Masks and Face Coverings for the Lay Public : A Narrative Update

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.

Children's experiences of mask-wearing: a systemic review and narrative synthesis

RATIONALE

Masks have been widely used as a preventative tool during the COVID-19 pandemic. However, the use of masks by children has been controversial, with international guidelines recommending a risk-based approach to national policymakers.

AIMS AND OBJECTIVES

We aimed to conduct a systematic review that explores children's experiences of mask-wearing, drawing on an evidence base that describes mask-wearing in different contexts including air pollution, and to prevent the spread of infectious disease.

METHODS

We searched MEDLINE, Embase and PsycINFO in June 2021, with repeat searches in August 2022 and January 2024, for primary research studies exploring children's experiences of masks. Included studies reported on participants between 4 and 14 years (inclusive), with no restrictions on language where an English translation was available. Two reviewers independently screened titles and abstracts and reviewed full texts, with discrepancies resolved by a third reviewer. We used the Mixed Methods Appraisal Tool for quality appraisal and narrative synthesis to identify key findings. We also conducted stakeholder consultation (Patient and Public Involvement (PPI)) with nine children, where they submitted annotated drawings of their preferred masks to complement our review findings.

RESULTS

We screened 982 titles and abstracts and reviewed 94 full texts. 45 studies were included in the synthesis. Children's experiences of mask-wearing were influenced by their perceived necessity, social norms around their use and parental attitudes. Challenges related to mask-wearing were described, including difficulty reading facial expressions and physical discomfort. Children found it easier to wear masks when sitting and in cooler environments, and they benefited from unmasking during outdoor break time at school. As part of the PPI consultation, children highlighted the importance of mask design and the environmental impact of masks.

CONCLUSION

Children's experiences of mask-wearing were varied and context-dependent, with several mask-design challenges raised. Future policy on mask-wearing needs to consider the context in which mask-wearing would be most beneficial, and how local adaptations to policy can respond to children's needs.

Impact of community mask mandates on SARS-CoV-2 transmission in Ontario after adjustment for differential testing by age and sex

Mask use for prevention of respiratory infectious disease transmission is not new but has proven controversial during the SARS-CoV-2 pandemic. In Ontario, Canada, irregular regional introduction of community mask mandates in 2020 created a quasi-experiment useful for evaluating the impact of such mandates; however, Ontario SARS-CoV-2 case counts were likely biased by testing focused on long-term care facilities and healthcare workers. We developed a regression-based method that allowed us to adjust cases for under-testing by age and gender. We evaluated mask mandate effects using count-based regression models with either unadjusted cases, or testing-adjusted case counts, as dependent variables. Models were used to estimate mask mandate effectiveness, and the fraction of SARS-CoV-2 cases, severe outcomes, and costs, averted by mask mandates. Models using unadjusted cases as dependent variables identified modest protective effects of mask mandates (range 31-42%), with variable statistical significance. Mask mandate effectiveness in models predicting test-adjusted case counts was higher, ranging from 49% (95% CI 44-53%) to 76% (95% CI 57-86%). The prevented fraction associated with mask mandates was 46% (95% CI 41-51%), with 290,000 clinical cases, 3,008 deaths, and loss of 29,038 quality-adjusted life years averted from 2020 June to December, representing $CDN 610 million in economic wealth. Under-testing in younger individuals biases estimates of SARS-CoV-2 infection risk and obscures the impact of public health preventive measures. After adjustment for under-testing, mask mandates emerged as highly effective. Community masking saved substantial numbers of lives, and prevented economic costs, during the SARS-CoV-2 pandemic in Ontario, Canada.

Assessment of mask use on oxygen saturation in adults and children with asthma

Background: Mask use is recommended to reduce the transmission of severe acute respiratory syndrome coronavirus 2. The safety of mask use in adults and children with asthma is unknown. Objective: The objective of this study is to evaluate the effect of mask use on peripheral oxygen saturation (SpO₂) in those with and those without asthma. Methods: A two-stage cross-sectional study was performed. In the first stage, the SpO₂ concentration in adults and children with and without asthma was measured with the adults and children at rest during mask use. In the second stage, children years 6-17 performed a 6-minute walk test while wearing masks. The SpO₂ concentration was measured before the exercise and at 3 and 6 minutes into exercise. Subjective dyspnea was evaluated by using the Pediatric Dyspnea Scale (PDS). Results: In the first stage, SpO₂ levels in 393 subjects were analyzed. In the second stage, 50 pediatric subjects were included, 25 with and 25 without asthma. There was no difference in SpO₂ levels between those with and those without asthma in adults and children wearing masks while at rest, with median SpO₂ 98% in both groups. There was no difference in oxygen saturation or reported level of dyspnea between the children with asthma and children without asthma performing the 6-minute walk test while wearing masks. Median SpO₂ levels were at or near 99% in the asthma and non-asthma groups at all time points. Median PDS scores were similar between the asthma and non-asthma groups. Conclusion: Mask use did not affect SpO₂ in adults and children at rest or in children performing low-to-moderate intensity exercise. These findings were consistent in those with and without asthma.

The role of primary care during the pandemic: shared experiences from providers in five European countries

BACKGROUND

The COVID-19 pandemic necessitated wide-ranging adaptations to the organisation of health systems, and primary care is no exception. This article aims to collate insights on the role of primary care during the pandemic. The gained knowledge helps to increase pandemic preparedness and resilience.

METHODS

The role of primary care during the pandemic in five European countries (Austria, Denmark, France, Hungary, Italy) was investigated using a qualitative approach, namely case study, based on document analysis and semi-structured interviews. In total, 31 interviews were conducted with primary care providers between June and August 2022. The five country case studies were subjected to an overarching analysis focusing on successful strategies as well as gaps and failures regarding pandemic management in primary care.

RESULTS

Primary care providers identified disruptions to service delivery as a major challenge emerging from the pandemic which led to a widespread adoption of telehealth. Despite the rapid increase in telehealth usage and efforts of primary care providers to organise face-to-face care delivery in a safe way, some patient groups were particularly affected by disruptions in service delivery. Moreover, primary care providers perceived a substantial propagation of misinformation about COVID-19 and vaccines among the population, which also threatened patient-physician relationships. At the same time, primary care providers faced an increased workload, had to work with insufficient personal protective equipment and were provided incongruous guidelines from public authorities. There was a consensus among primary care providers that they were mostly sidelined by public health policy in the context of pandemic management. Primary care providers tackled these problems through a diverse set of measures including home visits, implementing infection control measures, refurbishing used masks, holding internal meetings and relying on their own experiences as well as information shared by colleagues.

CONCLUSION

Primary care providers were neither well prepared nor the focus of initial policy making. However, they implemented creative solutions to the problems they faced and applying the learnings from the pandemic could help in increasing the resilience of primary care. Attributes of an integrated health system with a strong primary care component proved beneficial in addressing immediate effects of the pandemic.

Considerations for de-escalating universal masking in healthcare centers

Three years after the beginning of the COVID-19 pandemic, better knowledge on the transmission of respiratory viral infections (RVI) including the contribution of asymptomatic infections encouraged most healthcare centers to implement universal masking. The evolution of the SARS-CoV-2 epidemiology and improved immunization of the population call for the infection and prevention control community to revisit the masking strategy in healthcare. In this narrative review, we consider factors for de-escalating universal masking in healthcare centers, addressing compliance with the mask policy, local epidemiology, the level of protection provided by medical face masks, the consequences of absenteeism and presenteeism, as well as logistics, costs, and ecological impact. Most current national and international guidelines for mask use are based on the level of community transmission of SARS-CoV-2. Actions are now required to refine future recommendations, such as establishing a list of the most relevant RVI to consider, implement reliable local RVI surveillance, and define thresholds for activating masking strategies. Considering the epidemiological context (measured via sentinel networks or wastewater analysis), and, if not available, considering a time period (winter season) may guide to three gradual levels of masking: (i) standard and transmission-based precautions and respiratory etiquette, (ii) systematic face mask wearing when in direct contact with patients, and (iii) universal masking. Cost-effectiveness analysis of the different strategies is warranted in the coming years. Masking is just one element to be considered along with other preventive measures such as staff and patient immunization, and efficient ventilation.

Can mask mandates boost nature-based tourism? The role of escapism and travel anxiety

Tourism in a post-pandemic era will likely be oriented toward nature because contact with nature has restorative health benefits. The purpose of this study was to analyze the antecedents of tourists' intentions to visit nature-based resorts during a pandemic. A nationally representative sample of the Spanish population (n = 500) was recruited by an online commercial panel to test and empirically validate the proposed conceptual framework. The findings confirmed a direct relationship between negative perceptions of wearing face masks during the COVID-19 pandemic and tourists' intentions to visit nature-based resorts. The relationship between the perceived negative effects of wearing face masks and the intention to visit nature-based resorts was positively mediated by the need for escapism. This impact was less pronounced for anxious travelers, as shown by results corroborating the moderating effect of travel anxiety. The findings of this study contribute to research on tourism crises and provide future insights into the recovery of the industry during COVID-19.

Face masks while exercising trial (MERIT): a cross-over randomised controlled study

OBJECTIVES

Physical exertion is a high-risk activity for aerosol emission of respiratory pathogens. We aimed to determine the safety and tolerability of healthy young adults wearing different types of face mask during moderate-to-high intensity exercise.

DESIGN

Cross-over randomised controlled study, completed between June 2021 and January 2022.

PARTICIPANTS

Volunteers aged 18-35 years, who exercised regularly and had no significant pre-existing health conditions.

INTERVENTIONS

Comparison of wearing a surgical, cloth and filtering face piece (FFP3) mask to no mask during 4×15 min bouts of exercise. Exercise was running outdoors or indoor rowing at moderate-to-high intensity, with consistency of distance travelled between bouts confirmed using a smartphone application (Strava). Each participant completed each bout in random order.

OUTCOMES

The primary outcome was change in oxygen saturations. Secondary outcomes were change in heart rate, perceived impact of face mask wearing during exercise and willingness to wear a face mask for future exercise.

RESULTS

All 72 volunteers (mean age 23.9) completed the study. Changes in oxygen saturations did not exceed the prespecified non-inferiority margin (2% difference) with any mask type compared with no mask. At the end of exercise, the estimated average difference in oxygen saturations for cloth mask was -0.07% (95% CI -0.39% to 0.25%), for surgical 0.28% (-0.04% to 0.60%) and for FFP3 -0.21% (-0.53% to 0.11%). The corresponding estimated average difference in heart rate for cloth mask was -1.20 bpm (95% CI -4.56 to 2.15), for surgical 0.36 bpm (95% CI -3.01 to 3.73) and for FFP3 0.52 bpm (95% CI -2.85 to 3.89). Wearing a face mask caused additional symptoms such as breathlessness (n=13, 18%) and dizziness (n=7, 10%). 33 participants broadly supported face mask wearing during exercise, particularly indoors, but 22 were opposed.

CONCLUSION

This study adds to previous findings (mostly from non-randomised studies) that exercising at moderate-to-high intensity wearing a face mask appears to be safe in healthy, young adults.

TRIAL REGISTRATION NUMBER

NCT04932226.

Mind the gap: Data availability, accessibility, transparency, and credibility during the COVID-19 pandemic, an international comparative appraisal

Data transparency has played a key role in this pandemic. The aim of this paper is to map COVID-19 data availability and accessibility, and to rate their transparency and credibility in selected countries, by the source of information. This is used to identify knowledge gaps, and to analyse policy implications. The availability of a number of COVID-19 metrics (incidence, mortality, number of people tested, test positive rate, number of patients hospitalised, number of patients discharged, the proportion of population who received at least one vaccine, the proportion of population fully vaccinated) was ascertained from selected countries for the full population, and for few of stratification variables (age, sex, ethnicity, socio-economic status) and subgroups (residents in nursing homes, inmates, students, healthcare and social workers, and residents in refugee camps). Nine countries were included: Bangladesh, Indonesia, Iran, Nigeria, Turkey, Panama, Greece, the UK, and the Netherlands. All countries reported periodically most of COVID-19 metrics on the total population. Data were more frequently broken down by age, sex, and region than by ethnic group or socio-economic status. Data on COVID-19 is partially available for special groups. This exercise highlighted the importance of a transparent and detailed reporting of COVID-19 related variables. The more data is publicly available the more transparency, accountability, and democratisation of the research process is enabled, allowing a sound evidence-based analysis of the consequences of health policies.

The Global Impact of COVID-19: Historical Development, Molecular Characterization, Drug Discovery and Future Directions

In December 2019, an outbreak of a respiratory disease called the coronavirus disease 2019 (COVID-19) caused by a new coronavirus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in Wuhan, China. The SARS-CoV-2, an encapsulated positive-stranded RNA virus, spread worldwide with disastrous consequences for people's health, economies, and quality of life. The disease has had far-reaching impacts on society, including economic disruption, school closures, and increased stress and anxiety. It has also highlighted disparities in healthcare access and outcomes, with marginalized communities disproportionately affected by the SARS-CoV-2. The symptoms of COVID-19 range from mild to severe. There is presently no effective cure. Nevertheless, significant progress has been made in developing COVID-19 vaccine for different therapeutic targets. For instance, scientists developed multifold vaccine candidates shortly after the COVID-19 outbreak after Pfizer and AstraZeneca discovered the initial COVID-19 vaccines. These vaccines reduce disease spread, severity, and mortality. The addition of rapid diagnostics to microscopy for COVID-19 diagnosis has proven crucial. Our review provides a thorough overview of the historical development of COVID-19 and molecular and biochemical characterization of the SARS-CoV-2. We highlight the potential contributions from insect and plant sources as anti-SARS-CoV-2 and present directions for future research.

Social representations of mask wearing in the general population during the COVID-19 pandemic

Introduction

Although one of the most prominent interventions against COVID-19, face masks seem poorly adopted by the general population. A growing body of literature has found that using face masks has social meaning. This qualitative study assessed the perceptions, representations and practices of mask wearing in the general population.

Methods

A qualitative survey by short semi-structured walking interviews was carried out from April to December 2021 in 11 cities in France's Pays de la Loire region. Study locations were selected for their varied geographical, social, and economic characteristics, with urbanized and rural areas. Four domains linked to perceptions of masks and wearing them were explored: (i) evolution in mask wearing, (ii) decision-making methods for wearing and not wearing; (iii) incorporating the mask into way of life; (iv) projecting into the future.

Results

A total of 116 people were interviewed. Masks marked a shift from the ordinary world to the pandemic. Overall, interviewees considered masks an obstacle to breathing, communication, and social interactions, leading to establishing strategies circumventing the mask mandate. Poor attention was paid to their medical usefulness as an obligatory clothing accessory. Mask-wearing decisions were driven by social relations, common sense, and vulnerability. The greater the feeling of security (i.e., being with close relatives), the less it was worn or worn properly, with decreased attention to others and their health. Most participants did not remember learning to wear a mask. Some were convinced that mask-wearing could not be learned (experiential knowledge). Institutions (school and work) played a central role by facilitating incorporation of masks into daily life.

Conclusions

This study emphasizes the need to reinforce the individual medical values of face masks to prevent COVID-19. Ambitious education and training programmes should be planned to learn how and when to wear masks. Institutions (work and school) may be critical for this purpose.

Patient safety implications of wearing a face mask for prevention in the era of COVID-19 pandemic: a systematic review and consensus recommendations

In the past, the use of face masks in western countries was essentially limited to occupational health. Now, because of the COVID-19 pandemic, mask-wearing has been recommended as a public health intervention. As potential side effects and some contraindications are emerging, we reviewed the literature to assess the impact of them in daily life on patient safety and to provide appropriate guidelines and recommendations. We performed a systematic review of studies investigating physiological impact, safety, and risk of masks in predefined categories of patients, which have been published in peer-reviewed journals with no time and language restrictions. Given the heterogeneity of studies, results were analyzed thematically. We used PRISMA guidelines to report our findings. Wearing a N95 respirator is more associated with worse side effects than wearing a surgical mask with the following complications: breathing difficulties (reduced FiO₂, SpO₂^, PaO₂ increased ETCO₂, PaCO₂), psychiatric symptoms (panic attacks, anxiety) and skin reactions. These complications are related to the duration of use and/or disease severity. Difficulties in communication is another issue to be considered especially with young children, older person and people with hearing impairments. Even if benefits of wearing face masks exceed the discomfort, it is recommended to take an "air break" after 1-2 h consecutively of mask-wearing. However, well-designed prospective studies are needed. The COVID-19 pandemic could represent a unique opportunity for collecting large amount of real-world data.

Managing adult asthma during the COVID-19 pandemic: A 2022 review and current recommendations

Introduction: This review aims to examine asthma management during the COVID-19 pandemic. Method: Relevant recommendations and articles were identified by respiratory professional societies and PubMed search using the terms “asthma” and “COVID-19”, and examined for relevance and inclusion in this study. Results: Recommendations for the management of asthma have remained similar but are now supported by new evidence between the years 2020 and 2022. Patients with well-controlled, mild-to-moderate asthma are unlikely to be at increased risk of acquiring COVID-19 or having worse outcomes from COVID-19. All asthma patients should receive COVID-19 vaccination. Spirometry can be performed with the usual strict infection control procedures unless there is a suspicion of COVID-19. Mask-wearing and other health measures remain important for asthma patients. Conclusion: While previous recommendations were largely based on expert opinion, the tremendous amount of literature published since the pandemic first emerged 2 years ago has helped guide respiratory professional bodies to update their recommendations. This study provides a timely review of the various recommendations and can be used to guide healthcare professionals in managing asthma patients, as the world prepares for a future with COVID-19 becoming endemic. The long-term consequences of COVID-19 infection in asthma patients and the ripple effects of COVID-19 remain uncertain and deserve ongoing study. Keywords: Asthma, coronavirus, COVID-19, SARS-CoV-2

Travel in the Time of COVID: A Review of International Travel Health in a Global Pandemic

Purpose of Review

This review critically considers the impact of the COVID-19 pandemic on global travel and the practice of travel medicine, highlights key innovations that have facilitated the resumption of travel, and anticipates how travel medicine providers should prepare for the future of international travel.

Recent Findings

Since asymptomatic transmission of the virus was first recognized in March 2020, extensive efforts have been made to characterize the pattern and dynamics of SARS-CoV-2 transmission aboard commercial aircraft, cruise ships, rail and bus transport, and in mass gatherings and quarantine facilities. Despite the negative impact of further waves of COVID-19 driven by the more transmissible Omicron variant, rapid increases of international tourist arrivals are occurring and modeling anticipates further growth. Mitigation of spread requires an integrated approach that combines masking, physical distancing, improving ventilation, testing, and quarantine. Vaccines and therapeutics have played a significant role in reopening society and accelerating the resumption of travel and further therapeutic innovation is likely.

Summary

COVID-19 is likely to persist as an endemic infection, and surveillance will assume an even more important role. The pandemic has provided an impetus to advance technology for telemedicine, to adopt mobile devices and GPS in contact tracing, and to apply digital applications in research. The future of travel medicine should continue to harness these novel platforms in the clinical, research, and educational arenas.

The impact of non-pharmaceutical interventions on COVID-19 cases in South Australia and Victoria

OBJECTIVE

To assess the impact of different non-pharmaceutical interventions (NPIs) on COVID-19 cases across Victoria and South Australia.

METHODS

Poisson regression models were fit to examine the effect of NPIs on weekly COVID-19 case numbers.

RESULTS

Mask-wearing in Victoria had a pronounced lag effect of two weeks with an incidence rate ratio (IRR) of 0.27 (95%CI 0.26-0.29). Similarly, the effect of border closure (IRR 0.18; 95%CI 0.14-0.22) in South Australia and lockdown (IRR 0.88; 95%CI 0.86-0.91) in Victoria showed a decrease in incidence two weeks after the introduction of these interventions.

CONCLUSIONS

With the ongoing COVID-19 pandemic, varying levels of vaccination coverage rates and threats from variants of concern, NPIs are likely to remain in place. It is thus important to validate the effectiveness and timing of different interventions for disease control, as those that are more restrictive such as border control and lockdown can have an enormous impact on society.

IMPLICATIONS FOR PUBLIC HEALTH

Low case numbers and deaths in Australia's first wave of COVID-19 are thought to be due to the timely use of interventions. The observed two-week lag effect associated with a decrease in incidence provides justification for early implementation of NPIs for COVID-19 management and future pandemics.

[Mask use during the COVID-19 pandemic in Brazil: results of the EPICOVID19-BR study]

By March 3, 2022, the COVID-19 pandemic has caused more than 399 million infections and claimed the lives of more than five million people worldwide. To reduce infection rates, a series of prevention measures indicated by the World Health Organization (WHO) were adopted by countries, including the use of masks. This study aims to describe mask use in Brazil via data analysis from the EPICOVID19-BR, a population-based study conducted in 133 cities in the country in four phases between March and August 2020. The proportion of individuals who reported wearing a mask when they left their homes was 97.9% (95%CI: 97.8-98.0). The interviewer did not see interviewees' mask in 50% (95%CI: 49.9-51.1) of the cases at the time of the interview. However, between phase one and four of the survey, we observed a 4.4% decrease in the proportion of interviewees who failed to wear masks at the time of the interview. Mask non-visualization was more prominent in women, participants aged 10-19 and 20-29 years of indigenous, black, and brown skin color, and those with elementary and high school education and in the Central-West Region. The use of cloth masks showed a 91.4% predominance (95%CI: 91.2-1.5) with a 4.9% increase between phases 1 and 4. The results of the study bring important information to reinforce COVID-19 control policies in Brazil. The high percentage of people who failed to wear masks at the time of the interview suggests that it is still important to reinforce prevention and self-care, rather than relating mask wear to a mandatory measure.

Performance of Valved Respirators to Reduce Emission of Respiratory Particles Generated by Speaking

Wearing of face coverings serves two purposes: reducing the concentration of ambient particles inhaled and reducing the emission of respiratory particles generated by the wearer. The efficiency of different face coverings depends on the material, design, and fit. Face coverings such as N95 respirators, when worn properly, are highly efficient at filtering ambient particles during inhalation. Some N95 respirators, as well as other face covering types, include a one-way valve to allow easier exhalation while still maintaining a high efficiency of filtration of inhaled ambient particles. The extent to which these valves decrease the efficiency of filtration of emitted respiratory particles is, however, not well established. Here, we show that different valved N95s exhibit highly variable filtration efficiencies for exhaled respiratory particles. As such, valved N95s may not provide reliable source control of respired particles and their use should be discouraged in situations in which such source control is needed.

The science-policy relationship in times of crisis: An urgent call for a pragmatist turn

In this conceptual paper, we argue that at times of crisis, what is sometimes called "evidence-based" or "science-driven" policymaking-establishing scientific truths and then implementing them-must be tempered by a more agile, deliberative and inclusive approach which acknowledges and embraces uncertainty. We offer pragmatism as one potential option, using examples from the UK to illustrate how such an approach might have changed particular crisis decisions and led to better outcomes. We propose that to better prepare for the next public health crisis, five pragmatism-informed shifts are needed in the science-policy relationship: from scientism to science-informed narrative rationality that emerges from practice; from knowledge-then-action to acting judiciously under uncertainty; from hierarchies of evidence to pluralist inquiry; from polarized camps to frame-reflective dialogue; and from an "inside-track" science-policy dialogue to greater participatory democracy. We suggest an agenda for a pragmatist-informed program of applied research on crisis public health policymaking.

Antimicrobial Resistance in the COVID-19 Landscape: Is There an Opportunity for Anti-Infective Antibodies and Antimicrobial Peptides?

Although COVID-19 has captured most of the public health attention, antimicrobial resistance (AMR) has not disappeared. To prevent the escape of resistant microorganisms in animals or environmental reservoirs a "one health approach" is desirable. In this context of COVID-19, AMR has probably been affected by the inappropriate or over-use of antibiotics. The increased use of antimicrobials and biocides for disinfection may have enhanced the prevalence of AMR. Antibiotics have been used empirically in patients with COVID-19 to avoid or prevent bacterial coinfection or superinfections. On the other hand, the measures to prevent the transmission of COVID-19 could have reduced the risk of the emergence of multidrug-resistant microorganisms. Since we do not currently have a sterilizing vaccine against SARS-CoV-2, the virus may still multiply in the organism and new mutations may occur. As a consequence, there is a risk of the appearance of new variants. Nature-derived anti-infective agents, such as antibodies and antimicrobial peptides (AMPs), are very promising in the fight against infectious diseases, because they are less likely to develop resistance, even though further investigation is still required.

From science to politics: COVID-19 information fatigue on YouTube

Objective

The COVID-19 pandemic is the first pandemic where social media platforms relayed information on a large scale, enabling an “infodemic” of conflicting information which undermined the global response to the pandemic. Understanding how the information circulated and evolved on social media platforms is essential for planning future public health campaigns. This study investigated what types of themes about COVID-19 were most viewed on YouTube during the first 8 months of the pandemic, and how COVID-19 themes progressed over this period.

Methods

We analyzed top-viewed YouTube COVID-19-related videos in English from December 1, 2019 to August 16, 2020 with an open inductive content analysis. We coded 536 videos associated with 1.1 billion views across the study period. East Asian countries were the first to report the virus, while most of the top-viewed videos in English were from the US. Videos from straight news outlets dominated the top-viewed videos throughout the outbreak, and public health authorities contributed the fewest. Although straight news was the dominant COVID-19 video source with various types of themes, its viewership per video was similar to that for entertainment news and YouTubers after March.

Results

We found, first, that collective public attention to the COVID-19 pandemic on YouTube peaked around March 2020, before the outbreak peaked, and flattened afterwards despite a spike in worldwide cases. Second, more videos focused on prevention early on, but videos with political themes increased through time. Third, regarding prevention and control measures, masking received much less attention than lockdown and social distancing in the study period.

Conclusion

Our study suggests that a transition of focus from science to politics on social media intensified the COVID-19 infodemic and may have weakened mitigation measures during the first waves of the COVID-19 pandemic. It is recommended that authorities should consider co-operating with reputable social media influencers to promote health campaigns and improve health literacy. In addition, given high levels of globalization of social platforms and polarization of users, tailoring communication towards different digital communities is likely to be essential.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13151-7.

Facemasks: Perceptions and use in an ED population during COVID-19

Study objective

Facemask use is associated with reduced transmission of SARS-CoV-2. Most surveys assessing perceptions and practices of mask use miss the most vulnerable racial, ethnic, and socio-economic populations. These same populations have suffered disproportionate impacts from the pandemic. The purpose of this study was to assess beliefs, access, and practices of mask wearing across 15 urban emergency department (ED) populations.

Methods

This was a secondary analysis of a cross-sectional study of ED patients from December 2020 to March 2021 at 15 geographically diverse, safety net EDs across the US. The primary outcome was frequency of mask use outside the home and around others. Other outcome measures included having enough masks and difficulty obtaining them.

Results

Of 2,575 patients approached, 2,301 (89%) agreed to participate; nine had missing data pertaining to the primary outcome, leaving 2,292 included in the final analysis. A total of 79% of respondents reported wearing masks “all of the time” and 96% reported wearing masks over half the time. Subjects with PCPs were more likely to report wearing masks over half the time compared to those without PCPs (97% vs 92%). Individuals experiencing homelessness were less likely to wear a mask over half the time compared to those who were housed (81% vs 96%).

Conclusions

Study participants reported high rates of facemask use. Respondents who did not have PCPs and those who were homeless were less likely to report wearing a mask over half the time and more likely to report barriers in obtaining masks. The ED may serve a critical role in education regarding, and provision of, masks for vulnerable populations.

Communication with face masks during the COVID-19 pandemic for adults with hearing loss

Face masks have become common protective measures in community and workplace environments to help reduce the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Face masks can make it difficult to hear and understand speech, particularly for people with hearing loss. An aim of our cross-sectional survey was to investigate the extent that face masks as a health and safety protective measure against SARS-CoV-2 have affected understanding speech in the day-to-day lives of adults with deafness or hearing loss, and identify possible strategies to improve communication accessibility. We analyzed closed- and open-ended survey responses of 656 adults who self-identified as D/deaf or hard of hearing. Over 80% of respondents reported difficulty with understanding others who wore face masks. The proportion of those experiencing difficulty increased with increasing hearing loss severity. Recommended practical supports to facilitate communication and social interaction included more widespread use of clear face masks to aid lip-reading; improved clarity in policy guidance on face masks; and greater public awareness and understanding about ways to more clearly communicate with adults with hearing loss while wearing face masks.

Can We Afford to Exclude Patients Throughout Health Technology Assessment?

Health technology assessment (HTA) is intended to determine the value of health technologies and, once a technology is recommended for funding, bridge clinical research and practice. Understanding the values and beliefs expressed by patients and health professionals can help guide this knowledge transfer and work toward managing the expectations of end users. We gathered patient and patient group leader experiences to gain insights into the roles that patients and patient advocacy groups are playing. We argue that through partnerships and co-creation between HTA professionals, researchers and patient advocates we can strengthen the HTA process and better align with service delivery where person-centered care and shared decision making are key elements. Patient experiences and knowledge are important to the democratization of evidence and the legitimacy of HTAs. Patient preference studies are used to balance benefits with potential harms of technologies, and patient-reported outcomes (PROs) can measure what matters to patients over time. A change in culture in HTA bodies is occurring and with further transformative thinking patients can be involved in every step of the HTA process. Patients have a right to be involved in HTAs, with patients' values central to HTA deliberations on a technology and where patients can provide valuable insights to inform HTA decision-making; and in ensuring that HTA methodologies evolve. By evaluating the implementation of HTA recommendations we can determine how HTA benefits patients and their communities. Our shared commitment can positively effect the common good and provide benefits to individual patients and their communities.

Rapid evidence review to inform safe return to campus in the context of coronavirus disease 2019 (COVID-19)

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted predominantly through the air in crowded and unventilated indoor spaces, especially among unvaccinated people. Universities and colleges are potential settings for its spread. Methods: An interdisciplinary team from public health, virology, and biology used narrative methods to summarise and synthesise evidence on key control measures, taking account of mode of transmission. Results: Evidence from a wide range of primary studies supports six measures.  Vaccinate (aim for > 90% coverage and make it easy to get a jab). Require masks indoors, especially in crowded settings. If everyone wears well-fitting cloth masks, source control will be high, but for maximum self-protection, respirator masks should be worn.  Masks should not be removed for speaking or singing. Space people out by physical distancing (but there is no “safe” distance because transmission risk varies with factors such as ventilation, activity levels and crowding), reducing class size (including offering blended learning), and cohorting (students remain in small groups with no cross-mixing). Clean indoor air using engineering controls—ventilation (while monitoring CO2 levels), inbuilt filtration systems, or portable air cleaners fitted with high efficiency particulate air [HEPA] filters). Test asymptomatic staff and students using lateral flow tests, with tracing and isolating infectious cases when incidence of coronavirus disease 2019 (COVID-19) is high. Support clinically vulnerable people to work remotely. There is no direct evidence to support hand sanitising, fomite controls or temperature-taking. There was no evidence that freestanding plastic screens, face visors and electronic air-cleaning systems are effective. Conclusions: The above evidence-based measures should be combined into a multi-faceted strategy to maximise both student safety and the continuation of in-person and online education provision. Those seeking to provide a safe working and learning environment should collect data (e.g. CO2 levels, room occupancy) to inform their efforts.

Development and validation of the discomfort of cloth Masks-12 (DCM-12) scale

During the COVID-19 pandemic, the use of face masks by the public has helped to slow the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the community. Cloth masks have been recommended because of their effectiveness, availability, and reusability. Like other types of face masks, however, user discomfort while wearing cloth masks is thought to engender behaviors that limit the effectiveness of cloth masks as source control (e.g., adjusting or removing one's mask temporarily while in public). To design cloth masks that are more tolerable, a measurement instrument for assessing subjective user discomfort is needed. Across two studies, we identified and confirmed a two-dimensional factor structure underlying the discomfort of cloth masks - discomfort related to the breathability and discomfort related to the tightness of the mask against the face and head. Additionally, we provide replicable evidence that both factor-subscales predict the self-reported frequencies of problematic mask-wearing behaviors.

Evaluating the Association of Face Covering Mandates on COVID-19 Severity by State

Objective:

During the COVID-19 pandemic in the United States, mitigation measures were implemented on a state-by-state basis. Governors were responsible for establishing interventions appropriate for their states and the timing of implementation. This paper evaluated the association between the presence and timing of a mask mandate and the severity of the COVID-19 epidemic by state.

Methods:

The states were divided into 3 categories based on when the governors of each state implemented a mask mandate: Early (mask mandate implemented between March 2020 and June 2020), Late (July 2020-December 2020), and Never (no mask mandate implemented). The rates of hospitalizations and mortality (per 100 000) were assessed at the different time points during the pandemic across these categories from March to December 2020.

Results:

The mortality rates across all 3 groups were observed to be highest in the beginning and toward the end of the pandemic in 2020 with the peak observed in the Early group between April and May 2020. Also, the rates of hospitalization increased steadily across all groups. The Early mask group was comprised of 86.7% and 13.3% states with Democratic and Republican governors respectively, and no states in the Never category had Democratic governors.

Conclusion:

These results support the benefit of implementing a mask mandate to minimize the impact of the COVID-19 pandemic and the role of political affiliation of governors on that impact.

Peers for the fearless: Social norms facilitate preventive behaviour when individuals perceive low COVID-19 health risks

A strategy frequently adopted to contain the COVID-19 pandemic involves three non-pharmaceutical interventions that depend on high levels of compliance in society: maintaining physical distance from others, minimizing social contacts, and wearing a face mask. These measures require substantial changes in established practices of social interaction, raising the question of which factors motivate individuals to comply with these preventive behaviours. Using Austrian panel survey data from April 2020 to April 2021, we show that perceived health risks, social norms, and trust in political institutions stimulate people to engage in preventive behaviour. A moderation analysis shows that the effectiveness of social norms in facilitating preventive behaviour increases when people's perceptions of health risks decrease. No such moderation effect is observed for trust in political institutions. These results suggest that strong social norms play a crucial role in achieving high rates of preventive behaviour, especially when perceived levels of health risks are low.

Miasmas, mental models and preventive public health: some philosophical reflections on science in the COVID-19 pandemic

When the history of the COVID-19 pandemic is written, it is likely to show that the mental models held by scientists sometimes facilitated their thinking, thereby leading to lives saved, and at other times constrained their thinking, thereby leading to lives lost. This paper explores some competing mental models of how infectious diseases spread and shows how these models influenced the scientific process and the kinds of facts that were generated, legitimized and used to support policy. A central theme in the paper is the relative weight given by dominant scientific voices to probabilistic arguments based on experimental measurements versus mechanistic arguments based on theory. Two examples are explored: the cholera epidemic in nineteenth century London-in which the story of John Snow and the Broad Street pump is retold-and the unfolding of the COVID-19 pandemic in 2020 and early 2021-in which the evidence-based medicine movement and its hierarchy of evidence features prominently. In each case, it is shown that prevailing mental models-which were assumed by some to transcend theory but were actually heavily theory-laden-powerfully shaped both science and policy, with fatal consequences for some.

Unmasking the Ethics of Public Health Messaging in a Pandemic

Uncertainty is inherent in new and unexpected viral outbreaks such as the current COVID-19 pandemic. It imposes challenges for health officials in soliciting cooperative behavioural changes based on incomplete information. In this paper, we use evolving mask recommendations in the United States as an example to analyse the ethical importance and practical demonstration of trustworthiness in pandemic messaging and decision-making. We argue that responsible public health interventions in the time of uncertainties requires explicit intersecting ethical considerations both in action and in communication to promote trustworthiness. First, as public health decisions have to be made in the face of incomplete and evolving data, health officials need to exhibit competence while committing to epistemic humility. They can explain the methods used in making and updating mask recommendations as well as explicitly acknowledge the need to incorporate sociocultural and other contextual considerations in translating scientific data into mask recommendations. Second, officials and agencies must uphold and communicate decisional transparency as part of their effort to demonstrate accountability and promote the public's understanding of the evolving pandemic. Third, especially since both the pandemic and mask recommendations may have disparate impact on different populations, officials should start with the fair implementation of the least restrictive measures that can help reduce harm.

Spreading of Infections on Network Models: Percolation Clusters and Random Trees

We discuss network models as a general and suitable framework for describing the spreading of an infectious disease within a population. We discuss two types of finite random structures as building blocks of the network, one based on percolation concepts and the second one on random tree structures. We study, as is done for the SIR model, the time evolution of the number of susceptible (S), infected (I) and recovered (R) individuals, in the presence of a spreading infectious disease, by incorporating a healing mechanism for infecteds. In addition, we discuss in detail the implementation of lockdowns and how to simulate them. For percolation clusters, we present numerical results based on site percolation on a square lattice, while for random trees we derive new analytical results, which are illustrated in detail with a few examples. It is argued that such hierarchical networks can complement the well-known SIR model in most circumstances. We illustrate these ideas by revisiting USA COVID-19 data.

Moral uncertainty: A case study of Covid-19

BACKGROUND

Most writing about uncertainty in healthcare has addressed empirical uncertainty - that is, resulting from insufficient or conflicting facts.

OBJECTIVE

To consider moral uncertainty by exploring how different theories apply to a single clinical case.

METHOD

In this philosophical reflection, I briefly acknowledge empirical uncertainty before introducing and exploring the topic of moral uncertainty - defined as the question of what to do when we do not know what (morally) to do-using a case study of my own mother's deterioration and death from Covid-19.

RESULTS

I identify and apply a number of philosophical theories relevant to managing moral uncertainty, including utilitarianism, deontology, practical rationality and feminist philosophy.

CONCLUSION

Different moral theories lead to different conclusions about the best course of action in situations of moral uncertainty.

PRACTICE IMPLICATIONS

Detailed analysis and close reading of a single case can provide insights into how to act in morally complex situations, but learning is in the form of enriched understanding, not formulaic rules.

Opening the policy blackbox: unravelling the process for changing national diagnostic and treatment guidelines for vivax malaria in seven countries

BACKGROUND

The changing global health landscape has highlighted the need for more proactive, efficient and transparent health policy-making. After more than 60 years of limited development, novel tools for vivax malaria are finally available, but need to be integrated into national policies. This paper maps the malaria policy-making processes in seven endemic countries, to identify areas where it can be improved to align with best practices and optimal efficiency.

METHODS

Data were collected during a workshop, convened by the Asia Pacific Malaria Elimination Network's Vivax Working Group in 2019, and subsequent interviews with key stakeholders from Cambodia, Ethiopia, Indonesia, Pakistan, Papua New Guinea (PNG), Sri Lanka and Vietnam. Documentation of policy processes provided by respondents was reviewed. Data analysis was guided by an analytic framework focused on three a priori defined domains: "context," "actors" and "processes".

RESULTS

The context of policy-making varied with available funding for malaria, population size, socio-economic status, and governance systems. There was limited documentation of the process itself or terms of reference for involved actors. In all countries, the NMP plays a critical role in initiating and informing policy change, but the involvement of other actors varied considerably. Available evidence was described as a key influencer of policy change; however, the importance of local evidence and the World Health Organization's endorsement of new treatments and diagnostics varied. The policy process itself and its complexity varied but was mostly semi-siloed from other disease specific policy processes in the wider Ministry of Health. Time taken to change and introduce a new policy guideline previously varied from 3 months to 3 years.

CONCLUSIONS

In the medium to long term, a better alignment of anti-malarial policy-making processes with the overall health policy-making would strengthen health governance. In the immediate term, shortening the timelines for policy change will be pivotal to meet proposed malaria elimination milestones.

Rapid evidence review to inform safe return to campus in the context of coronavirus disease 2019 (COVID-19)

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted predominantly through the air in crowded and unventilated indoor spaces among unvaccinated people. Universities and colleges are potential settings for its spread. Methods: An interdisciplinary team from public health, virology, and biology used narrative methods to summarise and synthesise evidence on key control measures, taking account of mode of transmission. Results: Evidence from a wide range of primary studies supports six measures.  Vaccinate (aim for > 90% coverage and make it easy to get a jab). Require masks indoors, especially in crowded settings. If everyone wears well-fitting cloth masks, source control will be high, but for maximum self-protection, respirator masks should be worn.  Masks should not be removed for speaking or singing. Space people out by physical distancing (but there is no "safe" distance because transmission risk varies with factors such as ventilation, activity levels and crowding), reducing class size (including offering blended learning), and cohorting (students remain in small groups with no cross-mixing). Clean indoor air using engineering controls-ventilation (while monitoring CO 2 levels), inbuilt filtration systems, or portable air cleaners fitted with high efficiency particulate air [HEPA] filters). Test asymptomatic staff and students using lateral flow tests, with tracing and isolating infectious cases when incidence of coronavirus disease 2019 (COVID-19) is high. Support clinically vulnerable people to work remotely. There is no direct evidence to support hand sanitising, fomite controls or temperature-taking. There is evidence that freestanding plastic screens, face visors and electronic air-cleaning systems are ineffective. Conclusions: The above six evidence-based measures should be combined into a multi-faceted strategy to maximise both student safety and the continuation of in-person and online education provision. Staff and students seeking to negotiate a safe working and learning environment should collect data (e.g. CO 2 levels, room occupancy) to inform conversations.

Cerebral and systemic physiological effects of wearing face masks in young adults

The COVID-19 pandemic led to widespread mandates requiring the wearing of face masks, which led to debates on their benefits and possible adverse effects. To that end, the physiological effects at the systemic and at the brain level are of interest. We have investigated the effect of commonly available face masks (FFP2 and surgical) on cerebral hemodynamics and oxygenation, particularly microvascular cerebral blood flow (CBF) and blood/tissue oxygen saturation (StO₂), measured by transcranial hybrid near-infrared spectroscopies and on systemic physiology in 13 healthy adults (ages: 23 to 33 y). The results indicate small but significant changes in cerebral hemodynamics while wearing a mask. However, these changes are comparable to those of daily life activities. This platform and the protocol provides the basis for large or targeted studies of the effects of mask wearing in different populations and while performing critical tasks.

Disparities and Temporal Trends in COVID-19 Exposures and Mitigating Behaviors Among Black and Hispanic Adults in an Urban Setting

IMPORTANCE

COVID-19, caused by SARS-CoV-2 virus, has disproportionately affected Black and Hispanic communities in the US, which can be attributed to social factors including inconsistent public health messaging and suboptimal adoption of prevention efforts.

OBJECTIVES

To identify behaviors and evaluate trends in COVID-19-mitigating practices in a predominantly Black and Hispanic population, to identify differences in practices by self-reported ethnicity, and to evaluate whether federal emergency financial assistance was associated with SARS-CoV-2 acquisition.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was conducted by telephone from July 1 through August 30, 2020, on a random sample of adults who underwent SARS-CoV-2 testing at a safety-net health care system in Chicago during the surge in COVID-19 cases in the spring of 2020. Behaviors and receipt of a stimulus check were compared between participants testing positive and negative for SARS-CoV-2. Differences in behaviors and temporal trends were assessed by race and ethnicity.

MAIN OUTCOMES AND MEASURES

SARS-CoV-2 infection was assessed using nasopharyngeal quantitative reverse transcriptase-polymerase chain reaction testing. Mitigating behaviors and federal emergency financial assistance were assessed by survey. Race and ethnicity data were collected from electronic health records.

RESULTS

Of 750 randomly sampled individuals, 314 (41.9%) consented to participate (169 [53.8%] women). Of those, 159 (51%) self-reported as Hispanic and 155 (49%) as non-Hispanic (120 [38.2%] Black), of whom 133 (84%) and 76 (49%) tested positive for SARS-CoV-2, respectively. For all participants, consistent mask use (public transport: adjusted odds ratio [aOR], 0.00; 95% CI, 0.00-0.34; social gatherings: aOR, 0.10; 95% CI, 0.00-0.50; running errands: aOR, 0.18; 95% CI, 0.07-0.42; at work: aOR, 0.23; 95% CI, 0.07-0.79) and hand sanitizer use (aOR, 0.26; 95% CI, 0.13-0.52) were associated with lower odds of infection. During 3 sampled weeks, mitigation practices were less frequent among Hispanic compared with non-Hispanic participants (eg, mask use while running errands: aOR, 0.26; 95% CI, 0.15-0.46). Hispanic participants were at high risk of infection (aOR, 5.52; 95% CI, 4.30-7.08) and more likely to work outside the home (aOR, 2.05; 95% CI, 1.27-3.30) compared with non-Hispanic participants, possibly because of limited receipt of stimulus checks (aOR, 0.03; 95% CI, 0.02-0.07) or unemployment benefits (aOR, 0.36; 95% CI, 0.16-0.74).

CONCLUSIONS AND RELEVANCE

In this survey study of adults in a large US city, public health messaging improved preventive behaviors over time but lagged among Hispanic participants; messaging tailored to Hispanic communities, especially for mask use, should be prioritized. Hispanic individuals were at higher risk for infection, more often worked outside the home, and were less likely to have received a stimulus check; this suggests larger studies are needed to evaluate the provision of economic support on SARS-CoV-2 transmission dynamics in low-income populations.

COVID-19 false dichotomies and a comprehensive review of the evidence regarding public health, COVID-19 symptomatology, SARS-CoV-2 transmission, mask wearing, and reinfection

Scientists across disciplines, policymakers, and journalists have voiced frustration at the unprecedented polarization and misinformation around coronavirus disease 2019 (COVID-19) pandemic. Several false dichotomies have been used to polarize debates while oversimplifying complex issues. In this comprehensive narrative review, we deconstruct six common COVID-19 false dichotomies, address the evidence on these topics, identify insights relevant to effective pandemic responses, and highlight knowledge gaps and uncertainties. The topics of this review are: 1) Health and lives vs. economy and livelihoods, 2) Indefinite lockdown vs. unlimited reopening, 3) Symptomatic vs. asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 4) Droplet vs. aerosol transmission of SARS-CoV-2, 5) Masks for all vs. no masking, and 6) SARS-CoV-2 reinfection vs. no reinfection. We discuss the importance of multidisciplinary integration (health, social, and physical sciences), multilayered approaches to reducing risk ("Emmentaler cheese model"), harm reduction, smart masking, relaxation of interventions, and context-sensitive policymaking for COVID-19 response plans. We also address the challenges in understanding the broad clinical presentation of COVID-19, SARS-CoV-2 transmission, and SARS-CoV-2 reinfection. These key issues of science and public health policy have been presented as false dichotomies during the pandemic. However, they are hardly binary, simple, or uniform, and therefore should not be framed as polar extremes. We urge a nuanced understanding of the science and caution against black-or-white messaging, all-or-nothing guidance, and one-size-fits-all approaches. There is a need for meaningful public health communication and science-informed policies that recognize shades of gray, uncertainties, local context, and social determinants of health.

Online information on face masks: analysis of websites in Italian and English returned by different search engines

OBJECTIVE

Countries have major differences in the acceptance of face mask use for the prevention of COVID-19. This work aims at studying the information online in different countries in terms of information quality and content.

DESIGN

Content analysis.

METHOD

We analysed 450 webpages returned by searching the string 'are face masks dangerous' in Italy, the UK and the USA using three search engines (Bing, Duckduckgo and Google) in August 2020. The type of website and the stance about masks were assessed by two raters for each language and inter-rater agreement reported as Cohen's kappa. The text of the webpages was collected from the web using WebBootCaT and analysed using a corpus analysis software to identify issues mentioned.

RESULTS

Most pages were news outlets, and few (2%-6%) from public health agencies. Webpages with a negative stance on masks were more frequent in Italian (28%) than English (19%). Google returned the highest number of mask-positive pages and Duckduckgo the lowest. Google also returned the lowest number of pages mentioning conspiracy theories and Duckduckgo the highest. Webpages in Italian scored lower than those in English in transparency (reporting authors, their credentials and backing the information with references). When issues about the use of face masks were analysed, mask effectiveness was the most discussed followed by hypercapnia (accumulation of carbon dioxide), contraindication in respiratory disease and hypoxia, with issues related to their contraindications in mental health conditions and disability mentioned by very few pages.

CONCLUSIONS

This study suggests that: (1) public health agencies should increase their web presence in providing correct information on face masks; (2) search engines should improve the information quality criteria in their ranking; (3) the public should be more informed on issues related to the use of masks and disabilities, mental health and stigma arising for those people who cannot wear masks.

Safety protocols in an exercise facility result in no detectable sars-CoV2 spread: A case study

Coronavirus 2019 (COVID-19) disease has been a public health emergency of international concern with millions of confirmed cases globally. Closed environments with reduced ventilation contribute to the spread of COVID-19, including superspreading events. Exercising in closed places further increases the risk for transmission. Therefore, many fitness facilities were closed as part of mandated shutdowns early in the pandemic. Evidence-based safety protocols have now emerged and substantially reduce the risk of transmission. We report three positive cases of SARS-CoV-2 identified at a Dojo exercise facility in Manlius, NY, at three distinct time points. All cases were present in the Dojo 2 days prior to symptoms, a time period considered to be highly infectious. The safety protocols included universal mask wearing (no valves), multiple high-efficiency particulate air (HEPA) filters, and reduced capacity which resulted in no known spread of COVID-19.

Face Mask Usage among Young Polish People during the COVID-19 Epidemic-An Evolving Scenario

The usage of face masks has been mandated in many countries in an attempt to diminish the spread of SARS-CoV-2. In this cross-sectional study, we aimed to determine face mask-wearing behaviors and practices in 1173 young Polish people during the second wave of the COVID-19 epidemic in October 2020. The majority of respondents (97.4%) declared that they wore face masks in areas/situations where it is mandatory. The most common types of utilized face masks were cloth masks (47.7%) and surgical masks (47%), followed by respirators (N95/FFP3) (3.2%) and half-face elastomeric respirators (0.9%). Over 38% reported frequently disinfecting their face masks, especially females. Respondents reporting personal atopic predisposition (64.5% vs. 72.1%; p = 0.02) or sensitive skin (65.5% vs. 74.3%; p = 0.005) declared multiple use of face masks less commonly than other individuals. Individuals suffering from facial skin lesions declared disinfecting face masks more commonly (40.8% vs. 34.9%; p = 0.04). Overall, the self-declared utilization of face masks among young people in Poland has improved since the beginning of the epidemic as compared with our previous study. Until the mass vaccination of the public is achieved and government policy is changed, face mask use remains a valuable tool to decrease the transmission of SARS-CoV-2.

SARS-CoV-2 biology and variants: anticipation of viral evolution and what needs to be done

The global propagation of SARS-CoV-2 and the detection of a large number of variants, some of which have replaced the original clade to become dominant, underscores the fact that the virus is actively exploring its evolutionary space. The longer high levels of viral multiplication occur - permitted by high levels of transmission -, the more the virus can adapt to the human host and find ways to success. The third wave of the COVID-19 pandemic is starting in different parts of the world, emphasizing that transmission containment measures that are being imposed are not adequate. Part of the consideration in determining containment measures is the rationale that vaccination will soon stop transmission and allow a return to normality. However, vaccines themselves represent a selection pressure for evolution of vaccine-resistant variants, so the coupling of a policy of permitting high levels of transmission/virus multiplication during vaccine roll-out with the expectation that vaccines will deal with the pandemic, is unrealistic. In the absence of effective antivirals, it is not improbable that SARS-CoV-2 infection prophylaxis will involve an annual vaccination campaign against 'dominant' viral variants, similar to influenza prophylaxis. Living with COVID-19 will be an issue of SARS-CoV-2 variants and evolution. It is therefore crucial to understand how SARS-CoV-2 evolves and what constrains its evolution, in order to anticipate the variants that will emerge. Thus far, the focus has been on the receptor-binding spike protein, but the virus is complex, encoding 26 proteins which interact with a large number of host factors, so the possibilities for evolution are manifold and not predictable a priori. However, if we are to mount the best defence against COVID-19, we must mount it against the variants, and to do this, we must have knowledge about the evolutionary possibilities of the virus. In addition to the generic cellular interactions of the virus, there are extensive polymorphisms in humans (e.g. Lewis, HLA, etc.), some distributed within most or all populations, some restricted to specific ethnic populations and these variations pose additional opportunities for/constraints on viral evolution. We now have the wherewithal - viral genome sequencing, protein structure determination/modelling, protein interaction analysis - to functionally characterize viral variants, but access to comprehensive genome data is extremely uneven. Yet, to develop an understanding of the impacts of such evolution on transmission and disease, we must link it to transmission (viral epidemiology) and disease data (patient clinical data), and the population granularities of these. In this editorial, we explore key facets of viral biology and the influence of relevant aspects of human polymorphisms, human behaviour, geography and climate and, based on this, derive a series of recommendations to monitor viral evolution and predict the types of variants that are likely to arise.

Downsides of face masks and possible mitigation strategies: a systematic review and meta-analysis

OBJECTIVE

To identify, appraise and synthesise studies evaluating the downsides of wearing face masks in any setting. We also discuss potential strategies to mitigate these downsides.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, CENTRAL and EuropePMC were searched (inception-18 May 2020), and clinical registries were searched via CENTRAL. We also did a forward-backward citation search of the included studies.

INCLUSION CRITERIA

We included randomised controlled trials and observational studies comparing face mask use to any active intervention or to control.

DATA EXTRACTION AND ANALYSIS

Two author pairs independently screened articles for inclusion, extracted data and assessed the quality of included studies. The primary outcomes were compliance, discomforts, harms and adverse events of wearing face masks.

RESULTS

We screened 5471 articles, including 37 (40 references); 11 were meta-analysed. For mask wear adherence, 47% (95% CI 25% to 68%, p<0.0001), more people wore face masks in the face mask group compared with control; adherence was significantly higher (26%, 95% CI 8% to 46%, p<0.01) in the surgical/medical mask group than in N95/P2 group. The largest number of studies reported on the discomfort and irritation outcome (20 studies); fewest reported on the misuse of masks, and none reported on mask contamination or risk compensation behaviour. Risk of bias was generally high for blinding of participants and personnel and low for attrition and reporting biases.

CONCLUSIONS

There are insufficient data to quantify all of the adverse effects that might reduce the acceptability, adherence and effectiveness of face masks. New research on face masks should assess and report the harms and downsides. Urgent research is also needed on methods and designs to mitigate the downsides of face mask wearing, particularly the assessment of possible alternatives.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework website https://osf.io/sa6kf/ (timestamp 20-05-2020).

Community practice of using face masks for the prevention of COVID-19 in Saudi Arabia

Community face masking is possibly of great value in reducing COVID-19 transmission, especially when universally adopted with high compliance. The aim of this study is to investigate the knowledge, common misconceptions, barriers, and the compliance of the community with the use of face masks for the prevention of COVID-19. A validated questionnaire was administered to the participants through a web link by using various social media. The collected data were statistically analyzed for significant differences according to demographic variables. The average knowledge of face masks and their role in preventing COVID-19 transmission was 95.64%, with no differences among most of the demographical factors. Older groups and females demonstrated a better attitude towards wearing face masks than other groups did (p<0.001). Another significant difference in the participant's attitude was noticed between the various educational levels, employment, and nationality (p<0.001). Of the total respondents, 88.2% encouraged wearing face masks. Misconceptions about wearing face masks were very low. The frequency of wearing face masks at public places, workplaces, or social gatherings was 87.2%, 80.5%, and 47.5% respectively. There was a significant variation in the compliance with wearing face masks between the various groups based on age, gender, nationality, and employment status (p<0.001). The inconvenience in wearing face masks was reported by 36.3%. Face irritation and ear pain were reported by 70.2% and 43.5%, respectively. The inconvenience of wearing face masks with eyeglasses was reported by 44.3% of those wearing eyeglasses. In general, the study demonstrated a good attitude among participants towards wearing face masks. Although the respondents in the study were aware of the benefits of wearing face masks, the barriers may have decreased their desire to do so. These barriers include difficulty in breathing, discomfort, face irritation, and ear pain.

An Update on the Relationship of SARS-CoV-2 and Male Reproduction

Since the outbreak of the COVID-19, up to now, infection cases have been continuously rising to over 200 million around the world. Male bias in morbidity and mortality has emerged in the COVID-19 pandemic. The infection of SARS-CoV-2 has been reported to cause the impairment of multiple organs that highly express the viral receptor angiotensin-converting enzyme 2 (ACE2), including lung, kidney, and testis. Adverse effects on the male reproductive system, such as infertility and sexual dysfunction, have been associated with COVID-19. This causes a rising concern among couples intending to have a conception or who need assisted reproduction. To date, a body of studies explored the impact of SARS-CoV-2 on male reproduction from different aspects. This review aims to provide a panoramic view to understand the effect of the virus on male reproduction and a new perspective of further research for reproductive clinicians and scientists.