumn-winter 2020 COVID-19 lockdown in Greece: observational data

BACKGROUND

Wearing facemasks is of proven efficacy as a public health protective measure against COVID-19. Currently there are no observational data concerning the wearing of facemasks and the adherence to guidelines concerning their handling.

METHODS

Registration of the way passers-by were wearing facemasks at 26 different locations of five major cities in Greece. The results were correlated with the rate of COVID-19 deaths in the region.

RESULTS

In total, 119,433 passers-by were registered, 57,043 females (47.8%) and 62,390 males (52.2%). From the total sample, 81.1% were wearing the mask properly, 10.8% had their nose out, 6.2% were wearing it under the jaw, and 1.9% had no mask at all . There was a significant difference between males and females concerning any use of mask. Inappropriate use of was correlated with COVID-19 death rate in the studied region.

CONCLUSION

Our findings suggest that under conditions of mandatory wearing and in central locations of major cities, during walking, proper use of masks is suboptimal, but still contributes with some protection. Fear and risk perception seem to be strong factors contributing to adherence to proper mask wearing.

Effectiveness of Mask-Wearing on Respiratory Illness Transmission in Community Settings: A Rapid Review

OBJECTIVE

Respiratory illnesses, including coronavirus disease 2019 (COVID-19), have resulted in millions of deaths globally. Guidance on mask-wearing in community settings has been inconsistent. This review examined the effectiveness of mask-wearing on respiratory virus transmission in community settings.

METHODS

A search was conducted for English language reports of randomized controlled trials of mask-wearing in the community and effect on laboratory-confirmed respiratory infections or influenza-like illness. Investigators abstracted study characteristics and assessed bias. Meta-analysis was conducted to calculate pooled risk estimates.

RESULTS

Eleven studies were included. In 7 studies that evaluated influenza-like illness symptoms as an outcome (3029 participants), this study found mask-wearing associated with a decreased risk of influenza-like illness (overall risk ratio [RR], 0.83; 95% confidence interval [CI], 0.71 to 0.96). Studies examining laboratory-confirmed respiratory infections as an outcome (10,531 participants) showed no statistically significant association between mask-wearing and infections (RR, 1.04; 95% CI, 0.60-1.80). However, masking combined with enhanced hand hygiene was associated with a decreased risk for both influenza-like illness symptoms (RR, 0.88; 95% CI, 0.51-1.51) and laboratory-confirmed respiratory infection (RR, 0.79; 95% CI, 0.52-1.18).

CONCLUSIONS

Masking in community settings decreases transmission of influenza-like illness. Mask-wearing combined with enhanced hand hygiene reduces transmission of influenza-like illness and laboratory-confirmed respiratory infection.

Comparative effectiveness of N95, surgical or medical, and non-medical facemasks in protection against respiratory virus infection: A systematic review and network meta-analysis

The aim of this systematic review and network meta‐analysis is to evaluate the comparative effectiveness of N95, surgical/medical and non‐medical facemasks as personal protective equipment against respiratory virus infection. The study incorporated 35 published and unpublished randomized controlled trials and observational studies investigating specific mask effectiveness against influenza virus, SARS‐CoV, MERS‐CoV and SARS‐CoV‐2. We searched PubMed, Google Scholar and medRxiv databases for studies published up to 5 February 2021 (PROSPERO registration: CRD42020214729). The primary outcome of interest was the rate of respiratory viral infection. The quality of evidence was estimated using the GRADE approach. High compliance to mask‐wearing conferred a significantly better protection (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.23–0.82) than low compliance. N95 or equivalent masks were the most effective in providing protection against coronavirus infections (OR, 0.30; CI, 0.20–0.44) consistently across subgroup analyses of causative viruses and clinical settings. Evidence supporting the use of medical or surgical masks against influenza or coronavirus infections (SARS, MERS and COVID‐19) was weak. Our study confirmed that the use of facemasks provides protection against respiratory viral infections in general; however, the effectiveness may vary according to the type of facemask used. Our findings encourage the use of N95 respirators or their equivalents (e.g., P2) for best personal protection in healthcare settings until more evidence on surgical and medical masks is accrued. This study highlights a substantial lack of evidence on the comparative effectiveness of mask types in community settings.

Perceived Effectiveness and Sustainability of Face Masks Among German Citizens During the 2nd Wave of the COVID-19 Pandemic—A Cross-Sectional Study

Background

The COVID-19 pandemic, which began at the end of 2019, has led to a significant increase in the demand for face masks in Germany and around the globe. Since non-reusable masks are often not correctly disposed of and are not biodegradable, their increasing use harms the environment. Both the ongoing pandemic and the rising environmental pollution eventually pose a threat to human health. Yet, it is unclear whether mask users are conscious of this, and which factors influence their choice of face masks. This study investigates the user preferences, perceived effectiveness, and the sustainability of different mouth/nose protection (MNP) to lay the foundation for developing more sustainable and effective alternatives.

Methods

A national (Germany-wide) cross-sectional study with a sample of 1,036 participants was conducted. Descriptive data analysis was deployed to describe trends and socio-demographic differences among the respondents. Different socio-demographic groups among the respondents were compared regarding their infection risk perception, compliance toward the use of personal protective measures, their choice of MNP, and knowledge level of sustainability and effectiveness of various MNP using inferential statistics (Chi2 test/Whitney–Mann-U-test/Kruskal–Wallis-test).

Results

The results suggest that, in addition to protective effectiveness, the reusability of MNP is important to not just most respondents but especially to older participants. In contrast, the price, shape, and design were not as important. The knowledge level of the effectiveness and sustainability of MNP was high among the participants and was not associated with socioeconomic characteristics. However, the knowledge level directly influenced the choice of MNP.

Conclusion

There seems to be an inclination to use sustainable MNP, provided their level of protection is similar to medical masks or FFP2/FFP3 masks. The willingness to wear a sustainable option increases with age.

Functionalized non-woven surfaces for combating the spread of the COVID-19 pandemic

The worldwide outbreak of SARS-CoV-2 infection has necessitated mandatory use of face masks, personal protective equipment and intake of a healthy diet for immunity boosting. As per WHO's recommendation, continuous use of masks has been proven effective in decreasing the SARS-CoV-2 infection rate. The present study reports on the bacterial filtration efficacy (BFE) of a novel 4-ply functionalized non-woven face mask. We synthesized a polypropylene-based fabric with inner layers of melt-blown fine fibres coated with polylactic acid and immune-boosting herbal phytochemicals. Experimental studies on the synthesized face mask demonstrated a BFE of greater than 99% against Staphylococcus aureus (a bacterium species frequently found in mammalian respiratory tract). A thorough computational analysis using LibDock algorithm demonstrated an effective docking performance of herbal phytochemicals against harmful virus structures. More importantly, the face mask also showed sufficient and stable breathability as per regulatory standards. A breathing resistance of 30 Pa at an aerosol flow rate of 30 l h⁻¹ was reported under standard temperature and pressure conditions, indicating a high potential for real-world applications.

Interventions for the Current COVID-19 Pandemic: Frontline Workers' Intention to Use Personal Protective Equipment

BACKGROUND

Frontline workers (FLWs) are at a higher risk of COVID-19 infection during care interactions than the general population. Personal protective equipment (PPE) is regarded as an effective intervention for limiting the transmission of airborne viruses. However, research examining FLWs' intention to use PPE is limited.

OBJECTIVES

This study addresses this research gap and also contributes by expanding the conceptual mechanism of planned behavior theory by incorporating three novel dimensions (perceived benefits of PPE, risk perceptions of the epidemic, and unavailability of PPE) in order to gain a better understanding of the factors that influence FLWs' intentions to use PPE.

METHOD

Analysis is based on a sample of 763 FLWs in Pakistan using a questionnaire survey, and the structural equation modeling approach is employed to evaluate the suppositions.

RESULTS

Study results indicate that attitude, perceived benefits of PPE, and risk perceptions of the epidemic have positive influence on FLWs' intention to use PPE. In comparison, the unavailability of PPE and the cost of PPE have opposite effects. Meanwhile, environmental concern has a neutral effect.

CONCLUSIONS

The study results specify the importance of publicizing COVID-19's lethal impacts on the environment and society, ensuring cheap PPE, and simultaneously enhancing workplace safety standards.

Efficacy and practice of facemask use in general population: a systematic review and meta-analysis

In recent decades, respiratory infections, including SARS, HINI and the currently spreading COVID-19, caused by various viruses such as influenza and coronavirus have seriously threatened human health. It has generated inconsistent recommendations on the mandatory use of facemasks across countries on a population level due to insufficient evidence on the efficacy of facemask use among the general population. This meta-analysis aimed to explore (1) the efficacy of facemask use on preventing respiratory infections, and (2) the perceptions, intentions, and practice about facemask use among the general population worldwide. We searched PubMed, MEDLINE, Web of Science, Cochrane, bioRxiv, and medRxiv databases since inception to August 17, 2020. From 21,341 records identified, eight RCTs on facemask in preventing infections and 78 studies on perception, intention, and practice of facemask use among the general population were included in the analysis. The meta-analysis of RCTs found a significant protective effect of facemask intervention (OR = 0.84; 95% CI = 0.71-0.99; I2 = 0%). This protective effect was even more pronounced when the intervention duration was more than two weeks (OR = 0.76; 95% CI = 0.66-0.88; I2 = 0%). The meta-analysis of observational studies on perception, intention, and practice on facemask use showed that 71% of respondents perceived facemasks to be effective for infection prevention, 68% of respondents would wear facemasks, and 54% of respondents wore facemasks for preventing respiratory infections. Differences in perception, intention, and practice behavior of facemask use in different regions may be related to the impact of respiratory infections, regional culture, and policies. The governments and relevant organizations should make effort to reduce the barriers in the use of facemasks.

Impact of the COVID-19 Pandemic on the Pediatric Hospital Visits: Evidence from the State of Florida

Although early evidence reported a substantial decline in pediatric hospital visits during COVID-19, it is unclear whether the decline varied across different counties, particularly in designated Medically Underserved Areas (MUA). The objective of this study is to explore the state-wide impact of COVID-19 on pediatric hospital visit patterns, including the economic burden and MUA communities. We conducted a retrospective observational study of pediatric hospital visits using the Florida State all-payer Emergency Department (ED) and Inpatient dataset during the pandemic (April-September 2020) and the same period in 2019. Pediatric Treat-and-Release ED and inpatient visit rates were compared by patient demographics, socioeconomic, diagnosis, MUA status, and hospital characteristics. Pediatric hospital visits in Florida decreased by 53.7% (62.3% in April-June, 44.2% in July-September) during the pandemic. The Treat-and-Release ED and inpatient visits varied up to 5- and 3-fold, respectively, across counties. However, changes in hospital visits across MUA counties were similar compared with non-MUA counties except for lower Treat-and-Release ED volume in April-May. The disproportional decrease in visits was notable for the underserved population, including Hispanic and African American children; Medicaid coverages; non-children's hospitals; and diagnosed with respiratory diseases, appendicitis, and sickle-cell. Florida Hospitals experienced a USD 1.37 billion (average USD 8.3 million) decline in charges across the study period in 2020. Disproportionate decrease in hospital visits, particularly in the underserved population, suggest a combined effect of the persistent challenge of care access and changes in healthcare-seeking behavior during the pandemic. These findings suggest that providers and policymakers should emphasize alternative interventions/programs ensuring adequate care during the pandemic, particularly for high-risk children.

Face mask use in the community and cutaneous reactions to them during the COVID-19 pandemic: results of a national survey in Italy

To mitigate the outbreak of coronavirus disease 2019 pandemic, many countries have imposed the public use of face masks. We investigated attitudes and skin reactions in the Italian individuals wearing face masks during the pandemic. A cross-sectional survey on a random sample (N=1001) of the Italian adult population was conducted in May 2020 by the Italian Group for Epidemiological Research in Dermatology, and the Gallup International Association. Univariable and multivariable regression analysis were used to estimate the odds ratios and their 95% confidence intervals. Most individuals (72.5%) wore a mask, 56.5% used a surgical mask and 53.0% a disposable mask. One-third changed the mask at least once a day, two-thirds kept a distance of at least one meter from each other, 50% washed their hands before wearing a mask, and 17.6% adopted multiple hygienic behaviors. Twenty percent of individuals reported redness, swelling, itching or erosions in the skin area of mask contact; the risk of this reaction was associated with young age, the use of respirators and a history of pre-existing contact eczema, psoriasis or atopic dermatitis. Health educational programs may improve compliance with combined preventive measures and reduce skin reactions.

Should coronavirus policies remain in place to prevent future paediatric influenza deaths?

The 2019-2020 to 2020-2021 influenza seasons in the USA saw a dramatic 99.5% decrease in paediatric mortality, with only one influenza death recorded during the latter season. This decrease has been attributed to a substantial reduction in transmission, resulting from the various restrictive measures enacted during the COVID-19 pandemic, onset March 2020. The relative disappearance of influenza raises specific policy questions, such as whether these measures should be kept in place after COVID-19 transmission reaches acceptable levels or herd immunity is achieved. Given the nature of these measures as liberty restricting, it is worth discussing their intended outcome and what values they promote. Do these measures in fact promote health, or simply give the comfort of safety while undermining long-term health and individual liberties? I argue that the year-long endurance of the pandemic well into 2021 may have flattened our value landscape into one where health reigns supreme. Discussions are underway regarding whether we should modify previously accepted health risks, such as the risk of contracting influenza. In this paper, I attempt to clarify the values that motivate our policies and discuss how our present historical context has appreciated the value of health. I also provide an analysis of various pandemic policies and their relation to influenza paediatric deaths. Ultimately, the cost of certain measures on values such as education, socialisation and liberty, among others, is too high to justify their use beyond regulating the spread of COVID-19.

Change in Pediatric Health Care Spending and Drug Utilization during the COVID-19 Pandemic

Objective: To evaluate how the restrictive measures implemented during the SARS-CoV-2 pandemic have influenced the incidence of the most common children’s diseases and the consumption of medications in 2020 compared to 2019. Methods: We involved all family pediatricians of the local health authority of Latina, from which we requested data of monthly visits in 2019 and 2020 for six common diseases disseminated through droplets and contact, and the territorial and integrative pharmaceutical unit of the area, from which we requested data of the net expenditure regarding the most commonly used drugs at pediatric age. Results: There was significant reduction in the incidence of the evaluated diseases and in the consumption of investigated drugs between 2019 and 2020 in the months when the restrictive measures were in place, with an attenuation of this effect during the months of the gradual loosening of those measures. Conclusion: Nonpharmaceutical intervention measures have caused changes in the diffusion of common pediatric diseases. We believe that the implementation of a reasonable containment strategy, even outside of the pandemic, could positively influence the epidemiology of infectious and allergic diseases in children, and healthcare system spending.

Outpatient healthcare personnel knowledge and attitudes towards infection prevention measures for protection from respiratory infections

BACKGROUND

Healthcare personnel (HCP) knowledge and attitudes toward infection control measures are important determinants of practices that can protect them from transmission of infectious diseases.

METHODS

Healthcare personnel were recruited from Emergency Departments and outpatient clinics at seven sites. They completed knowledge surveys at the beginning and attitude surveys at the beginning and end of each season of participation. Attitudes toward infection prevention and control measures, especially medical masks and N95 respirators, were compared. The proportion of participants who correctly identified all components of an infection control bundle for seven clinical scenarios was calculated.

RESULTS

The proportion of participants in the medical mask group who reported at least one reason to avoid using medical masks fell from 88.5% on the pre-season survey to 39.6% on the post-season survey (odds ratio [OR] for preseason vs. postseason 0.11, 95% CI 0.10-0.14). Among those wearing N95 respirators, the proportion fell from 87.9% to 53.6% (OR 0.24, 95% CI 0.21-0.28). Participants correctly identified all components of the infection control bundle for 4.9% to 38.5% of scenarios.

CONCLUSIONS

Attitudes toward medical masks and N95 respirators improved significantly between the beginning and end of each season. The proportion of HCP who correctly identified the infection control precautions needed for clinical scenarios was low, but it improved over successive years of participation in the study.

Unmasking the mask studies: why the effectiveness of surgical masks in preventing respiratory infections has been underestimated

BACKGROUND

Pre-pandemic empirical studies have produced mixed statistical results on the effectiveness of masks against respiratory viruses, leading to confusion that may have contributed to organizations such as the WHO and CDC initially not recommending that the general public wear masks during the coronavirus disease 2019 pandemic.

METHODS

A threshold-based dose-response curve framework is used to analyse the effects of interventions on infection probabilities for both single and repeated exposure events. Empirical studies on mask effectiveness are evaluated with a statistical power analysis that includes the effect of adherence to mask usage protocols.

RESULTS

When the adherence to mask usage guidelines is taken into account, the empirical evidence indicates that masks prevent disease transmission: all studies we analysed that did not find surgical masks to be effective were under-powered to such an extent that even if masks were 100% effective, the studies in question would still have been unlikely to find a statistically significant effect. We also provide a framework for understanding the effect of masks on the probability of infection for single and repeated exposures. The framework demonstrates that masks can have a disproportionately large protective effect and that more frequently wearing a mask provides super-linearly compounding protection.

CONCLUSIONS

This work shows (1) that both theoretical and empirical evidence is consistent with masks protecting against respiratory infections and (2) that non-linear effects and statistical considerations regarding the percentage of exposures for which masks are worn must be taken into account when designing empirical studies and interpreting their results.

Effects of N95 Mask Use on Pulmonary Function in Children

OBJECTIVE

To assess whether use of an N95 mask by children is associated with episodes of desaturation or respiratory distress.

STUDY DESIGN

Twenty-two healthy children were assigned at random to 1 of 2 groups: one group wearing N95 masks without an exhalation valve and the other group wearing N95 masks with an exhalation valve. We tracked changes in partial pressure of end-tidal carbon dioxide (P_ETCO2), oxygen saturation, pulse rate, and respiratory rate over 72 minutes of mask use. All subjects were monitored every 15 minutes, the first 30 minutes while not wearing a mask and the next 30 minutes while wearing a mask. They then performed a 12-minute walking test.

RESULTS

The children did not experience a statistically significant change in oxygen saturation or pulse rate during the study. There were significant increases in respiratory rate and P_ETCO2 in the children wearing an N95 mask without an exhalation valve, whereas these increases were seen in the children wearing a mask with an exhalation valve only after the walking test.

CONCLUSIONS

The use of an N95 mask could potentially cause breathing difficulties in children if the mask does not have an exhalation valve, particularly during a physical activity. We believe that wearing a surgical mask may be more appropriate for children.

Coronavirus lockdown and virus suppression: An international analysis

This paper analyses the effect of lockdown against the coronavirus which is one of the fastest growing threats in the world. We focus on three categories of lockdown and group four continents, Asia, America, Europe, and Africa together to assess the effectiveness of such a measure to contain the virus. We also look at a number of variables linked to the spread of the virus to determine the factors affecting the growth of new confirmed cases. We show evidence that countries in Europe are more likely to impose a national lockdown than any other continent. For the empirical analysis, we undertake the cross-sectional regression model, logistic regression model and logistic growth curve as a method to apply the data collected over the period March to June 2020 as this is the data available at the time this paper is composed. The empirical results of this paper indicate that countries which impose the strictest form of lockdown will result in a reduction in growth of new confirmed cases.