tag:theconversation.com,2011:/ca/topics/ppe-84851/articlesPPE – The Conversation2022-11-20T15:22:34Ztag:theconversation.com,2011:article/1947262022-11-20T15:22:34Z2022-11-20T15:22:34ZWith COVID, flu and RSV circulating, it’s time to follow the evidence: Return to mask mandates<figure><img src="https://images.theconversation.com/files/495816/original/file-20221117-13-u0jyep.JPG?ixlib=rb-1.1.0&rect=0%2C10%2C3190%2C2069&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ontario Premier Doug Ford and Health Minister Sylvia Jones in conversation at Queen's Park, the day after Ontario’s chief medical officer of health ‘strongly recommended’ mask wearing.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Chris Young</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/with-covid--flu-and-rsv-circulating--it-s-time-to-follow-the-evidence--return-to-mask-mandates" width="100%" height="400"></iframe>
<p>The number of children and babies with respiratory illnesses currently <a href="https://globalnews.ca/news/9273442/mcmaster-childrens-hospital-patient-crisis-grows/">exceeds the capacity of our health system</a> to care for them. More adult Canadians will die directly of COVID-19 this year <a href="https://public.tableau.com/app/profile/bill.comeau/viz/CanadaCovid19_16636261617930/Dashboard1">than died last year or in 2020</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bar graph showing deaths from COVID in Canada" src="https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=260&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=260&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=260&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=326&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=326&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495812/original/file-20221117-23-1isdxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=326&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">COVID deaths in 2022 outnumber those in 2020 or 2021.</span>
<span class="attribution"><span class="source">(Bill Comeau)</span></span>
</figcaption>
</figure>
<p>Eight per cent of vaccinated people with COVID infections that don’t require hospitalization <a href="https://doi.org/10.1038/s41591-022-01840-0">end up with long COVID</a>, with each subsequent infection <a href="https://doi.org/10.1038/s41591-022-02051-3">repeating the risk</a>. COVID increases the risk of <a href="https://doi.org/10.1038/s41591-022-01689-3">cardiovascular</a> <a href="https://doi.org/10.1016/S0140-6736(22)01214-4">and</a> <a href="https://www.ecdc.europa.eu/sites/default/files/documents/Prevalence-post-COVID-19-condition-symptoms.pdf">other health</a> <a href="https://doi.org/10.1038/s41591-022-01840-0">problems</a>, enough to cause a stark rise in <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm">excess deaths</a> and to <a href="https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf">shorten life expectancy</a>.</p>
<p>In 2020, when adult intensive care units were at risk of being overwhelmed, we wore masks and accepted restrictions. With pediatric intensive care now at risk, will leaders follow the evidence and tell us to mask up? While federal officials and <a href="https://www.cbc.ca/news/canada/toronto/ontario-dr-kieran-moore-announcement-1.6650571">several provinces are now recommending masks in all indoor public settings</a> — although <a href="https://toronto.ctvnews.ca/ontario-s-top-doctor-goes-against-own-advice-while-maskless-at-toronto-party-1.6159050">Ontario’s Chief Medical Officer of Health Kieran Moore was seen without one at a party</a> — <a href="https://www.ctvnews.ca/canada/what-provinces-and-territories-are-saying-about-mask-mandates-as-covid-19-rsv-flu-cases-rise-1.6157262">there are no returns to mandates for the public yet</a>.</p>
<h2>Wear the best mask available</h2>
<p>We now know that <a href="https://doi.org/10.1073/pnas.2014564118">masks prevent the spread of respiratory diseases</a>; some better than others. </p>
<figure class="align-right ">
<img alt="A young woman wearing a white face masks with overhead ties" src="https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=536&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=536&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495815/original/file-20221117-16-6d6tbj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=536&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Vitacore CaN99 respirator with overhead elastic; N95s, CaN99 and FFP3 typically provide greater than 90 per cent filtration without formal fit testing.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The most effective masks, and the only ones recognized as respiratory protection by formal standards, are respirator masks: N95s, CaN99s, FFP3s and reusable elastomeric respirators. In workplaces, respirators are fit-tested to the individual, resulting in greater than 99 per cent protection. </p>
<p>Even without fit testing, respirator masks prevent <a href="https://doi.org/10.1093/annhyg/meq085">more than</a> <a href="https://doi.org/10.1371/journal.pone.0245688">90 per cent</a> <a href="https://doi.org/10.1097/MD.0000000000023709">of particles</a> smaller than one micron from reaching the wearer (submicron particles, the smallest among <a href="https://doi.org/10.1016%2FS2213-2600(20)30323-4">those thought</a> <a href="https://doi.org/10.1080/23744235.2022.2140822">to be</a> <a href="https://doi.org/10.1038/s41564-021-01047-y">relevant</a>).</p>
<p>Respirator masks are relatively expensive — typically a few dollars each — but thanks to Canadian manufacturers, they are <a href="https://www.clothmasks.org/">available</a> and there are no longer concerns about supply chains for front-line workers. They can be safely <a href="https://www.clothmasks.org/extended-use">reused, with good retention of their filtration</a>. New designs are comfortable and fit most faces. </p>
<figure class="align-left ">
<img alt="A young woman wearing a black face mask with ear loops" src="https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495818/original/file-20221117-14-4riq8j.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A KN95/KF94 mask with ear loops typically provides about 70 per cent filtration.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>N95s are secured with overhead attachments, providing a good seal at the edges. KN95s and KF94s have excellent filtration material, but their ear loops do not provide as secure a seal, and <a href="https://doi.org/10.1371/journal.pone.0258191">their filtration</a> is <a href="https://doi.org/10.1371/journal.pone.0245688">around 70 per cent</a>. A certified medical mask with a well-fitted cloth mask over it, preferably with overhead ties, provides <a href="https://doi.org/10.1038/s41591-022-01840-0">comparable</a> <a href="https://doi.org/10.1016/j.ajic.2021.10.041">filtration</a> at lower cost.</p>
<figure class="align-right ">
<img alt="A young woman wearing a cloth face mask over a surgical mask" src="https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495821/original/file-20221117-27-lavqq2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A well-fitting cloth mask over a certified medical mask typically produces about 70 per cent filtration.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Certified Level 1 medical masks alone do not fit well, which affects their filtration ability because unfiltered air passes around the edges with every breath. In tests on humans, these have <a href="https://doi.org/10.1371/journal.pone.0264090">typically </a><a href="https://doi.org/10.1371/journal.pone.0245688">filtered </a><a href="https://doi.org/10.1001/jamainternmed.2020.8168">at around 50 per cent</a>, similar to <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">well-designed</a> <a href="https://doi.org/10.1371/journal.pone.0264090">two-layer cotton cloth masks, ideally with overhead ties</a>; both are around 50 per cent.</p>
<p>Poorly fitting <a href="https://doi.org/10.1016/j.ajic.2021.10.041">cloth masks</a> and non-certified procedure masks are likely worse than 50 per cent, but better than nothing. The World Health Organization advises: “<a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks">Make wearing a mask a normal part of being around other people</a>,” to which we would add: wear the best mask available.</p>
<figure class="align-left ">
<img alt="A young woman wearing a blue surgical face mask" src="https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=514&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=514&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=514&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=646&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=646&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495823/original/file-20221117-23-agh7u5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=646&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Level 1 certified mask provides filtration around 50 per cent because of visible gaps and poor fit. To test fit, breathe out rapidly and feel for air leaks around the mask with your hands.</span>
<span class="attribution"><span class="source">(Gurleen Dulai, Ranmeet Dulai)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The filtration data above are mirrored by epidemiologic data showing that <a href="http://dx.doi.org/10.15585/mmwr.mm7106e1">protection correlates with mask type</a>. In studies of source control (prevention of contamination of the air by respiratory particles), the same hierarchy of efficiency is seen, with N95s at the top. N95s with exhalation valves are an exception and should not be used to prevent spread of respiratory diseases.</p>
<p><a href="https://doi.org/10.1136/bmj-2021-068302">Masks protect </a><a href="https://doi.org/10.1073/pnas.2014564118">against COVID-19</a> and other respiratory infections. They are also an <a href="https://doi.org/10.7326/M20-6625">ideal tool to counter COVID variants</a>, as well as <a href="https://theconversation.com/influenza-and-covid-19-whats-in-store-for-the-fall-winter-respiratory-virus-season-193076">RSV and influenza</a>. Working on basic physical principles — <a href="https://doi.org/10.7326/M20-6625">impaction, sedimentation and diffusion</a> — they protect regardless of the variant or strain. </p>
<p>Staying home when sick is helpful, but many people are infectious <a href="https://doi.org/10.1186/s12879-022-07440-0">before they have symptoms, or never have symptoms</a>. Wearing a mask to prevent infected particles from reaching the environment is basic pollution management: control is best at the source. </p>
<p>Wearing a mask to protect the individual, once controversial, is now settled by <a href="https://www.clothmasks.org/mask-hierarchy">filtration science</a> and <a href="http://dx.doi.org/10.15585/mmwr.mm7106e1">epidemiology</a>. The impact of mask mandates in countries where spontaneous mask wearing was low was repeatedly demonstrated, proving that masks protect us all.</p>
<h2>Why people aren’t wearing masks</h2>
<p>Why aren’t people wearing masks? Some remember the <a href="https://doi.org/10.1111/1467-9566.13525">inconsistency of the advice</a> early in the pandemic. Masks may be conflated with closures and capacity restrictions and the resulting hardships. Whatever the reason — <a href="https://www.theguardian.com/world/2021/oct/26/the-great-cover-up-why-the-uk-stopped-wearing-face-masks">stigma, peer pressure or concern about virtue signalling</a> — countries outside Asia do not have a mask-wearing culture. </p>
<figure class="align-center ">
<img alt="Infographic summarizing the literature on filtration properties of respirators and masks." src="https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=976&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=976&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495814/original/file-20221117-27-xjcwhn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=976&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Infographic summarizing the literature on filtration properties of respirators and masks.</span>
<span class="attribution"><span class="source">(Shiblul Hasan)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Under these circumstances, it will likely take more than strong recommendations to achieve the <a href="https://doi.org/10.1073/pnas.2014564118">high uptake of mask use that will be most effective</a> in reducing transmission of respiratory viruses. Masks protect individuals, imperfectly. Mask mandates (or high voluntary use of masks) protect populations.</p>
<p>Bringing back mask mandates with unequivocal signalling from governments about the effectiveness of both masks and mask mandates would be the best immediate response to our current crisis. <a href="https://doi.org/10.1038/s41398-022-01814-3">Confidence that mask-wearing is effective correlates geographically with willingness to wear a mask</a>: in time, we hope knowledge will change culture. Strong communication from political and public health leadership would increase community understanding that the minor inconvenience of wearing a mask in public indoor spaces is justified by the death and disability prevented. </p>
<p>In North America, the strategy of using masks according to personal judgment has predictably failed, the strategy of strongly recommending masks is unproven, and it’s too late to experiment. Mask mandates, however, are backed by strong evidence of effectiveness in <a href="https://www.nber.org/papers/w27891">both Canada</a> and the <a href="https://doi.org/10.1377/hlthaff.2020.00818">United States</a>. </p>
<p>Mask mandates are less damaging to a recovering economy than physical distancing and capacity limits, and less damaging to learning than a return to remote schooling.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two line graphs showing relationship between school openings, mask use and community COVID 19 cases and deaths" src="https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=249&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=249&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=249&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=313&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=313&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495824/original/file-20221117-25-ga6i04.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=313&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The relationship between mode of school opening (remote, hybrid and in-person) and mask use at school with community cases and deaths, based on county-level data in the U.S.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1073/pnas.21034201">(Chernozhukov et al, PNAS 2021:118;e2103420118)</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Schools and universities represent a particularly important opportunity. COVID spreads between children in schools <a href="https://doi.org/10.1073/pnas.2103420118">to infect the whole population; this is mitigated by mask wearing</a>. After Massachusetts lifted its mask mandate, school boards did so at different times, creating a natural experiment: <a href="https://doi.org/10.1056/NEJMoa2211029">transmission was higher among students and staff where mandates were lifted</a> compared with where they were still in place. </p>
<p>There is <a href="https://web.archive.org/web/20220826213955/https:/healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Do-face-masks-interfere-with-language-development.aspx">no convincing</a> <a href="https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html">evidence</a> to date that masks reduce social or language skills. Decreasing spread in schools would increase learning by reducing student and teacher sick days and preserving in-person instruction. Keeping children in schools <a href="https://www.washingtonpost.com/business/2022/11/15/work-absences-childcare/">keeps parents at work</a>.</p>
<p>Mask mandates will not produce a rapid fix of our current problems with respiratory viruses. Indicators will lag by weeks. Until we have a <a href="https://doi.org/10.1038/s41586-022-05398-2">whole-of-society approach</a> that recognizes that <a href="https://doi.org/10.1016/S0140-6736(21)00869-2">COVID is airborne</a>, mask mandates offer us the best immediate opportunity to preserve our health-care system, mitigate death and disability from respiratory viruses, support the economy and safely maintain social contacts in our private lives. </p>
<p><em>Rebecca Rudman, co-founder of the Windsor Essex Sewing Force and member of McMaster’s Cloth Mask Knowledge Exchange, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/194726/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Clase is editor-in-chief of clothmasks.org and a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group that includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article. She is a member of McMaster's Centre of Excellence in Protective Equipment and Materials. Catherine has received consultation, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter. In 2018 she co-chaired a KDIGO potassium controversies conference sponsored at arm's length by Fresenius Medical Care, AstraZeneca, Vifor Fresenius Medical Care, Relypsa, Bayer HealthCare and Boehringer Ingelheim. Catherine Clase receives funding from CIHR, and is a member of the Green Party, the American Society of Nephrology, the Canadian Society of Nephrology, the American Association of Textile Chemists and Colorists and ASTM International.</span></em></p><p class="fine-print"><em><span>Charles-Francois de Lannoy receives funding from the Natural Sciences and Engineering Research Council (NSERC) of Canada, the Global Water Futures (GWF) Research organization, Ontario Centres of Excellence (OCE), Federal Economic Development Agency for Southern Ontario (FedDev), Canadian Foundation for Innovation (CFI), the French Embassy, and McMaster University. He has received funding in partnership with Pall Water, Trojan Technologies, Hatch Ltd., and PW Fabrication. He has engaged in various research projects and testing/validation of facemasks for several private companies in Ontario. He is affiliated with the Cloth Mask Knowledge Exchange as an expert advisor.</span></em></p><p class="fine-print"><em><span>Ken G. Drouillard receives funding from Natural Sciences and Engineering Research Council (NSERC) of Canada, Environment and Climate Change Canada, Ontario Ministry of Environment, Conservation and Parks and Mitacs. He is affiliated with the WE-Spark Health Institute, Detroit River Canadian Cleanup Committee, International Association of Great Lakes Research, Editor of Bulletin of Environmental Contamination and Toxicology and science advisor for Windsor-Essex Sewing Force. </span></em></p>In 2020, with adult ICUs at risk of being overwhelmed, we wore masks and accepted restrictions. Now pediatric intensive care is at risk. Will leaders follow the evidence and tell us to mask up?Catherine Clase, Professor of Medicine, Epidemiologist, Physician, McMaster UniversityCharles-Francois de Lannoy, Associate Professor, Chemical Engineering, McMaster UniversityKen G. Drouillard, Professor, Great Lakes Institute for Environmental Research, School of the Environment, University of WindsorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1912652022-10-23T19:02:26Z2022-10-23T19:02:26ZWhat should rich countries do with spare masks and gloves? It’s the opposite of what the WHO recommends<figure><img src="https://images.theconversation.com/files/490496/original/file-20221018-9021-5rvd4z.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/due-shortage-medical-supplies-coronavirus-covid19-1685561587">Shutterstock</a></span></figcaption></figure><p>Most developed countries hold significant quantities of medical supplies in reserve to respond in an emergency. </p>
<p>For example, Australia has its <a href="https://www.health.gov.au/initiatives-and-programs/national-medical-stockpile">National Medical Stockpile</a>, which stocks personal protective equipment, such as masks and gloves, among other items. New Zealand has its <a href="https://www.health.govt.nz/our-work/emergency-management/national-reserve-supplies">national reserve supplies</a>.</p>
<p>If these supplies are not used in an emergency, such as a pandemic, they typically stay in the stockpile until their use-by date, then are sent to landfill. </p>
<p>Surely there’s a better way, especially with some developing nations short of medical supplies. Donating surplus stock to developing countries seems an obvious solution. </p>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/poms.13828">Our study</a> looked at the likely impact of donating excess stock to developing countries – dated items close to or past their labelled use-by date. We found this a viable option, even better than donating fresh items.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-were-on-a-global-panel-looking-at-the-staggering-costs-of-covid-17-7m-deaths-and-counting-here-are-11-ways-to-stop-history-repeating-itself-190658">We were on a global panel looking at the staggering costs of COVID – 17.7m deaths and counting. Here are 11 ways to stop history repeating itself</a>
</strong>
</em>
</p>
<hr>
<h2>What’s in the stockpile?</h2>
<p>In 2011, Australia’s stockpile <a href="https://www.anao.gov.au/sites/default/files/AuditReport_2013-2014_53.pdf">contained about</a> 3,000 pallets of expired stock, the bulk of which was personal protective equipment, including 98 million latex gloves. </p>
<p>While some of the reserves have been used during COVID, items are being restocked. So these too will likely expire if not used. For instance, we know surgical masks in the stockpile are <a href="https://www.anao.gov.au/sites/default/files/Auditor-General_Report_2020-21_22.pdf">already expiring</a>.</p>
<p>Similar issues have been seen in other developed countries such as the <a href="https://www.oig.dhs.gov/reports/2014-08/dhs-has-not-effectively-managed-pandemic-personal-protective-equipment-and">United States</a>, <a href="https://oag.parliament.nz/2020/ppe/docs/ppe.pdf">New Zealand</a> and <a href="https://globalnews.ca/news/6651402/ontario-coronavirus-masks-medical-supplies-expired/">Canada</a>, before and during the current pandemic.</p>
<h2>Why not donate surplus stock?</h2>
<p>This expiration and waste is in sharp contrast to the situation in some developing countries. Some are forced to reuse <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932219/">normally disposable items</a>, such as surgical gloves, masks and <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-8-4">syringes</a>.</p>
<p>While donation of surplus stock seems an obvious solution, donations of dated medical supplies are <a href="https://daisi.com.au/category/dr-gary-mckay-deregistered-expired-products-will-not-be-included-in-daisi-donations/">typically discouraged</a>. </p>
<p>The World Health Organization (WHO) <a href="https://www.who.int/publications/i/item/9789241501408">recommends against it</a>. It expects donations to arrive in another country with an expiry date of:</p>
<blockquote>
<p>at least one year, or half the shelf life if the expiry date is less than one year.</p>
</blockquote>
<p>The idea is to protect recipients from degraded or faulty stock.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/wealthy-nations-starved-the-developing-world-of-vaccines-omicron-shows-the-cost-of-this-greed-172763">Wealthy nations starved the developing world of vaccines. Omicron shows the cost of this greed</a>
</strong>
</em>
</p>
<hr>
<h2>We found a pragmatic option</h2>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/poms.13828">Our study</a> modelled the impact of donating stock, in particular personal protective equipment and similar low-risk products. We did not look at donating dated vaccines or medicines, which come with higher safety risks. </p>
<p>We found dated donations close to or recently past their use-by date was the best option. This benefited the recipient country the most, as it was least likely to push local suppliers out of business.</p>
<p>The next best option was donating fresh stock. The least preferable option was donating very dated stock, such as items out of date by more than a year.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Open cardboard box of hand sanitiser" src="https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490493/original/file-20221018-16-mqo4r8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The best option was donating stock, such as hand sanitiser, close to or slightly past its use-by date.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hand-sanitizer-container-box-delivery-self-1686800215">Shutterstock</a></span>
</figcaption>
</figure>
<h2>How could old stock be better?</h2>
<p>It’s easy to assume that donating large volumes of fresh, excess stock, still within its use-by date, would be the best option. But we showed how this can distort the local market.</p>
<p>Flooding the local market with free, fresh products can force local suppliers to lower their products’ market price, and make them potentially stop making or supplying these products.</p>
<p>This discourages any further attempts to develop local supply capacity, and makes the recipient country more reliant on donations. </p>
<p>This may be compounded by corruption. If corrupt officials siphon donated products and sell them on the black market, this too may force local suppliers out of business. This may also drive prices up on the black market, putting an extra strain on already stretched health-care systems.</p>
<p>Whether or not such corruption is involved, somewhat dated supplies could enable the local supplier to stay in business and supply the country’s health-care system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-get-more-people-to-pay-taxes-indonesia-should-stamp-out-corruption-by-officials-at-the-top-57512">To get more people to pay taxes, Indonesia should stamp out corruption by officials at the top</a>
</strong>
</em>
</p>
<hr>
<h2>What should happen next?</h2>
<p>Some surplus medical supplies <a href="https://globallinks.org/our-programs/medical-surplus-recovery/">are being donated</a>. But
these programs are small scale and face many restrictions and challenges. These include a <a href="https://knowledge.insead.edu/operations/supply-chain-solutions-healthcare-inequality">limited and unpredictable supply</a> of donated items and relying heavily on <a href="https://naturallymodernlife.com/how-this-non-profit-health-system-is-reducing-waste/">volunteers and community partners</a> to distribute donated stock.</p>
<p>So donating surplus stock could be better coordinated at a larger scale.</p>
<p>Our evidence calls us to rethink what we do with dated donations of low-risk medical supplies.</p>
<p>Masks, respirators, syringes and hand sanitisers from national stockpiles would be a good start. Such products can continue to be useful even when dated, especially if the products are stored well.</p>
<p>Indeed, even in developed countries, personal protective equipment has been distributed past its expiration date <a href="https://www.bbc.com/news/uk-england-nottinghamshire-52025950">when needed</a> <a href="https://abcnews.go.com/Health/wireStory/mask-day-doctors-virus-epicenter-washington-69653568">during the pandemic</a>.</p>
<p>It would be prudent to run a pilot program to donate dated, surplus stock, possibly with a single product. </p>
<p>Medical suppliers could also get on board. They may be willing to pay the costs of such a donation program if it allows them to regularly restock national stockpiles and similar reserves with fresh items. </p>
<p>Many countries were <a href="https://www.cbc.ca/news/politics/ppe-pandemic-covid-coronavirus-masks-1.5645120">surprised</a> at the start of the pandemic to find how much expired stock was in their reserves. A donation program would prevent this happening again and help us better prepare for the next pandemic.</p><img src="https://counter.theconversation.com/content/191265/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>During COVID, rich countries have used masks and gloves from their medical stockpiles. But not all countries are so fortunate. We found the best way to help. It may not be what you think.Spring Zhou, Lecturer, operations and supply chain management, University of WollongongTava Olsen, Professor of Operations and Supply Chain Management, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1906582022-09-15T02:28:33Z2022-09-15T02:28:33ZWe were on a global panel looking at the staggering costs of COVID – 17.7m deaths and counting. Here are 11 ways to stop history repeating itself<p>A global report released <a href="https://www.thelancet.com/commissions/covid19">today</a> highlights massive global failures in the response to COVID-19.</p>
<p>The report, which was convened by The Lancet journal and to which we contributed, highlights widespread global failures of prevention and basic public health.</p>
<p>This resulted in an estimated 17.7 million excess deaths due to COVID-19 (including those not reported) to September 15.</p>
<p>The report also highlights that the pandemic has reversed progress made towards the United Nations <a href="https://sdgs.un.org/goals">Sustainable Development Goals</a> in many countries further impacting on health and wellbeing.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1570196346703081472"}"></div></p>
<p>The report, from <a href="https://covid19commission.org">The Lancet COVID-19 Commission</a>, found most governments were ill-prepared, too slow to act, paid too little attention to the most vulnerable in their societies, and were hampered by low public trust and an epidemic of misinformation.</p>
<p>However, countries of the Western Pacific – including East Asia, Australia and New Zealand – adopted <a href="https://theconversation.com/australias-response-to-covid-in-the-first-2-years-was-one-of-the-best-in-the-world-why-do-we-rank-so-poorly-now-187606">more successful</a> control strategies than most.</p>
<p>This had resulted in an estimated 300 deaths per million in the region
(around <a href="https://ourworldindata.org/grapher/total-covid-cases-deaths-per-million?country=%7EAUS">558 per million</a> in Australia and <a href="https://ourworldindata.org/grapher/total-covid-cases-deaths-per-million?country=%7ENZL">382 per million</a> in New Zealand to September 12). This is compared with more than 3,000 per million in the <a href="https://ourworldindata.org/grapher/total-covid-cases-deaths-per-million?country=%7EUSA">United States</a> and the <a href="https://ourworldindata.org/grapher/total-covid-cases-deaths-per-million?country=%7EGBR">United Kingdom</a>. </p>
<p>The report also sets out 11 key recommendations for ending the pandemic and preparing for the next one.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/imagining-covid-is-like-the-flu-is-cutting-thousands-of-lives-short-its-time-to-wake-up-190545">Imagining COVID is 'like the flu' is cutting thousands of lives short. It's time to wake up</a>
</strong>
</em>
</p>
<hr>
<h2>Co-operation lacking</h2>
<p>The report is the result of two years’ work from global experts in public policy, health, economics, social sciences and finance. We contributed to the public health component.</p>
<p>One of the report’s major criticisms is the failure of global cooperation for the financing and distribution of vaccines, medicines and personal protective equipment for low-income countries. </p>
<p>This is not only <a href="https://theconversation.com/wealthy-nations-starved-the-developing-world-of-vaccines-omicron-shows-the-cost-of-this-greed-172763">inequitable</a> but has raised the risk of <a href="https://theconversation.com/new-covid-variants-have-changed-the-game-and-vaccines-will-not-be-enough-we-need-global-maximum-suppression-157870">more dangerous variants</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1465879532422909957"}"></div></p>
<p>The report highlighted the critical role of strong and equitable public health systems. These need to have: strong relationships with local communities; investment in behavioural and social science research to develop more effective interventions and health communication strategies; and continuously updated evidence.</p>
<h2>11 recommendations</h2>
<p>The report made 11 recommendations to end the pandemic and prepare for future ones.</p>
<p><strong>1. Vaccines plus other measures</strong> – establishing global and national “vaccination plus” strategies. This would combine mass immunisation in all countries, ensure availability of testing and treatment for new infections and long COVID, coupled with public health measures such as face masks, promotion of safe workplaces, and social and financial support for self-isolation.</p>
<p><strong>2. Viral origins</strong> – an unbiased, independent and rigorous investigation is needed to investigate the origins of SARS-CoV-2, the virus that causes COVID-19, including from a natural spillover from animals or a possible laboratory-related spillover. This is needed to prevent future pandemics and strengthen public trust in science and public authorities.</p>
<p><strong>3. Bolster the World Health Organization</strong> and maintain it as the lead organisation for <a href="https://theconversation.com/too-late-already-bolted-how-a-faster-who-response-could-have-slowed-covid-19s-spread-160860">responding to emerging infectious diseases</a>. Give WHO new regulatory authority, more backing by national political leaders, more contact with the global scientific community and a larger core budget.</p>
<p><strong>4. Establish a global pandemic agreement</strong> and strengthen <a href="https://theconversation.com/at-what-point-is-a-disease-deemed-to-be-a-global-threat-heres-the-answer-185547">international health regulations</a>. New pandemic arrangements should include bolstering WHO’s authority, creating a global surveillance and monitoring system for infectious disease outbreaks. It would also include regulations for processing international travellers and freight under global pandemic conditions, and the publication of an annual WHO report on global pandemic preparedness and response.</p>
<p><strong>5. Create a new WHO Global Health Board</strong> to support WHO decision-making especially on controversial matters. This would be composed of heads of government representing each of the six WHO regions and elected by the member states of those regions.</p>
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<p><strong>6. New regulations to prevent pandemics</strong> from natural spillovers and research-related activities and for investigating their origins. Prevention of <a href="https://theconversation.com/5-virus-families-that-could-cause-the-next-pandemic-according-to-the-experts-189622">natural spillovers</a> would require better regulation of domestic and wild-animal trade and enhancement of surveillance systems for pathogens (disease-causing micro-organisms) in domestic animals and humans. The <a href="https://globalhealth.org/programs/world-health-assembly/">World Health Assembly</a> should also adopt new global regulations on biosafety to regulate international research programs dealing with dangerous pathogens.</p>
<p><strong>7. A ten-year global strategy</strong> by <a href="https://www.dfat.gov.au/trade/organisations/g20">G20 (Group of Twenty)</a> nations, with accompanying finance, to ensure all WHO regions, including the world’s poorer regions, can produce, distribute, research and develop vaccines, treatments and other critical pandemic control tools. </p>
<p><strong>8. Strengthen national health systems</strong> based on the foundations of public health and universal health coverage and grounded in human rights and gender equality.</p>
<p><strong>9. Adopt national pandemic preparedness plans</strong>, which include scaling up community-based public health systems, investment in a skilled workforce, investment in public health and scientific literacy to “immunise” the public against dis-information, investment in behavioural and social sciences research to develop more effective interventions, protection of vulnerable groups, establishment of safe schools and workplaces, and actions to improve coordinated surveillance and monitoring for new variants.</p>
<p><strong>10. Establishment of a new Global Health Fund</strong> where – with the support of WHO – there is increased and effective investment for both pandemic preparedness and health systems in developing countries, with a focus on primary care. </p>
<p><strong>11. Sustainable development and green recovery plans</strong>. The pandemic has been a setback for sustainable development so bolstering funding to meet sustainability goals is needed.</p>
<h2>Unlock a new approach</h2>
<p>To improve the world’s ability to respond to pandemics we need to unlock a new approach. The key component to any meaningful transformation is to collaborate and work towards a new era of multilateral cooperation. </p>
<p>Governments in Australia, Aotearoa New Zealand and elsewhere have talked about “building back better”. We need to take the lessons learnt from the failures of the past few years and build a stronger framework. This will not only help reduce the dangers of COVID-19 but also forestall the next pandemic and any future global crisis. </p>
<p>By reassessing and strengthening global institutions and co-operation, we can build and define a more resilient future.</p>
<hr>
<p><em>Chris Bullen, Professor of Public Health, University of Auckland, co-authored this article and The Lancet COVID-19 Commission report on which it was based.</em></p><img src="https://counter.theconversation.com/content/190658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Thwaites is Chair of Monash Sustainable Development Institute and ClimateWorks Australia which receive funding for research, education and action projects from the Australian and state governments as well as from philanthropy and industry. He is former Deputy Premier of Victoria and a member of the Australian Labor Party.</span></em></p><p class="fine-print"><em><span>Liam Smith receives funding from a number of government schemes, government bodies and private sector funders. </span></em></p><p class="fine-print"><em><span>Margaret Hellard receives funding from a number of government funding schemes and government bodies and philanthropic organisations for work on COVID-19.
Margaret Hellard also receives funding from Gilead Sciences and Abbvie for research unrelated to COVID-19.</span></em></p>We found most governments were ill-prepared, too slow to act, paid too little attention to the most vulnerable, and were hampered by low public trust and an epidemic of misinformation.John Thwaites, Chair, Monash Sustainable Development Institute & ClimateWorks Australia, Monash UniversityLiam Smith, Director, BehaviourWorks, Monash Sustainable Development Institute, Monash UniversityMargaret Hellard, Adjunct Professor, Monash University; Associate Director and Head, Centre for Population Health, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1894362022-09-05T13:09:47Z2022-09-05T13:09:47ZThe PPE used throughout the COVID-19 pandemic is getting tangled up in wildlife<figure><img src="https://images.theconversation.com/files/481952/original/file-20220831-14-b7noe0.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Used masks threaten urban wildlife.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Throughout the COVID-19 pandemic, masking has been one of the key public health measures put in place to combat the disease. Since March 2020, billions of disposable surgical masks have been used around the world, raising the question: What happens to all those used masks?</p>
<p>As researchers in single use plastic and microplastic pollution, the onset of a global wave of plastic debris pollution became evident to us in the early days of the pandemic — we could see the evidence even during lockdowns when exercise was limited to short daily walks in the neighbourhood. Masks and gloves were on the ground, fluttering in the wind and hanging on fencing. </p>
<p>As ecologists, we were also aware of where the debris would end up — in nests, for example, or wrapped around the legs or in the stomachs of wildlife.</p>
<p>In Canada, a team of researchers led by conservation biologist Jennifer Provencher <a href="https://doi.org/10.1139/er-2018-0079">studied how plastic debris impacts wildlife</a>. In a study conducted during a canal cleanup in The Netherlands, biologists at the Naturalis Biodiversity Center documented <a href="https://doi.org/10.1163/15707563-bja10052">that Personal Protective Equipment (PPE) debris would interact with wildlife in the same way as other plastics</a>. </p>
<h2>Effects on wildlife</h2>
<p>There’s <a href="https://www.reddit.com/r/RATS/comments/i4nv66/face_masks_for_the_win/">a cartoon circulating on the internet</a> that goes like this: a rat comes home carrying bags of groceries to see two rats laying in bunk beds made from medical grade masks. The rat in the bottom bunk exclaims, “Free hammocks, all over town. It’s like a miracle!”</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1294320425099571202"}"></div></p>
<p>We shared this cartoon with our colleagues at the beginning of the pandemic, while we were conducting surveys of PPE litter around Toronto streets and parking lots. </p>
<p>We found that within the area that we were surveying — which covered an area of Toronto equivalent to about 45 football fields — over 14,000 disposable masks, gloves or hand wipes accumulated by the end of the year. That’s a lot of rat hammocks.</p>
<p>We set out to understand the breadth of the harm that PPE is doing to wildlife. What we learned is just how many other people were equally concerned. </p>
<h2>Jarring images</h2>
<p>We conducted a global survey using social media accounts of wildlife interactions with PPE debris. The images are jarring: A hedgehog wrapped in a face mask, the earloops tangled in its quills. A tiny bat, with the earloops of two masks wrapped around its wing. A nest, full of ivory white eggs, insulated with downy feathers and a cloth mask. </p>
<p>Many of these animals are dead, but most were alive at the time of observation. Some were released from their plastic entanglement by the people who captured the photo.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CDAB4MQBCKO","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<p>In total, we found 114 cases of wildlife interactions with PPE debris as documented on social media by concerned people around the world. Most of the wildlife were birds (83 per cent), although mammals (11 per cent), fish (two per cent), invertebrates such as an octopus (four per cent) and sea turtles (one per cent) were also observed. </p>
<p>The majority of observations originated in the United States (29), England (16), Canada (13) and Australia (11), likely representing both the increase in access to mobile devices and our English-language search terms. Observations also came from 22 other countries, with representation from all continents except Antarctica. </p>
<h2>Weighing costs and benefits</h2>
<p>With an <a href="https://doi.org/10.1021/acs.est.0c02178">estimated 129 billion face masks</a> <a href="https://doi.org/10.1016/j.jece.2021.105222">used monthly around the world</a>, how do we, as ecologists and environmental researchers, tell a global population experiencing a global pandemic to use fewer masks? We don’t. </p>
<p>N95 masks have been essential in reducing the transmission of COVID-19 and, although they are more environmentally harmful than cloth masks, <a href="https://doi.org/10.1021/acs.chas.1c00016">the benefit to health is demonstrably superior</a>.</p>
<p>So, what could we have done better? One thing we noted during our PPE litter surveys is the abundance of discarded masks and gloves in close proximity to public garbage bins. </p>
<p>We hypothesize that a lack of clear messaging from municipalities and provinces about safe ways to dispose of PPE, along with our reluctance to gather near sources of discarded PPE, may have contributed to this global pollution event.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a public rubbish bin filled with PPE and surgical masks to the point of overflow" src="https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/481955/original/file-20220831-12-g98rae.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Developing better ways for people to get rid of their PPE waste may help prevent used surgical masks from ending up in the environment.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>These are lessons that can still be implemented as we continue to cycle through waves of this pandemic; the use of masks is not yet behind us. Our surveys continue as we track an accumulation of PPE debris that will likely find its way into more nests and tangled around the bodies of more animals.</p>
<p>The rise of single use plastic use due to COVID-19 may not have been avoidable. But the rise in plastic pollution could have been mitigated with some investment in public outreach and modifications to waste management infrastructure to allow for masks and other PPE to be disposed of and processed correctly with minimal leakage to the environment.</p><img src="https://counter.theconversation.com/content/189436/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Billions of face masks and other personal protective equipment have been used throughout the pandemic. Containing plastic, these items are damaging wildlife and their environments.Shoshanah Jacobs, Associate Professor, Integrative Biology, University of GuelphJackie Saturno, Research Associate, Dalhousie UniversityJustine Ammendolia, PhD Student, Resource and Environmental Studies, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1772292022-02-24T02:40:02Z2022-02-24T02:40:02ZHow to get the most out of your N95 mask or other respirator<figure><img src="https://images.theconversation.com/files/447952/original/file-20220223-19-lwpq4w.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C995%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/n95-filtering-face-mask-white-medical-1651463458">Shutterstock</a></span></figcaption></figure><p>Although mask mandates are <a href="https://www.theguardian.com/australia-news/2022/feb/22/victoria-queensland-mask-rules-mandate-nsw-covid-restrictions-omicron-cases-peak">lifting in some states</a>, many people will continue to wear masks to protect themselves and others from the more <a href="https://smw.ch/article/doi/smw.2022.w30133">transmissible</a> Omicron variant. </p>
<p>For instance, they might be visiting a loved one in hospital, travelling on a plane or bus, or still need to wear one at work in hospitality or retail.</p>
<p>Any mask is better than none. However, a type of mask known as a respirator is <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1750-2659.2011.00198.x">more effective</a> at preventing the spread of SARS-CoV-2 (the virus that causes COVID) than a cloth or surgical mask, provided you use it properly.</p>
<p>Here is a practical guide to getting the most out of your respirator.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/time-to-upgrade-from-cloth-and-surgical-masks-to-respirators-your-questions-answered-174877">Time to upgrade from cloth and surgical masks to respirators? Your questions answered</a>
</strong>
</em>
</p>
<hr>
<h2>What is a respirator?</h2>
<p>Respirators are designed to fit your face closely to help prevent you breathing in airborne particles through the gaps around the edges. </p>
<p>They are made of a plastic with an electrostatic charge that repels viral particles, preventing at least 95% of particles from getting through.</p>
<p>They are made to a specific <a href="https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-face-masks-and-barrier-face-coverings#s3">manufacturing standard</a>. Depending on where they are certified, they <a href="https://breathesafeair.com/mask-ratings/">may be called</a> N95 (in the USA), P2 (Australia or New Zealand), FFP2 (Europe), KF94 (Korea) or KN95 (China). </p>
<p>Some have a cup shape; others look like a <a href="https://advantechsterilizers.ca/product/halyard-fluidshield-n95-respirator-mask-46767-46827/">duck bill</a> due to the way they stick out.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1416601279191674883"}"></div></p>
<h2>Who can use a respirator?</h2>
<p>Adults can use respirators but the US Food and Drug Administration (FDA) does not <a href="https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-face-masks-and-barrier-face-coverings#s3">recommend them for children</a>. That’s because they are not designed for smaller face sizes so may not provide full protection.</p>
<p>Facial hair, unfortunately, <a href="https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/n95-respirators-surgical-masks-face-masks-and-barrier-face-coverings#s3">interferes with the fit</a>. That’s because the edge of the respirator cannot form a tight seal around the face and chin.</p>
<p>If you don’t want to remove your beard or moustache, use a surgical mask. Or you can <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2778913">double mask</a> by wearing a cloth mask over a surgical mask.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1481661722293329924"}"></div></p>
<h2>Which respirator is best?</h2>
<p>This depends on personal preference and size. Try a few different types to find one that fits well. P2 respirators found in hardware stores are often in larger sizes that suit men. Chemists sell others that might better suit a smaller face. </p>
<p>Look for an adjustable nose piece and <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2772936">straps that go over the back of the head</a> rather than loops that go over the ears. This will ensure a tighter fit. </p>
<p>Do not buy respirators with valves because they do not prevent the release of viral particles into the air. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-wear-a-mask-in-the-heat-169941">How to wear a mask in the heat</a>
</strong>
</em>
</p>
<hr>
<h2>Watch out for counterfeits</h2>
<p>Avoid a false sense of security when wearing respirators, as they won’t have been professionally “fit tested” the way they would be for health workers. </p>
<p>When buying respirators online, look out for <a href="https://www.cdc.gov/niosh/npptl/usernotices/counterfeitResp.html">counterfeit</a> <a href="https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/n95list1.html">products</a>. For example, avoid individual respirators with unmarked packaging, or boxes with an FDA logo, as use of the logo to market products <a href="https://www.fda.gov/about-fda/website-policies/fda-logo-policy">is prohibited</a>. The box should include the <a href="https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html">manufacturer’s name and address</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-the-best-mask-for-covid-19-a-mechanical-engineer-explains-the-science-after-2-years-of-testing-masks-in-his-lab-175481">What is the best mask for COVID-19? A mechanical engineer explains the science after 2 years of testing masks in his lab</a>
</strong>
</em>
</p>
<hr>
<h2>How do I put one on?</h2>
<p>The US <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html">Centers for Disease Control and Prevention</a> advises you: </p>
<ul>
<li><p>wash or sanitise your hands before putting on the respirator </p></li>
<li><p>check the respirator for any tears, holes or moisture. Never use one that is damaged or wet</p></li>
<li><p>separate the elastic straps, then hold the respirator in your hand with the nose piece at the top </p></li>
<li><p>place the respirator over your nose and mouth</p></li>
</ul>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person placing respirator over nose and mouth" src="https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=467&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=467&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447953/original/file-20220223-27-pac5i9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=467&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Place respirator over nose and mouth.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html">CDC</a></span>
</figcaption>
</figure>
<ul>
<li>place one elastic loop at the top of your head, near the crown, and the other at the base, below your ears. Make sure the straps lay flat, are not twisted and are not criss-crossed</li>
</ul>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person placing respirator elastic straps over the back of the head" src="https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447954/original/file-20220223-13-1e21dhc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">One elastic loop goes at the top of the head, the other at the base.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html">CDC</a></span>
</figcaption>
</figure>
<ul>
<li>adjust the flexible strip across your nose and cheeks, pressing on each side of the nose with the fingertips of both hands to mould it to your face</li>
</ul>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Press down with your fingers across the nose and cheek" src="https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447956/original/file-20220223-13-w6rokm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Use fingertips to mould respirator to face.</span>
<span class="attribution"><a class="source" href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html">CDC</a></span>
</figcaption>
</figure>
<ul>
<li><p>check the edges to make sure there are no creases or hair stuck under the edge</p></li>
<li><p>perform a “<a href="https://www.health.qld.gov.au/__data/assets/pdf_file/0035/974294/p2-n95-fit-check.pdf">fit check</a>”. Take a quick deep breath in, which should cause the respirator to suck inwards. Then breathe out, which should re-inflate it. If your glasses fog up, if you feel air coming in or going out around the edges, or the respirator does not suck in, there is not a good seal. Try repositioning it and “fit check” again</p></li>
<li><p>sanitise your hands after putting on your respirator. Once on, avoid touching the front, which may be contaminated. If you do, sanitise your hands again.</p></li>
</ul>
<h2>Can I re-use them?</h2>
<p>While respirators are labelled for single use, they can be reused outside health-care settings with care:</p>
<ul>
<li><p>the more you reuse a respirator the more likely it is to <a href="https://www.ajicjournal.org/article/S0196-6553(11)00770-X/fulltext">fail</a> because the wear on the elastic straps causes a poorer fit or components break. Most are good for at least five wears but some can go for at least 20 </p></li>
<li><p>have several on the go and alternate them on different days. Store each one after use in its own paper bag, to allow it to dry out between uses </p></li>
<li><p>remove the respirator if it gets wet. When removing, touch only the straps. Move the respirator away from your face so you don’t contaminate your skin or hair</p></li>
<li><p>when the respirator loses its fit, gets damaged or has been used too often, pop it in the bin.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/have-you-stopped-wearing-reusable-fabric-masks-heres-how-to-cut-down-waste-without-compromising-your-health-175243">Have you stopped wearing reusable fabric masks? Here's how to cut down waste without compromising your health</a>
</strong>
</em>
</p>
<hr>
<h2>What not to do</h2>
<ul>
<li><p>don’t <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/use-n95-respirator.html">wash or microwave</a> your respirator. This interferes with its <a href="https://www.mdpi.com/1660-4601/19/2/641/htm">electrostatic charge</a> and ability to <a href="https://www.wired.com/story/the-physics-of-the-n95-face-mask/">filter viruses</a> </p></li>
<li><p>don’t store it in a plastic bag as it will not dry out between uses. </p></li>
</ul>
<p>Respirators reduce the spread of SARS-CoV-2 but will not stop it alone. It is essential to stay home if unwell, get fully vaccinated, physically distance where possible, regularly wash or sanitise your hands, and if coughing or sneezing, do so into your elbow.</p><img src="https://counter.theconversation.com/content/177229/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thea van de Mortel teaches into the graduate Infection Prevention and Control program at Griffith University.</span></em></p><p class="fine-print"><em><span>Peta-Anne Zimmerman is a Board Director of the Australasian College for Infection Prevention and Control, Co-Director of the Collaborative for the Advancement of Infection Prevention and Control, and is the Program Advisor of the Griffith University Graduate Infection Prevention and Control Programs.</span></em></p>If you’re thinking of upgrading from a cloth or surgical mask to a respirator, here’s what you need to know.Thea van de Mortel, Professor, Nursing and Deputy Head (Learning & Teaching), School of Nursing and Midwifery, Griffith UniversityPeta-Anne Zimmerman, Senior Lecturer/Program Advisor Griffith Graduate Infection Prevention and Control Program, Griffith UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1748772022-01-17T22:56:09Z2022-01-17T22:56:09ZTime to upgrade from cloth and surgical masks to respirators? Your questions answered<figure><img src="https://images.theconversation.com/files/440978/original/file-20220117-25-ldsl5u.jpg?ixlib=rb-1.1.0&rect=85%2C42%2C9404%2C6274&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/woman-putting-on-medical-n95-600w-1905906772.jpg">Shutterstock</a></span></figcaption></figure><p>With the rapid spread of Omicron, many countries are rethinking their COVID mask advice for the community. </p>
<p>Respirators have been mandatory in public places in <a href="https://www.france24.com/en/europe/20210125-austria-makes-ffp2-masks-mandatory-in-shops-public-transport">Austria</a> for a year. Now, the <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/types-of-masks.html">United States Centers for Disease Control and Prevention</a> suggests respirators be considered for greater protection, for instance, on public transport or in enclosed crowded spaces. It’s time to rethink and upgrade masks for you and your family.</p>
<h2>What is a respirator?</h2>
<p>Respirators, often wrongly called “masks” because of their appearance, are personal protective equipment made to a particular standard and designed to prevent inhalation of hazardous airborne contaminants. </p>
<p>In the US, respirator standards are managed by the <a href="https://www.cdc.gov/niosh/topics/respirators/">National Institute for Occupational Safety and Health</a> (NIOSH), and cover three things: filter efficiency, breathing resistance and fit. A filter that meets the N95 standard (equivalent to Europe’s FFP2) must capture at least 95% of particles in the most penetrating size range at a high flow rate. In Australia, a respirator must meet <a href="https://www.tga.gov.au/publication/guidance-medicalsurgical-face-masks-and-respirator-standards-key-performance-aspects">TGA standards</a>.</p>
<p>A respirator that consists entirely of filtering material – rather than having layers, say for waterproofing – is called a filtering facepiece respirator (FFR). An FFR can be worn multiple times but must eventually be thrown away. Research suggests FFRs lose their ability to fit well after <a href="https://www.ajicjournal.org/article/S0196-6553(11)00770-X/fulltext">20 wears</a> – due to stretching of straps or failure of the nose clip or edge components.</p>
<p>The filter material is usually a non-woven polypropylene electret, which means the fibres carry an electrical charge to enhance particle collection while ensuring low breathing resistance. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&rect=6%2C0%2C4268%2C3119&q=45&auto=format&w=1000&fit=clip"><img alt="N95 respirator held up by hand" src="https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&rect=6%2C0%2C4268%2C3119&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=438&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=438&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=438&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=550&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=550&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440975/original/file-20220117-30-7xfyoy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=550&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">N95 masks capture 95% of particles of a certain size.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/n95-respirators-surgical-masks-face-600w-1672342378.jpg">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Why were we told to wear cloth masks at first?</h2>
<p>It was initially assumed SARS-CoV-2 spread via droplets (in coughs and sneezes) which caused infection when they landed on the mouth, nose or eyes. For such particles, a cloth or surgical mask is an efficient form of <em>source control</em> to protect others from virus emitted by the wearer. </p>
<p>Now it’s understood the virus is <a href="https://theconversation.com/covid-how-the-disease-moves-through-the-air-173490">airborne</a>. Virus-laden particles build up in the air over time indoors because of breathing and speaking. </p>
<h2>Will a respirator protect me even if others are unmasked?</h2>
<p>It depends on the type of exposure and how long you are exposed. It is important to consider your risk depending on <a href="https://theconversation.com/heres-where-and-how-you-are-most-likely-to-catch-covid-new-study-174473">where you are, what you’re doing, with whom and how long you’re there</a>. </p>
<p>The <a href="https://www.cidrap.umn.edu/news-perspective/2021/10/commentary-what-can-masks-do-part-1-science-behind-covid-19-protection">safest situation</a>, especially for prolonged contact in crowded settings, is when everyone is wearing well-fitting N95 respirators. </p>
<p>It’s hard to show evidence to support respirator use in the community – but lack of randomised controlled trials (RCT) does not mean they are not effective. Studying masks or respirators at a population level is complex and involves many variables. There is <a href="https://www.sciencedirect.com/science/article/pii/S0020748920301139?via%3Dihub">strong evidence</a> from RCTs in health workers and laboratory studies showing respirators are effective for source control and personal protection.</p>
<h2>I really like my cloth mask. Is it OK to keep wearing it?</h2>
<p>Probably not. Cloth masks are not made to any particular standard, so their properties and quality vary considerably. </p>
<p>In general, they are poor filters of small airborne particles. </p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=502&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=502&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=502&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=631&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=631&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441003/original/file-20220117-25-ews7fg.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=631&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mask effectiveness table.</span>
<span class="attribution"><span class="source">Lisa M Brosseau</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<hr>
<h2>Surgical masks are cheaper – can I just switch to those?</h2>
<p>Not really. While some surgical masks may have better filtration capacity than cloth masks, they were designed primarily to prevent the emission of large droplets. Some medical-grade surgical masks may also offer protection from body fluid splashes or sprays. No surgical mask will prevent the emission or inhalation of small infectious particles, however.</p>
<p>A key deficiency of surgical and cloth masks is their loose fit compared to respirators. </p>
<p>While some older, hard-cup style respirators may be uncomfortable, newer styles are <a href="https://www.washingtonpost.com/outlook/2022/01/11/n95-masks-cdc-walensky/">better tolerated</a>. This may be due to their greater surface area, which could contribute to lower breathing resistance. </p>
<h2>Should I have my respirator professionally fitted?</h2>
<p>No. When respirators are used to protect workers from airborne hazards such as dust or pollution, employers are legally required to undertake fit-testing (see for example the US <a href="https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.134">Occupational Safety and Health Administration</a> fit-testing standard). But even non-fit tested respirators will provide <a href="https://onlinelibrary.wiley.com/doi/10.1111/j.1750-2659.2011.00198.x">superior protection</a> over cloth or surgical masks. </p>
<p>A respirator should rest against your face with no gaps, especially around the nose and chin. To create a tight seal, form the nose clip and place both straps around your head, adjusting them if necessary. </p>
<p>If the facepiece collapses a small amount when you inhale, the respirator probably fits well. Get in the habit of doing a <a href="https://youtu.be/pGXiUyAoEd8?t=140">“self seal-check”</a> before each wear. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1481751378569871360"}"></div></p>
<h2>Shouldn’t respirators be reserved for healthcare professionals?</h2>
<p>No. Early in the pandemic, the public were discouraged from buying respirators because of a global shortage of personal protective equipment and the assumption healthcare workers were at higher risk of catching COVID from so-called “aerosol-generating procedures” such as intubation. </p>
<p>We now know <a href="https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15475">everyday activities like talking and singing</a> are <em>more</em> likely to generate infectious aerosols than medical procedures. </p>
<p>As with vaccines, there are global equity issues and we need to <a href="https://www.statnews.com/2021/01/07/national-hi-fi-mask-initiative-needed-with-vaccine-rollouts/">expand manufacturing capacity</a> to ensure sufficient supply for everyone. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/latest-isolation-rules-for-critical-workers-gets-the-balance-right-but-thats-not-the-end-of-the-story-174884">Latest isolation rules for critical workers gets the balance right. But that's not the end of the story</a>
</strong>
</em>
</p>
<hr>
<h2>What about the cost and environmental impact?</h2>
<p>Compared to cloth masks, respirators (which are not washable) cost more and have a greater environmental impact. But disposable respirators can be used for <a href="https://journals.lww.com/md-journal/fulltext/2020/12110/determination_of_the_optimal_time_for_n95.143.aspx">extended periods</a> if they are not wet or damaged, and there are re-usable options such as <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/elastomeric-respirators-strategy/index.html">elastometric respirators</a>. A respirator should be thrown away when it gets dirty or the straps, nose clip or other components lose their integrity. </p>
<p>Costs and environmental concerns need to be weighed against the costs and waste produced by a single COVID hospital admission. In Australia, the average daily cost of an Intensive Care Unit stay has been <a href="https://www.mja.com.au/journal/2019/211/7/financial-cost-intensive-care-australia-multicentre-registry-study">estimated at $4375</a>. </p>
<h2>What if I can’t afford or get my hands on a N95 respirator?</h2>
<p>The Korean KF94 and Chinese KN95s are cheaper alternatives that provide better protection than a surgical or cloth mask. <a href="https://www.nytimes.com/wirecutter/blog/12-signs-you-have-a-fake-n95-kn95-or-kf94-mask/?smtyp=cur&smid=tw-nytimes">Beware counterfeits</a>, such as those without a GN stamp to show they meet manufacturing standards. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="KN95 mask" src="https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440973/original/file-20220117-27-zzvh3f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">KN95 masks may be easier to find and cheaper but beware fakes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/yU6Svw6NFhI">Unsplash/Markus Winkler</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>If you can’t get hold of a respirator, you can <a href="https://ozsage.org/wp-content/uploads/2021/09/OzSage-Masks1-4.pdf">improve protection of a surgical or cloth mask</a>. </p>
<p>Options include “<a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2778913">double masking</a>” by wearing a tight-fitting cloth mask over a surgical mask. You can also “knot and tuck” a surgical mask by tying the sides and tucking the remainder inside. Finally, a well-designed cloth mask (with three layers) can perform as well as a good quality surgical mask. </p>
<p>It’s still true that something is better than nothing. But don’t count on these types of masks to provide the same level of protection for the same amount of time as an N95 respirator.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-covid-control-to-chaos-what-now-for-australia-two-pathways-lie-before-us-174325">From COVID control to chaos – what now for Australia? Two pathways lie before us</a>
</strong>
</em>
</p>
<hr>
<h2>Respirators should be provided and required</h2>
<p>The World Health Organization has stressed the importance of a “vaccines-plus” approach. </p>
<p>There is a strong case, when prevalence of COVID is high, for governments to both mandate and fund the provision of respirators for the public, <a href="https://www.cbs58.com/news/500-000-n95-masks-given-away-in-48-hours-more-on-the-way">as some parts of the US</a> are now doing.</p><img src="https://counter.theconversation.com/content/174877/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC, MRFF and has consulted for Ascend Performance Materials, Detmold Group and Cleanspace in the last 5 years.</span></em></p><p class="fine-print"><em><span>Lisa M Brosseau has no research funding.</span></em></p><p class="fine-print"><em><span>Trish Greenhalgh receives funding from Wellcome Trust, NIHR, MRC, ESRC, Health Data Research UK and Health Foundation. </span></em></p><p class="fine-print"><em><span>Leyla Asadi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The airborne nature of COVID supports routine use of respirators by the public. Here, experts explain the science behind this recommendation.Leyla Asadi, PhD candidate and infectious diseases doctor, University of AlbertaC Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyLisa M Brosseau, Research Consultant, Center for Infectious Disease Research and Policy, University of MinnesotaTrish Greenhalgh, Professor of Primary Care Health Sciences, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1676322021-09-16T02:55:40Z2021-09-16T02:55:40ZOverlooked and undervalued, New Zealand’s community caregivers have become the ‘invisible’ essential workers<figure><img src="https://images.theconversation.com/files/421451/original/file-20210915-21-1p3erhq.jpg?ixlib=rb-1.1.0&rect=51%2C0%2C5760%2C3828&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>As Auckland enters it’s fifth week in level 4 lockdown and the rest of New Zealand stays at level 2, spare a thought for the nation’s invisible network of essential community support workers. </p>
<p>They are the people caring for those who, through age or disability, cannot work or leave their homes, cannot independently care for themselves, and who in many cases have underlying mental health and cognitive problems. </p>
<p>While other front-line essential workers are rightly recognised for their service, it’s important we also remember those less obvious workers who put their own health and well-being at risk to care for and support some of our most vulnerable citizens. </p>
<p>Often these community workers receive little support themselves. And while the stress on <a href="https://www.nzherald.co.nz/nz/covid-19-coronavirus-delta-outbreak-auckland-hospitals-calling-for-more-icu-nurses/UGLIHB2SWH36WCKGYQ4UQWELDM/">hospital staff</a>, <a href="https://www.rnz.co.nz/news/national/449850/covid-19-lockdown-putting-huge-pressure-on-supermarket-workers-union">supermarket workers</a> and even <a href="https://www.stuff.co.nz/national/health/coronavirus/126199938/during-covid-spare-a-thought-for-our-leaders-mental-health">political leaders</a> has been acknowledged, this other essential group has largely gone unnoticed.</p>
<p>As one community worker told us when reflecting on being overlooked as essential workers and the potential impact this could have on their own well-being: </p>
<blockquote>
<p>At the start, the government kind of didn’t even really consider us as health workers, did they? </p>
</blockquote>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/421453/original/file-20210915-23-jgtb3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/421453/original/file-20210915-23-jgtb3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=339&fit=crop&dpr=1 600w, https://images.theconversation.com/files/421453/original/file-20210915-23-jgtb3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=339&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/421453/original/file-20210915-23-jgtb3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=339&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/421453/original/file-20210915-23-jgtb3r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=426&fit=crop&dpr=1 754w, https://images.theconversation.com/files/421453/original/file-20210915-23-jgtb3r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=426&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/421453/original/file-20210915-23-jgtb3r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=426&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Community care workers struggled for even basic protective equipment due to unclear official guidelines.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Struggle for pay and PPE</h2>
<p>In our ongoing <a href="https://www.hrc.govt.nz/resources/research-repository/wellbeing-essential-workers-during-covid-19-community-support">research</a>, we have so far heard from over 75 community support workers nationwide about their well-being during the COVID-19 pandemic.</p>
<p>They are employed mostly by private companies (some not-for-profit) contracted to a variety of government agencies, including the Ministry of Health, ACC and district health boards.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/languishing-burnout-and-stigma-are-all-among-the-possible-psychological-impacts-as-delta-lingers-in-the-community-167103">Languishing, burnout and stigma are all among the possible psychological impacts as Delta lingers in the community</a>
</strong>
</em>
</p>
<hr>
<p>Our preliminary findings show these workers struggled to gain recognition throughout the first national lockdown in 2020. Furthermore, they struggled to <a href="https://www.scoop.co.nz/stories/PO2004/S00097/home-support-workers-are-on-the-front-line-so-why-havent-they-been-paid.htm">be paid</a> and <a href="https://www.stuff.co.nz/national/health/coronavirus/120412322/coronavirus-home-care-workers-stockpiling-masks-gloves-and-hand-sanitiser">to receive</a> even the most basic personal protective equipment (PPE) provided by their employers:</p>
<blockquote>
<p>Our employers were so slack, not recognising that we needed [PPE]. But they were following Ministry of Health guidelines and so it was government […] it was the World Health Organization — it was everybody.</p>
<p>What was wrong with people to think that we could go out there and do our jobs without PPE? And then why do we have to have such a battle for it? Because it was actually hard enough doing the job without having all of that as well.</p>
</blockquote>
<p>This very real struggle underscored a wider battle by community care workers to be appreciated for their work — or even to be “seen”. As one support worker noted: </p>
<blockquote>
<p>In comparison with nurses, who are angels, caregivers are just ignored […] it’s like a little underworld where, all over your city, women, mostly in uniforms in little cars, are getting in and out of the cars and going into houses and doing things that nobody has any idea about. </p>
</blockquote>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1431807787709829129"}"></div></p>
<h2>Working in isolation</h2>
<p>Despite working with people in the most vulnerable situations, support workers spoke of being turned away or facing public backlash when trying to use essential worker queues at supermarkets.</p>
<p>And yet these support workers are undeniably essential. In many ways they are the “glue” in the health system, as another told us: </p>
<blockquote>
<p>One thing I want to make sure that you understand is that we look after [everyone from] medically fragile children to palliative [cases]. We look after all of them — anybody that wants to remain in the community, then has a health issue, we look after them. </p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/low-wage-essential-workers-get-less-protection-against-coronavirus-and-less-information-about-how-it-spreads-138076">Low-wage essential workers get less protection against coronavirus – and less information about how it spreads</a>
</strong>
</em>
</p>
<hr>
<p>Even during the best of (non-pandemic) times, these workers operate in isolation. The majority hardly ever see a co-worker, and almost never see a manager in person. Communication is via impersonal emails, phone apps or call centres. </p>
<p>But during lockdowns, support workers are the only people isolated clients see — they step in as communicators and carers. In effect they become like family. They have to deal – alone – with the confusion and anxiety of their clients. Their own well-being and mental health often come second:</p>
<blockquote>
<p>I felt unsupported in regards to dealing with these [client] behaviours at the time, because there were no people on the ground. They were all working from home, so they were all on a phone. So, in some cases, my biggest “PPE” would have been having someone there, and it wasn’t there. I had someone on a phone.</p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/historic-pay-equity-settlement-for-nz-care-workers-delivers-mixed-results-114283">Historic pay equity settlement for NZ care workers delivers mixed results</a>
</strong>
</em>
</p>
<hr>
<h2>‘I would have just loved a phone call’</h2>
<p>As with other healthcare workers, coping is a strategy built up over time by community support workers: </p>
<blockquote>
<p>It’s like, right, suck it up and just, you know, dry those tears and put on that smile and be your bouncy self again […] I’ve had to learn.</p>
</blockquote>
<p>But unlike other healthcare workers, such as those at COVID testing and vaccination stations and hospitals, community support workers don’t have a team around them for support: </p>
<blockquote>
<p>We just had days and days where we didn’t hear anything from our employer and we felt really alone and vulnerable. And, of course, when we went into lockdown and everything, we didn’t feel supported at all. </p>
<p>It was very frightening. We had to go out there as essential workers and, oh God, it was stressful.</p>
</blockquote>
<p>Asked what might improve their well-being, a common refrain has been that employers and society in general pay attention and care more: </p>
<blockquote>
<p>Somehow showing how you’re valued […] It would be nice just to have a “you’re doing well” or something. </p>
<p>I would have just loved a phone call, just to check if I’m coping or not.</p>
</blockquote><img src="https://counter.theconversation.com/content/167632/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This project is funded by the Health Research Council's 'Wellbeing of Essential Workers during Covid-19: Community Support Workers', in partnership with the E tū and PSA Unions. The findings here represent the views of the authors, not the funder and not necessarily the research partners.</span></em></p><p class="fine-print"><em><span>Amber Nicholson receives funding from the Health Research Council. </span></em></p><p class="fine-print"><em><span>Fiona Hurd receives funding from the Health Research Council. </span></em></p>Throughout the pandemic, community carers have risked their own health and well-being, but have struggled for even basic support and equipment.Katherine Ravenswood, Associate Professor in Employment Relations, Auckland University of TechnologyAmber Nicholson, Lecturer in Management, Auckland University of TechnologyFiona Hurd, Head of Department, International Business, Strategy & Entrepreneurship, Auckland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1610542021-06-23T13:49:55Z2021-06-23T13:49:55ZLearning from COVID: how to improve future supplies of medical equipment and vaccines<figure><img src="https://images.theconversation.com/files/405975/original/file-20210611-19-1qk2o1h.jpg?ixlib=rb-1.1.0&rect=10%2C0%2C988%2C583&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Lessons can we now take forward.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/covid19-out-stock-store-lightbox-sign-1711242220">Maridav/Shutterstock</a></span></figcaption></figure><p>When the impact of the coronavirus first hit the UK, I stared at the empty rows in my local supermarket, cleared as a result of people stockpiling goods. I had read about “panic buying” in other countries but was not prepared for the scenes that greeted me. The bare shelves were a constant reminder of how fearful people were about the impact of COVID-19, lockdown and about feeding themselves and their families while being sequestered at home. My first thought was of a biblical locust plague; it was as if a swarm of locusts had worked their way through the store, clearing out all the family basics – flour, pasta, bread, toilet rolls and other essential staples. </p>
<p>More visible, tangible reminders of the coronavirus pandemic were the hand sanitiser stations, the new experience of wearing masks out in public and social distancing – the “hands, face and space” mantra that the UK government had adopted. This was our social obligation and responsibility in fighting this virus, by reducing transmission rates and hospital admissions. </p>
<p>Standing in a queue for goods with my 13-year-old son, as customers were being counted in and out, he remarked on the line stretching across the car park, the spacing enforced by staff, the sanitised baskets and trolleys and the face masks on everyone waiting. He asked if I had ever seen anything like this before. I told him no I had not, and I hoped I never would again. While the sanitising and face masks were seen as essential and enforced, staff in retail environments struggled to get access to personal protective equipment (PPE), a problem that also became apparent for frontline healthcare staff in hospitals and care workers in homes for the elderly. Staff shortages across sectors came from the reduced availability of PPE but also because of workers having to self-isolate. </p>
<figure class="align-center ">
<img alt="Empty supermarket shelf with 'one per customer' sign" src="https://images.theconversation.com/files/405972/original/file-20210611-17-bs5bcg.jpg?ixlib=rb-1.1.0&rect=2%2C2%2C995%2C745&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405972/original/file-20210611-17-bs5bcg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405972/original/file-20210611-17-bs5bcg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405972/original/file-20210611-17-bs5bcg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405972/original/file-20210611-17-bs5bcg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405972/original/file-20210611-17-bs5bcg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405972/original/file-20210611-17-bs5bcg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘It was as if a swarm of locusts had worked their way through the store’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/view-empty-shelves-department-store-during-1672031644">Orlowski Designs LLC/Shutterstock</a></span>
</figcaption>
</figure>
<p>Concerns over access to food and general supplies were endemic and similar fears existed about access to healthcare and whether hospitals would have enough staff and equipment – <a href="https://www.theguardian.com/society/2020/apr/27/uk-doctors-finding-it-harder-to-get-ppe-kit-to-treat-covid-19-patients-research-reveals">PPE, medicines, ventilators, oxygen and vaccines</a> – to treat patients with COVID-19, not to mention other <a href="https://www.macmillan.org.uk/assets/forgotten-c-impact-of-covid-19-on-cancer-care.pdf">urgent medical issues</a>. In India more recently, oxygen shortages ravaged the care that emergency departments were able to give to COVID patients and <a href="https://www.bbc.co.uk/news/world-asia-india-56891016">critical care beds</a> were limited. Pop-up isolation wards were created in train carriages as hospitals ran out of capacity to treat patients. </p>
<p>I study supply chains and health operations and have never experienced such a phenomenon as seen in 2020-21. And as one of the biggest vaccination drives in history rolls out globally, there are ongoing fears about vaccine supplies. The vaccination programme has been hailed as the way out of the pandemic, <a href="https://www.bbc.co.uk/news/uk-56141867">getting societies and economies back to where they once were</a>. The demand within such a short time frame is unprecedented.</p>
<h2>Supply chain disruptions</h2>
<p>Supply chain disruptions that lead to restricted access to products have happened before, but how we learn from these and how practice changes accordingly is a matter of debate. </p>
<p>I was a supply chain manager in a pharmacy in a large teaching hospital back in the early 2000s, and the recall of products from quality issues and medicine shortages was commonplace. We would receive alerts from regional and national bodies and take action to find affected stock to return or contact suppliers for additional stock. The systems were in place to accommodate this successfully. </p>
<p>Fast forward to 2020, the same practice is in place but other factors have exacerbated the frequency and magnitude of these issues. The globalisation of supply chains, the growth of pharmaceutical companies in this sector, the explosion of the generics market (where products are no longer patented and can be reproduced by other companies) offering high-volume low-cost medicines such as paracetamol, have increased complexity in the pharmaceutical supply chain. Added to this are new trading agreements (eg Brexit), the grounding of the Ever Given ship in the Suez Canal (<a href="https://www.bbc.co.uk/news/world-middle-east-56625680">which delayed supplies</a>) and of course the pandemic. So many high-risk and high-impact events all occurring within one year, have caused chaos with medicines supplies and associated equipment. </p>
<p>Problems within supply chains are endemic, with capacity struggling to match product demand. The pandemic has affected all supply chains so we have seen large scale shortages of key items which are vital to business, including medicines, semi-conductors for computers and electronic devices, wood and clothing. In the US, the erosion of <a href="https://hbr.org/2021/05/the-challenge-of-rebuilding-u-s-domestic-supply-chains">“industrial commons”</a> – domestic capabilities needed to produce goods for home use – was cited as a cause of supply chain deficiencies. The US invoked the Defense Production Act to <a href="https://www.cnbc.com/2020/12/28/biden-will-invoke-defense-production-act-to-boost-covid-vaccine-production-advisor-says.html">boost and retain domestic vaccine production</a> to support the country’s own COVID-19 vaccine rollout. </p>
<p>Lean manufacturing principles and “just in time” practices adopted by manufacturers – buying products to be delivered just in time for production to reduce stockholding – <a href="https://theconversation.com/coronavirus-the-perils-of-our-just-enough-just-in-time-food-system-133724">left companies with limited stocks</a> to respond to increasing demand, and no toilet rolls on supermarket shelves. In hospitals and other healthcare operations, stockholding capacity is dictated by storage facilities, which can be limited, and a reliance on multiple daily deliveries to keep up stock levels. This does not cause problems if there is fairly stable product demand. The pandemic, however, caused a huge surge in global demand for many healthcare products which resulted in widespread product shortages.</p>
<figure class="align-center ">
<img alt="Robotic arms in factory assemble a car body shell." src="https://images.theconversation.com/files/407213/original/file-20210618-20-12a7f9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/407213/original/file-20210618-20-12a7f9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/407213/original/file-20210618-20-12a7f9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/407213/original/file-20210618-20-12a7f9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/407213/original/file-20210618-20-12a7f9u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/407213/original/file-20210618-20-12a7f9u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/407213/original/file-20210618-20-12a7f9u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘Just in time’ manufacturing was coined from a system used by the Toyota car company in the 1930s.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/automotive-assembly-industry-exhibition-toyota-factory-1052833841">Bandit Chanheng/Shutterstock</a></span>
</figcaption>
</figure>
<p>Practices which for decades were seen as sensible: avoiding assets being tied up in stock or high levels of waste being generated, are not now effective in the current climate. Coupled with extensive globalisation, longer supply chains spanning multiple parties and countries have <a href="https://www.nytimes.com/2021/06/01/business/coronavirus-global-shortages.html">increased vulnerability</a>.</p>
<hr>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-the-perils-of-our-just-enough-just-in-time-food-system-133724">Coronavirus: The perils of our ‘just enough, just in time’ food system</a>
</strong>
</em>
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<p>The question must be asked about what we have learned from other epidemics, pandemics and vaccination programmes. From a medical perspective, <a href="https://blogs.bmj.com/ebn/2020/07/13/why-havent-we-learned-from-past-pandemics/">key lessons</a> relate to science, communication, co-operation and ethics. Understanding when information needs to be shared (when, how and by whom) and the evidence base which supports this, working in partnerships (politicians, public health officials, physicians, scientists and the media) to facilitate this and conducting this process in the most ethical manner. </p>
<p>Increased demand for PPE in the UK was predicted in <a href="https://www.theguardian.com/world/2020/may/07/what-was-exercise-cygnus-and-what-did-it-find">Exercise Cygnus</a> but recommendations were not deployed at the start of the pandemic. Exercise Cygnus, was a simulation of a flu outbreak at peak, carried out to war-game the UK’s pandemic readiness in 2016. The findings of the exercise indicated that the country was not sufficiently prepared to cope with the extreme demands of a pandemic. Key areas of concern included a lack of joint tactical-level plans and social care provision. The report listed four areas of “key learning” and 22 further “lessons identified” from the exercise, couched as recommendations to government. The creation of stockpiles of <a href="https://www.bmj.com/content/372/bmj.n335/rr-1">PPE and respirators</a> were mentioned. </p>
<p>The output of Exercise Cygnus should have been the blueprint that would dictate the UK’s COVID-19 pandemic response. Unfortunately, the lessons weren’t taken on and just four years later disaster struck.</p>
<h2>A question of access</h2>
<p>I knew that there were substantial issues in the pharmaceutical supply chain when I visited a retail pharmacy in December 2019 and there was no paracetamol available. Paracetamol is a very cheap product, made in high volume as a generic item, and readily available. The same issue emerged in March 2020 when paracetamol stocks were being readily snapped up to self-medicate COVID symptoms. </p>
<p>Supplies of medicines and vaccines during the pandemic have been problematic. Panic buying of essential products created a surge in demand leading to a pull on manufacturing capacity. A change in consumer behaviours also led to opportunistic criminal behaviour such as the manufacturing of <a href="https://www.globaltimes.cn/page/202102/1214637.shtml">fake COVID vaccines</a>. </p>
<p>Concerns were raised as to the impact of PPE shortage on healthcare workers and <a href="https://metro.co.uk/2021/06/10/covid-matt-hancock-denies-lying-to-boris-johnson-over-care-home-crisis-14747635/">possible deaths attributed to lack of it</a>. Questions were also asked about why local PPE manufacturers were not offered contracts and why <a href="https://www.dailymail.co.uk/news/article-8961343/Fury-18bn-PPE-scandal.html">poor quality products were ordered and received</a>.</p>
<p>In an attempt to protect its home population, India took steps in 2020 to <a href="https://medicalxpress.com/news/2021-04-india-export-covid-treatment-drug.html">ban exports of some medicines</a> used to manage COVID-19 symptoms, <a href="https://www.theguardian.com/world/2020/mar/04/india-limits-medicine-exports-coronavirus-paracetamol-antibiotics">for example</a> paracetamol and the antiviral drug remdesivir. As India is a large exporter of pharmaceuticals the impact of this decision was substantial. In the UK, supermarket and pharmacy shelves went bare and any stock that was available was <a href="https://www.theguardian.com/world/2020/mar/12/coronavirus-triggers-sharp-rise-in-price-of-pain-relief-medication">substantially higher in cost</a>, up to 30% in some cases for paracetamol, aspirin and ibuprofen. </p>
<p>Much of the world is heavily reliant on manufacturing countries <a href="https://pharmaceutical-journal.com/article/feature/india-and-china-spark-concerns-for-uk-drug-supplies">such as India and China for pharmaceutical products</a>. These are fragile points in a global supply chain that fractured under the impact of the pandemic. India is often described as the world’s pharma capital, where inexpensive, quality drugs are readily available. Despite this and <a href="http://www.businessworld.in/article/PHDCCI-Seeks-Govt-Support-For-Domestic-Vaccine-Industry/16-06-2021-393333/">the volume of vaccines</a> also produced in India, the country has still struggled with its own <a href="https://blogs.bmj.com/bmj/2021/05/10/the-second-covid-19-wave-and-the-paradox-of-indian-healthcare/?utm_source=twitter&utm_medium=social&utm_term=hootsuite&utm_content=sme&utm_campaign=usage">escalating COVID cases</a>.</p>
<figure class="align-center ">
<img alt="Woman doctor giving older Indian woman a vaccine shot into the shoulder" src="https://images.theconversation.com/files/405974/original/file-20210611-27-1t093x4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405974/original/file-20210611-27-1t093x4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405974/original/file-20210611-27-1t093x4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405974/original/file-20210611-27-1t093x4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405974/original/file-20210611-27-1t093x4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405974/original/file-20210611-27-1t093x4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405974/original/file-20210611-27-1t093x4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">COVID exposed fragile points in the vaccine global supply chain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-gloves-holding-syringe-making-injection-1766547584">BaLL LunLa/Shutterstock</a></span>
</figcaption>
</figure>
<p>Coupled with shortages in staff and mandated closures of manufacturing sites to reduce the risk of transmission, and ongoing issues around access to stock and logistics, <a href="https://www.europeanpharmaceuticalreview.com/article/116439/limiting-shortages-steps-for-the-uk-to-strengthen-drug-supply/">India and China struggled to respond to product demand</a>. This in itself led to repercussions in wider global supply chains, with demand shifting elsewhere or supplies going unfulfilled. </p>
<p>Vaccine supply chains are challenging based on the complexity of the product, distribution, geography, responsiveness and prioritisation of supplies. This is a fact that underpins decision making when creating vaccines, designing vaccination programmes and allocating supplies. The response to COVID-19 was to create up to <a href="https://www.nature.com/articles/d41586-021-00727-3">12 billion vaccines</a> by the end of 2021, building on previous capability, but with the added challenge of creating a working vaccine – as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7177048/">vaccines were not quickly created for previous</a> coronavirus strains.</p>
<h2>The race for a vaccine</h2>
<p>This mammoth task was achievable because of significant governmental intervention and <a href="https://www.europeanpharmaceuticalreview.com/news/124579/uk-government-invests-100-million-into-covid-19-vaccine-manufacturing/">investment</a> in research and development and manufacturing facilities. In the UK, targeted investment in the AstraZeneca/Oxford vaccine development reaped dividends, accompanied by proactive contract negotiation <a href="https://www.repubblica.it/cronaca/2021/02/07/news/kate_bingham_interview_vaccines_covid_astrazeneca_uk_coronavirus_johnson-286384093/">for eight vaccine candidates</a>. </p>
<p>Rapid vaccine creation for seasonal flu meant when the coronavirus hit, vaccine development happened faster. <a href="https://www.theguardian.com/society/2020/dec/08/how-has-a-covid-vaccine-been-developed-so-quickly">The process of vaccine creation can take up to ten years</a> but once the coronavirus gene sequencing was complete vaccine creation could commence. The AstraZeneca/Oxford vaccine took about <a href="https://www.bbc.co.uk/news/health-55041371">ten months</a> to launch. </p>
<p>Some epidemics recur year after year because the affected populations do not have access to appropriate vaccines and drugs. Diseases like COVID-19 do not respect borders. The case is therefore made for equitable access to vaccines and medicines to prevent increasing global transmission rates.</p>
<p>Countries with access to vaccines (through contracts or with the ability to produce them locally) have shown a preponderance to vaccine hoarding, nationalism and protectionism, limiting exports with the aim of <a href="https://www.theguardian.com/commentisfree/2021/mar/17/rich-countries-hoarding-vaccines-us-eu-africa">protecting their own populations</a> or to fulfil specific contracts. <a href="https://www.who.int/news/item/27-05-2021-covax-joint-statement-call-to-action-to-equip-covax-to-deliver-2-billion-doses-in-2021">COVAX</a> is the global mechanism for equitable access to COVID-19 vaccines but the initiative has been less successful than expected in securing only <a href="https://commonslibrary.parliament.uk/research-briefings/cbp-9240/">0.3% of vaccines</a> for lower income countries, 75% of which were administered in only ten countries. </p>
<p>Vaccine equity is a contentious issue. Leading up to the G7 summit in June 2021, the UK announced a donation of <a href="https://www.bbc.co.uk/news/uk-57436535">100 million surplus vaccines</a> to COVAX and other countries. </p>
<h2>Innovations in a time of crisis</h2>
<p>Access to PPE, ventilators, oxygen and other equipment needed by frontline staff for patients caused huge problems to healthcare staff across the world, exposing them to <a href="https://www.gmb.org.uk/news/hospital-staff-left-tears-over-lack-ppe">risk while delivering care</a>. The demand for PPE was such that it created a global shortage that needed a <a href="https://theconversation.com/how-asias-clothing-factories-switched-to-making-ppe-but-sweatshop-problems-live-on-141396">quick solution</a>. In 2020-21 there was a huge surge in PPE creation. Initially the focus was on safety and functionality but later this shifted to a <a href="https://theconversation.com/what-happens-to-waste-ppe-during-the-coronavirus-pandemic-137632">longer term, sustainability focus</a> and more recently to more security and protection designed into <a href="https://www.bbc.co.uk/news/health-52254745">protective equipment</a>.</p>
<p>The rush to source and manufacture more technical items such as ventilators has created new partnerships and high levels of innovation. In the <a href="https://www.ventilatorchallengeuk.com/">Ventilator Challenge UK</a>, a consortium of significant UK industrial, technology and engineering businesses from across the aerospace, automotive and medical sectors, came together to produce medical ventilators. </p>
<p>Some organisations responded to the urgency of product outages. Companies which had never produced medical or healthcare products re-engineered their production processes to do so. <a href="https://www.brewdog.com/uk/hand-sanitiser">Brewdog</a>, a beer manufacturer, showed how some businesses adapted at this time by turning its hand to making hand sanitiser.</p>
<p>The innovation, creativity and educated risk taking that saw some countries get ahead with vaccines were problematic for the European Union, which subsequently suffered delays to their own supplies – a situation that led <a href="https://www.theguardian.com/world/2021/mar/25/jean-claude-juncker-criticises-eu-over-covid-vaccine-spat-with-uk">to political acrimony</a> between the UK and the EU. Concerns about the pace of their vaccination campaign led the <a href="https://www.bbc.co.uk/news/world-europe-55822602">EU to demand</a> that the UK export AstraZeneca/Oxford vaccines to support their vaccination campaign and the UK refused to do so. Meanwhile, frustration with the EU’s handling of vaccine procurement led some member countries to decide to secure vaccines direct from manufacturers. </p>
<p>But while the UK and other governments confidently reported on the vaccines they’d secured and their volumes, there was little transparency as to delivery schedules. The upgrading of manufacturing sites to respond to greater demand for vaccines led to production and <a href="https://www.reuters.com/article/us-health-coronavirus-italy-vaccine-idUSKBN29Y1CD">delivery delays in Moderna, AstraZeneca/Oxford and Pfizer/BioNTech</a> stock in early 2021.</p>
<p>The strategic locating of split-site production facilities – vaccines being produced on multiple sites – can reduce the risk of process contamination or other issues and increase supply chain resilience. AstraZeneca chose to spread its production risk widely, with contracted <a href="https://www.nature.com/articles/d41586-021-00727-3">manufacturing capacity for 2.9 billion vaccine doses</a> to 25 firms in 15 countries. Although in one factory in the US used by two different vaccine firms, <a href="https://www.axios.com/johnson-johnson-plant-problems-2d0337fa-ef9a-411a-ae5e-1907127957e5.html">production was halted after cross-contamination concerns</a>. </p>
<p>When a pandemic hits, other materials, such as glass vials, tubing, and plastic bags, also become vital. With enhanced production of medicines and equipment comes the increased need to have storage receptacles and packing. The US also invoked legislation to withhold vital materials for domestic production, which was said to contribute to this shortage, but this <a href="https://theprint.in/health/us-removes-defense-production-act-ratings-on-astrazeneca-novavax-sanofi-vaccines/671563/">was lifted</a> in June 2021. Another choke point in the system, the fill and finish section, where the vaccine liquid is placed into vials and packaged for distribution, was recently boosted <a href="https://www.nature.com/articles/d41586-021-00727-3">by companies who make injectables</a> which should increase output volumes. </p>
<h2>What we must now do</h2>
<p>Moving forward, there are key areas of concern that we should focus on in our supply chains to promote greater stability and access to critical supplies. </p>
<p><strong>Go back to basics</strong>. At the height of the pandemic, rapid response was the order of the day. Having rushed to cope and adapt in the face of the pandemic, to keep businesses afloat, we now need to take stock of what businesses and supply chains look like. Changes made to strategies, practice and suppliers, the introduction of new technologies and ad hoc workforce configuration may not suitable as permanent solutions. Now is the time to review and redesign processes and systems. </p>
<p>Businesses can assess the products they buy and where in the world they are created and simulate scenarios of disruptions to identify and fix weak spots in their supply chains. This would inform products that should be stockpiled (due to scarcity or location) and those that can be accessed locally, so lower stock levels can be held or stock delivered just in time for use. The rapid creation of vaccines is a timely reminder of the importance of healthcare research and the production of pharmaceuticals. Investment in the pharmaceutical industry and research funding is essential to increase pandemic preparedness.</p>
<p><strong>Be prepared to be bold and take risks</strong>. The pandemic has changed our lives, ways of working and ways of being. What worked before may not work now. We have shown high levels of resilience in being innovative, seeking out novel solutions, designing new technologies, <a href="https://www.nature.com/articles/d41586-021-00727-3">engaging new suppliers to remove choke points</a> and <a href="https://hbr.org/2020/07/how-businesses-have-successfully-pivoted-during-the-pandemic">“pivoting”</a> to redesign supply chains. For example, Unilever chose to prioritise the production of its packaged food, surface cleaners, and personal hygiene product brands, in response to heightened demand. Knowing risk hotspots and mitigating these are <a href="https://www.emerald.com/insight/content/doi/10.1108/IJOPM-03-2020-0165/full/html">critical to business survival</a>. </p>
<p><strong>Supply chain configuration</strong>. The globalisation of supply chains is something that organisations have strived towards, to offer new business opportunities, greater responsiveness and maximum global presence. This came back to haunt companies during the pandemic, highlighting weaknesses and fractures that enhanced vulnerabilities. Going global, staying local, nearshoring manufacture and shortening supply chains which create <a href="https://brazilian.report/liveblog/2021/04/28/kick-off-production-butanvac-vaccine/">domestic vaccine production capability</a> should be debated as businesses learn from this pandemic. PPE sourcing was a critical issue during the pandemic and <a href="https://industrytoday.com/preventing-a-ppe-shortage-before-it-happens-again/">local sourcing proved essential</a>. </p>
<p><strong>New and existing alliances</strong>. The pandemic years 2020-21 offered great insight into business partnerships. Relationships were greatly tested and not all survived. Knowing why age-old relationships failed and new ones never got off the ground is a very salient lesson. Recognising the value of being creative with new partnerships, reducing the focus on costs as the basis for trading and seeking to work smarter are also takeaways from surviving the pandemic. Alliances formed to advance vaccine manufacturing and fill and finish (Sanofi, Merck, GSK, Pfizer) were <a href="https://www.nature.com/articles/d41586-021-00727-3">excellent examples of collaboration</a>. </p>
<p><strong>Build system resilience</strong>. The pandemic has impacted all aspects of society. To face future pandemics and large-scale supply chain disruptions we need to be stronger, more resilient and more agile. This relies heavily on enhancements in manufacturing, research intelligence, education, system infrastructure and technologies. It also relies on learning from previous pandemics and epidemics to increase our preparedness for emergency response. </p>
<p><strong>Learn from other supply chains</strong>. Vaccine and medicines supply chains are complex, from product creation through to administration to patients. Issues raised in this supply chain such as communication, risk identification and longer supply chains are generic and equally applicable to other supply chains across sectors. What we can learn from other supply chains are their response mechanisms, adaptations and levels of agility. Humanitarian logistics and perishable goods supply chains offer valuable insights. We can determine if such practice can be transferred to the pharmaceutical supply chain. While Amazon may be the distributor of medicines in the future, and vaccine supply chains can be informed by <a href="https://theconversation.com/what-vaccine-distribution-planners-can-learn-from-amazon-and-walmart-151893">Amazon success</a>, manufacturing will always be in the hands of specialist companies. </p>
<p><strong>Supply chain psychology</strong>. Key learning from the pandemic is understanding how supply chain stakeholders operated during this time. The buying behaviours of consumers impacted negatively on some supply chains. For others, panic buying meant businesses thrived as opposed to closing their doors. Surviving lockdown led to consumers buying more products <a href="https://www.yorkshirepost.co.uk/health/coronavirus/businesses-prepare-post-lockdown-revenge-buying-warns-yorkshire-academic-2841774">than they normally would</a>. Greater understanding of supply chain dynamics and consumer behaviours will strengthen supply chain design. </p>
<p>The pandemic has thrown a huge curve ball at our supply chains and caused chaos. This has been incredibly damaging for some businesses but has forced others to adapt and change, albeit painfully for many. In the same way that long COVID affects our patients, there may be a lag time in supply chains getting back to strength or a new level of normality. We have much to learn from how our supply chains performed during the pandemic, to reduce the impact of supply shortages of critical goods such as medicines and vaccines. The intelligence is waiting for us to mine and use it and there will be plenty more to follow. Let’s hope we use it wisely. </p>
<hr>
<p><em>This article is part of a series on recovering from the pandemic in a way that makes societies more resilient and able to deal with future challenges. It is supported by <a href="https://theconversation.com/uk/topics/resilience-in-recovery-106634">PreventionWeb</a>, a platform from the UN Office for Disaster Risk Reduction. Read more coverage <a href="https://theconversation.com/uk/topics/resilient-recovery-series-106366">here</a>.</em></p><img src="https://counter.theconversation.com/content/161054/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Liz Breen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Supply chains, choke points, and ‘just in time’ manufacturing – where things went right and wrong during the pandemic.Liz Breen, Director of the Digital Health Enterprise Zone (DHEZ), University of Bradford, Reader in Health Service Operations, University of BradfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1478962021-03-29T12:07:56Z2021-03-29T12:07:56Z‘Frugal design’ brings medical innovations to communities that lack resources during the pandemic<figure><img src="https://images.theconversation.com/files/391474/original/file-20210324-21-3yp66r.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4240%2C2380&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Maker spaces give engineers and designers the tools to build low-cost medical equipment using locally available materials.</span> <span class="attribution"><span class="source">Brandon Martin, Rice University</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Dr. Msandeni Chiume Kayuni found herself in the middle of a supply crisis as COVID-19 spread to Africa in April 2020. As head of Pediatrics at Kamuzu Central Hospital in Lilongwe, Malawi, her team faced a critical shortage of N95 and regular surgical face masks. Nurses and doctors were striking. </p>
<p>“We had members of hospital staff put their tools down because they did not feel it was safe to practice,” she told us in an interview.</p>
<p>Ingenuity kicked in. The Malawi team purchased raincoats from the local market to use as personal protective equipment when they could not afford appropriate gowns that cost three times as much. Unlike disposable gowns, the rain gear could easily be sanitized in bleach and reused.</p>
<p>Worldwide, as the global supply chain for basic PPE, diagnostic tests and equipment to treat critically ill COVID-19 patients buckled under the strain, medical personnel improvised and engineers began developing solutions almost overnight. Engineering students used university-based maker spaces to invent and produce new technologies – face shields, automated hand washing stations, diagnostic testing equipment and respiratory support equipment – that allowed health care workers to safely deliver effective care.</p>
<p>As engineers working in the <a href="https://scholar.google.com/citations?user=JvDMZEMAAAAJ&hl=en">U.S.</a> and <a href="https://www.researchgate.net/profile/Theresa-Mkandawire">Malawi</a> to develop effective and affordable medical devices for low-resource communities, we routinely practice and teach this level of resourcefulness, dubbed “frugal design.”</p>
<h2>Spreading the light</h2>
<p>Medical personnel reused available N95 masks, intended to be used once, for weeks or months, which required innovative ways to disinfect them, including heaters, gas sterilizers and ultraviolet light.</p>
<p>UVC – short-wavelength ultraviolet light – <a href="https://theconversation.com/ultraviolet-light-can-make-indoor-spaces-safer-during-the-pandemic-if-its-used-the-right-way-141512">kills or inactivates viruses</a>, including SARS-CoV-2, the virus that causes COVID-19. In the pandemic, scientists set up UVC systems in spare rooms at hospitals to sanitize masks. </p>
<p><a href="https://www.nebraskamed.com/sites/default/files/documents/covid-19/n-95-decon-process.pdf">The University of Nebraska Medical Center</a> equipped a room with UVC light towers and coated the walls with reflective foil to maximize the dose of UVC light. Dirty masks are clipped to rows of clothesline strung across the UVC room. An operator outside the room started the lights, and a detector in the room ensured the masks had received a virus-killing dose of light. Masks can be disinfected and <a href="https://doi.org/10.1080/15459624.2015.1018518">reused multiple times</a> without damaging their integrity. </p>
<p>Engineers in Houston, Malawi and Tanzania worked together to reduce the cost of <a href="https://a35c7f44-33a6-4729-a16a-f1176754cacf.filesusr.com/ugd/0b77a5_1bd6601353084b28b6e22302082fbbda.pdf">room-based UVC disinfection systems</a> to less than US$800, and several systems are now installed in hospitals in Malawi and Tanzania. Engineers at other locations <a href="https://doi.org/10.1101/2020.04.29.20085456">built disinfecting stations</a> by adapting UV lights in the hoods normally used to grow cells in culture or by repurposing the <a href="https://hackaday.com/2020/06/16/a-properly-engineered-uv-chamber-for-ppe-sanitization/">UV light in an aquarium sanitizer</a>.</p>
<h2>Local innovation for PPE</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman wearing a lab coat, face mask and hair covering holds two plastic face shields" src="https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1066&fit=crop&dpr=1 600w, https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1066&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1066&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1340&fit=crop&dpr=1 754w, https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1340&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/391482/original/file-20210324-13-o68y9h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1340&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Health care workers around the world turned to 3D-printed face shields in the early months of the pandemic.</span>
<span class="attribution"><span class="source">Julia Jenjezwa, Rice 360° Institute for Global Health</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Across the world, engineering students used novel maker spaces at universities with 3D printers and laser cutters to rush new PPE designs into large-scale local production. Students and staff at Malawi’s two engineering schools, Malawi Polytechnic and the Malawi University of Science and Technology, and at Tanzania’s Dar es Salaam Institute of Technology, <a href="https://www.nest360.org/post/dit-design-studio-innovation-for-covid-19-preparedness-in-tanzania">adapted open-source</a> designs to produce face shields. They consulted with clinicians at partner hospitals to improve comfort and safety while using only locally available materials. </p>
<p>Development organizations, including UNICEF and the United Nations Development Program, ordered over 8,000 face shields that were locally produced and delivered to area hospitals.</p>
<h2>Rethinking diagnostics designs</h2>
<p>Diagnostic laboratories could not obtain key supplies needed to run COVID-19 tests in the early stages of the pandemic. In early 2020, major hospitals and public health systems struggled to obtain <a href="https://www.mckinsey.com/industries/pharmaceuticals-and-medical-products/our-insights/covid-19-overcoming-supply-shortages-for-diagnostic-testing">swabs, sample tubes, reagents and equipment</a> needed to meet the increased demand for testing. </p>
<p>The first available COVID-19 test relied on <a href="https://www.who.int/docs/default-source/coronaviruse/whoinhouseassays.pdf?sfvrsn=de3a76aa_2">polymerase chain reaction</a>, or PCR, a method that increases the amount of a viral RNA in a sample to detectable levels. This method of testing requires specialized reagents and equipment to isolate viral RNA, transform it to DNA, and trigger the amplification process. </p>
<p>Because of the complexity of PCR-based testing and the scarcity of test reagents, the National Institutes of Health <a href="https://doi.org/10.1056/NEJMsr2022263">invested $1.5B in the RADx program</a> to spur innovators to find novel, affordable diagnostic tests. Many innovative tests have received <a href="https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#individual-molecular">emergency use authorization</a> from the Food and Drug Administration and are now used throughout the world.</p>
<p>For example, <a href="https://doi.org/10.1073/pnas.2011221117">researchers at Harvard</a> used a simple single-temperature reaction to amplify viral RNA, eliminating many of the necessary steps and reagents of PCR and speeding up the testing time. Researchers at Stanford adapted the <a href="https://twitter.com/i/status/1279182764781088768">mechanism inside a toy flashlight</a> to build a <a href="https://www.chemistryworld.com/news/hand-powered-centrifuge-setup-can-diagnose-covid-19-for-just-a-dollar-a-test/4012142.article">simple electricity-free centrifuge</a> to help perform this new COVID-19 test in areas that lack electricity and other laboratory infrastructure.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uqiPNUp8hvs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Devices like this hand-powered centrifuge could make COVID-19 testing more accessible in communities with limited access to electricity.</span></figcaption>
</figure>
<h2>Reinforcing ventilator supplies</h2>
<p>In response to the global shortage of ventilators in the first months of the pandemic last year, engineers designed simple devices to provide temporary breathing support. Open-source plans for two systems, <a href="https://doi.org/10.1007/s00134-020-06113-3">one</a> designed by the <a href="https://emergency-vent.mit.edu/">MIT Emergency Ventilator Project</a> and one designed by students and staff at <a href="http://oedk.rice.edu/apollobvm/">Rice University</a>, are available online. </p>
<p>A global <a href="https://www.cidrap.umn.edu/news-perspective/2021/03/who-sounds-alarm-over-covid-linked-oxygen-crisis">shortage of oxygen</a> in low-resource countries has led many health care providers in those countries to fall back on mechanical ventilation. Ventilators are also in short supply, in part because of <a href="https://www.washingtonpost.com/national-security/2021/01/29/usaid-trump-ventilators-watchdog/">problems with a U.S. ventilator donation program</a>.</p>
<p>Students and faculty at the Malawi University of Science and Technology developed a <a href="https://www.nest360.org/post/malawi-design-studios-poly-must-provide-locally-sourced-ppe-technologies-to-respond-to-covid-19">system similar to the MIT and Rice ventilators</a> that can be assembled using materials available in Malawi. Students at Malawi Polytechnic worked with local physicians to <a href="https://www.iol.co.za/news/africa/young-engineers-offer-new-hope-for-malawi-in-covid-19-fight-47086599">develop a ventilator with more features</a>.</p>
<h2>Hygiene innovation</h2>
<p>Public health officials emphasize the role of <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public">hand-washing, together with social distancing and face masks</a>, to curb the continued spread of COVID-19. However, many schools and even some hospitals in low-resource settings do not have running water and sinks allowing students and patients to regularly wash their hands. </p>
<p>In response, Brenald Dzonzi, an engineering student at Malawi Polytechnic, designed a no-touch hand-washing station. Small amounts of soap and water are automatically dispensed from pre-filled containers when a user stands in front of the station. The system is made from local materials and is now installed at a local hospital. Up to 2,000 patients can safely wash their hands before the system needs to be refilled. </p>
<p>Dzonzi was awarded the <a href="https://www.unicef.org/malawi/stories/brenald-touch-free-disinfection-public-places">UNICEF Youth Challenge award</a> to fund continued development of the hand-washing station.</p>
<h2>Elegant and sustainable design</h2>
<p>When equipment is unsuitable for an environment, because it can’t tolerate hot, dusty conditions, for example, it ends up discarded in equipment graveyards — serving no one. In contrast, successfully executed <a href="https://doi.org/10.1126/science.1257085">frugal designs</a> offer sustainability and suitability for low-resource environments. </p>
<figure class="align-center ">
<img alt="numerous rows of medical equipment in a storeroom" src="https://images.theconversation.com/files/366808/original/file-20201030-14-1abkwp6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/366808/original/file-20201030-14-1abkwp6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=281&fit=crop&dpr=1 600w, https://images.theconversation.com/files/366808/original/file-20201030-14-1abkwp6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=281&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/366808/original/file-20201030-14-1abkwp6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=281&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/366808/original/file-20201030-14-1abkwp6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=353&fit=crop&dpr=1 754w, https://images.theconversation.com/files/366808/original/file-20201030-14-1abkwp6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=353&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/366808/original/file-20201030-14-1abkwp6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=353&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A medical equipment ‘graveyard’ in Malawi.</span>
<span class="attribution"><span class="source">Rice 360° Institute for Global Health</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>An example of this type of elegant design is the <a href="https://doi.org/10.1371/journal.pone.0098781">FoldScope</a>, a low-cost paper microscope used to improve medical diagnostics and science education in low-resource settings. Other examples include <a href="https://equalizehealth.org/products/brilliance">LED-based</a> phototherapy lights used to treat jaundice in newborns, and <a href="https://doi.org/10.1371/journal.pone.0235031">low-cost CPAPs</a> that bring breathing support to small and sick newborns in low-resource health care facilities.</p>
<p>To encourage frugal design, universities across the world are changing <a href="https://doi.org/10.1126/science.1213947">how they teach engineering</a> — focusing on frugal design and engaging students like Dzonzi to invent solutions that <a href="https://doi.org/10.1007/s10439-016-1777-1">solve real problems</a>. Though the pandemic sparked a global need for frugal design, the practice is important generally for narrowing the health care gap between high- and low-resource communities and bringing health care services to underserved communities.</p><img src="https://counter.theconversation.com/content/147896/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Richards-Kortum receives funding from the National Institutes of Health, the National Science Foundation, the Bill & Melinda Gates Foundation, the MacArthur Foundation, ELMA Philanthropies, the Children's Investment Fund Foundation, and the Lemelson Foundation. </span></em></p><p class="fine-print"><em><span>Theresa Mkandawire does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Engineering students in Malawi and Tanzania have used the materials and tools available to them to build ventilators, personal protective equipment and UV disinfection systems.Rebecca Richards-Kortum, Professor of Bioengineering, Rice UniversityTheresa Mkandawire, Associate Professor of Civil Engineering, University of MalawiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1554122021-03-01T14:19:48Z2021-03-01T14:19:48ZTraditional healers in South Africa are exposed to infection, but few can get protective gear<figure><img src="https://images.theconversation.com/files/385749/original/file-20210223-16-1q5qrrv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most healers understand that blood exposure can result in infectious disease transmission.</span> <span class="attribution"><span class="source">Gulshan Khan/AFP via Getty Images</span></span></figcaption></figure><p>There are around two million traditional healers in <a href="https://www.academia.edu/2121522/Traditional_medicines_and_traditional_healers_in_South_Africa">sub-Saharan Africa</a>. More than <a href="https://www.gov.za/documents/traditional-health-practitioners-act#">200,000</a> live and work in South Africa. </p>
<p>Traditional healers are frequently <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3513988/">exposed</a> to bloodborne <a href="https://pubmed.ncbi.nlm.nih.gov/15117130/">pathogens</a> such as hepatitis B and HIV. In particular, they are exposed through the widespread practice of traditional “injections” by incision. This is when the healer makes small cuts in a patient’s skin using a razor blade to <a href="https://europepmc.org/article/med/17207159">rub herbs directly</a> into the bloodied tissue with their bare hands. They are also exposed to airborne pathogens such as <a href="https://jamanetwork.com/journals/jama/fullarticle/2768391">COVID-19</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/20375784/">tuberculosis (TB)</a> when treating patients. </p>
<p>Education and awareness campaigns have led to greater understanding among <a href="https://pubmed.ncbi.nlm.nih.gov/16831789/">traditional healers</a> about the causes and treatments for HIV, TB and other conditions for which effective treatment <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577748/">can be found</a> at public health facilities. However, many people seek treatment from traditional healers before definitive diagnoses have been made, placing the traditional healer at risk of occupational infection. </p>
<p>Traditional healers can and should benefit from efforts to protect people caring for the sick from bloodborne and airborne pathogens. The correct use of personal protective equipment is an evidence-based practice that prevents infection by creating a barrier between the patient’s body fluids and the health provider. But protective equipment is only effective if used correctly and regularly. </p>
<p>Our <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05515-9">research</a> in a rural South African town found that traditional healers are open to using gloves and masks, and many regularly do so. But they do not have access to formal training in putting on, taking off, and disposing of personal protective equipment. They also don’t have regular access to government-funded gloves or masks. Leaving aside any question about the efficacy of <a href="https://www.cambridge.org/core/journals/africa/article/abs/zulu-ritual-immunisation-in-perspective/57E04D8353D3231862565861644035E0">traditional methods</a> for diagnosis and <a href="https://www.tandfonline.com/doi/full/10.1016/S0968-8080%2810%2935500-5">treatment</a>, traditional healers should be made as safe as possible. </p>
<h2>Occupational hazards</h2>
<p>The practice of “injections” by incision can increase a healer’s risk of HIV infection. An average healer in the rural South African town where our research was done is exposed to blood in this way about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093076/">1,500 times</a> over their working life. </p>
<p>Most exposures on unbroken skin do not result in infection. But the risk of <a href="https://www.cdc.gov/hai/pdfs/bbp/exp_to_blood.pdf">infection varies</a> by the pathogen involved, the type of exposure, the amount of blood involved, and the amount of virus in the patient’s blood at the time of exposure. The average <a href="https://www.cdc.gov/hai/pdfs/bbp/exp_to_blood.pdf">risk of HIV infection</a> after a needle stick or cut exposure to HIV-infected blood is 0.3%, and after exposure to eye, nose or mouth is estimated to be 0.1%. </p>
<p>“Injections” result in substantial blood exposure, which is in contact with a healer’s bare skin. The exposure is primarily on the hands and arms. But, as people touch their faces <a href="https://pubmed.ncbi.nlm.nih.gov/25637115/">23 times per hour</a>, exposure to the mucous membranes (mouth, nose and eyes) is possible.</p>
<p>We partnered with the Kukula Traditional Healers Association in Mpumalanga to understand the risks of occupational acquisition of HIV in rural South Africa. From December 2017 to May 2018, we randomly selected 229 traditional healers to complete a survey assessing HIV risk behaviours (sexual activity, receiving a tattoo with an unclean needle, and occupational exposure during traditional treatments) and complete HIV testing. </p>
<p>We found that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3778517/">healers</a> have an HIV prevalence of 30% compared to 19% in the general population. HIV prevalence is <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111063">28.3%</a> in men who have sex with men and 58.6% among <a href="https://pubmed.ncbi.nlm.nih.gov/28981511/">female sex workers</a>. Our findings suggest that traditional healers are also a high-risk population for HIV acquisition. Specifically, healers who <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093076/">reported exposure</a> to patient blood have an <a href="https://journals.lww.com/aidsonline/Abstract/2020/12010/An_unrecognized_key_population__Traditional.16.aspx">2.4-fold higher</a> risk of being HIV-positive than those with no exposure, after other exposure risks (gender, age, number of sexual partners) are taken into consideration. </p>
<p>We found that the use of personal protective equipment among traditional healers is acceptable and most healers understand that blood exposure can result in infectious disease transmission. Despite positive attitudes, consistent glove use remains low due to financial constraints, glove availability, and distance to clinics and pharmacies (where they can be acquired). Of those we studied, only 10% of healers were willing to pay for their own gloves to ensure that they were protected. </p>
<p>These healers were motivated by <a href="https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05515-9">four things</a>:</p>
<ul>
<li>a belief that personal protective equipment is effective, </li>
<li>a trust of, and feeling of partnership with, the allopathic health system, </li>
<li>a fear of contracting disease, and </li>
<li>a belief that they are responsible for their own health.</li>
</ul>
<h2>Recommendations</h2>
<p>The emergence of COVID-19 will likely lead to increased glove and mask use among traditional healers, at least in the short term. Healers are becoming more educated and concerned about disease transmission – whether it be HIV or COVID-19. Personal protective equipment is slowly becoming more accessible (now being sold at local shops, instead of only large pharmacies) and socially acceptable in nonclinical situations. While we expect to see some improvements, proper use will likely remain a barrier to protection. </p>
<p>In the long term, we propose two strategies. </p>
<p>The first is engaging traditional healers who use personal protective equipment consistently to train those who do not. We believe these healers can be respected role models who can appreciate the challenges of protective equipment use among traditional healers and provide effective training and strategies to put on, take off, and dispose of it safely. </p>
<p>Secondly, improving access to personal protective equipment among healers and their patients. Healers either acquire protective equipment from select health facilities (for free) or purchase them from pharmacies. While free personal protective equipment is preferable (to the healer), many clinics do not provide this service and travel times to those that do can hinder uptake. </p>
<p>Purchasing personal protective equipment is made difficult by the sale of gloves and masks in bulk at large pharmacies, and the limited availability of some of these items because of COVID-19. Access to readily available personal protective equipment is essential to protecting traditional healers.</p><img src="https://counter.theconversation.com/content/155412/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carolyn Audet receives funding from the National Institutes of Health in the United States and from ViiV Health Care. </span></em></p><p class="fine-print"><em><span>Mosa Moshabela was nominated as the chairperson of the Standing Committee on Health in the Academy of Science of South Africa since 2020, and appointed by the Office of the Premier of KwaZulu-Natal as a Health Commissioner in the Provincial Planning Commission, a body that advises the Premier and the KZN Legislature on strategic planning and policy recommendations.</span></em></p><p class="fine-print"><em><span>Ryan G Wagner receives funding from South African National Research Foundation (grant #119234) and the National Institutes of Health (USA). </span></em></p>An average healer in the rural South African town where the study was done experiences about 1,500 occupational blood exposures in their lifetime.Carolyn Audet, Assistant Professor in the Department of Health Policy at the Vanderbilt Institute for Global Health , Vanderbilt UniversityMosa Moshabela, Deputy Vice-Chancellor of Research and Innovation (Acting), University of KwaZulu-NatalRyan G Wagner, Research Fellow, Wits School of Public Health, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1554832021-02-23T14:53:20Z2021-02-23T14:53:20ZSouth Africans are revolting against inept local government. Why it matters<figure><img src="https://images.theconversation.com/files/385266/original/file-20210219-23-1982qok.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Failures by municipalities to do their work are forcing many residents to take matters into their own hands.
</span> <span class="attribution"><span class="source">EFE-EPA/Nic Bothma</span></span></figcaption></figure><p>A sea change is under way at local government level in South Africa, one which all political parties had better watch out for. Citizens’ groups are taking control of municipal functions, some with the support of courts, and are delivering services where this sphere is collapsing.</p>
<p>The trend is being driven by voters who are sick of corrupt politicians – as every poll <a href="https://www.corruptionwatch.org.za/global-corruption-barometer-africa-2019/">makes clear</a>. For example, a poll <a href="https://citizensurveys.net/">run in late 2019</a> showed growing mistrust in political parties and politicians. There was a deep-seated belief that the country was headed in the wrong direction. <a href="https://citizensurveys.net/wp-content/uploads/2019/02/Abridged-South-African-Citizens-Survey-2018-Q4-Core-Report.pdf">Over 80%</a> of respondents thought corruption was increasing.</p>
<p>The sad state of the local sphere has been lamented by many, not least the late Auditor-General Kimi Makwetu. He <a href="https://www.agsa.co.za/Portals/0/Reports/MFMA/201819/GR/Section%201%20-%20Executive%20summary.pdf">noted</a> in 2018 that “on average almost 60% of the revenue shown in the books will never find its way into the bank account”, raising the alarm that such rampant corruption and incompetence would inevitably result in a growing revolt against rates and taxes.</p>
<p>The consequence has been precisely that – talk of withholding rates and taxes, and going further to simply do what has to be done – but which government seems incapable of doing. The “<em><a href="https://www.collinsdictionary.com/dictionary/english/gatvol">gatvol</a></em>” (fed-up) tipping point seems to be upon us.</p>
<h2>Growing discontent</h2>
<p>It is against this background that the country will have local government <a href="https://www.timeslive.co.za/politics/2021-02-11-2021-local-government-elections-will-go-ahead-as-planned-cyril-ramaphosa/">elections</a>, currently scheduled for August this year. </p>
<p>Soon the media will be replete with pundits talking about the low turnout that <a href="https://www.kas.de/documents/261596/10543300/The+South+African+non-voter+-+An+analysis.pdf/acc19fbd-bd6d-9190-f026-8d311078b670?version=1.0&t=1608150183902">generally affects local elections</a>. Some will touch on the way all parties are commonly “punished” at local rather than national elections, others will talk to the winners, losers and likely coalition partners. All this will be pretty predictable. Some of it may even be correct. But something more subterranean and interesting is happening.</p>
<p>There has been growing discontent with many local authorities. In some this has gone as far as concerned citizens successfully calling for the municipality to be dissolved and <a href="https://theconversation.com/landmark-court-ruling-highlights-crisis-in-south-africas-cities-and-towns-130140">put into administration</a>, as happened in Makhanda in the Eastern Cape province in 2020.</p>
<p>Elsewhere, citizen groups have found other ways of simply taking matters into their own hands. Instead of just moaning, people are taking action. </p>
<p>Events in <a href="https://www.kgetlengrivier.gov.za/">Kgetlengrivier Local Municipality</a>, in the platinum-rich North West province, have shown just how serious the situation has become.</p>
<p>In December 2020, in what was described as an <a href="https://www.moneyweb.co.za/news/south-africa/north-west-residents-take-matters-into-their-own-hands-and-get-courts-blessing/">“astonishing judgment”</a>, a judge in the North West High Court ordered the imprisonment of the municipal manager of Kgetlengrivier for 90 days. The sentence was suspended on condition that sewage spilling into the Elands and Koster rivers be cleared up. </p>
<p>Remarkably, the judge also gave the residents’ association the right to take control of the area’s sewage works, and to be paid by local and provincial governments for its efforts.</p>
<p>The local residents duly took over the job of clearing sewage, successfully.</p>
<p>The legality of this will be tested on appeal, and may well be overturned by a more risk averse higher court. But the seeds have been sown, and national government seems to agree – national ministers were respondents in the case, and did not appeal. And the governing African National Congress (ANC) had better be careful – most of the places where these events are occurring are in ANC-held municipalities.</p>
<p>Take events in <a href="https://www.bbc.com/news/av/world-africa-51479450">Harrismith</a> in the Free State, were residents also took over fixing the sewerage; or <a href="https://southcoastherald.co.za/250426/umdonis-tyred-citizens-threaten-withhold-rates/">Umdoni Municipality</a> in <a href="https://www.facebook.com/ward15umdoni/">Scottburgh</a>, in KwaZulu-Natal, where residents are threatening to stop paying rates. In Graaff-Reinet, in the Eastern Cape, residents have objected to increases in municipal rates, frustrated by the <a href="https://www.timeslive.co.za/news/south-africa/2020-02-17-raw-sewage-flows-into-sundays-river/">broken down sewerage</a> system and other municipal services.</p>
<p>This could be construed as anarchy. And it may well be. But anarchy is often criticised and used as a pejorative – a “descent” into anarchy – rather than analysed or understood as one possible “ascent” from a corrupt and coercive politics. It means something along the lines of a belief in abolishing all government, and organising residents on a voluntary, non-coercive, <a href="https://theconversation.com/what-is-anarchism-all-about-50373">cooperative basis</a>. </p>
<p>And this is happening, across the country, from withholding rates and taxes to taking over key service delivery functions.</p>
<p>South Africans may be leading themselves from the trough of corruption to something much more interesting, contested and dangerous to a young democracy. When an entire sphere of the state is <a href="https://www.sowetanlive.co.za/news/south-africa/2021-02-22-we-are-living-in-a-pigsty-lament-standerton-residents/?utm_source=&utm_medium=email&utm_campaign=We+are+living+in+a+pigsty%2C+lament+Standerton+residents+%7C+J%26J+vaccine+is+not+yet+official%2C+say+experts%C2%A0&utm_term=http%3A%2F%2Fwww.sowetanlive.co.za%2Fnews%2Fsouth-africa%2F2021-02-22-we-are-living-in-a-pigsty-lament-standerton-residents%2F">close to dysfunctional</a> and can have its power, functions and revenue turned over to citizen groups because of incompetence or malfeasance, something is very seriously wrong. Yet political parties still want voters to trust them, come election time.</p>
<h2>Loss of trust</h2>
<p>Trust in all spheres of government is close to rock bottom, as is trust in political parties. In the last <a href="https://www.ipsos.com/en-za">Ipsos poll</a>, no party was trusted by <a href="https://www.ipsos.com/en-za/political-party-landscape-south-africa-amidst-covid-19">a third of its own supporters</a>. The opinion voters have of politicians could not be lower, matched by pessimism: less than half of respondents felt the country was heading in the right direction.</p>
<p>The final straw may well have been watching with revulsion as the most politically connected stole money meant for life-saving <a href="https://www.iol.co.za/sundayindependent/news/1-774-service-providers-under-investigation-for-ppe-corruption-spree-siu-report-reveals-f7d93b31-4079-48af-a586-d6a6e470378b">COVID-19 protective equipment</a>. </p>
<p>Talk of withholding rates and taxes has now become commonplace. Community groups have been seeking legal advice on <a href="https://www.facebook.com/pg/Graaff-Reinet-Residents-Ratepayers-Association-102908934831171/posts/?ref=page_internal">withholding rates</a> and are sharing legal opinions about the issue. Why pay, if your money is merely going to be “eaten”? This is now backed up the North West High Court ruling. Who needs government?</p>
<p>If pollsters want to understand where South Africa is going, it seems that measuring political parties and their campaigns is perhaps necessary – much as a visit to the dentist is necessary – but it may miss the point.</p>
<p>They should be polling those who no longer care about the local sphere, and who see themselves as constituting a more legitimate and, frankly, competent part of the governance infrastructure. And while taps run dry, power cuts continue due to corruption or incompetence, and no politician has yet been jailed, who is to say they are wrong?</p><img src="https://counter.theconversation.com/content/155483/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Everatt does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There has been growing discontent with many local authorities and calls by concerned citizens for the municipalities to be dissolved.David Everatt, Professor of Urban Governance, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1545642021-02-11T15:06:47Z2021-02-11T15:06:47ZAre two cloth masks better than one for preventing the spread of COVID-19?<figure><img src="https://images.theconversation.com/files/383123/original/file-20210208-21-vgaszv.jpg?ixlib=rb-1.1.0&rect=389%2C71%2C3579%2C2789&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Layering face masks has been suggested as a way to increase protection against COVID-19 variants that may be more transmissible.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Double masking has emerged as a crowd-sourced method for adding extra layers to our masks, using the masks that we have — a response to concerns about the overall direction of the pandemic and the <a href="https://theconversation.com/why-new-covid-19-variants-are-on-the-rise-and-spreading-around-the-world-153530">transmissibility of new COVID-19 variants</a>. </p>
<p>When our group <a href="https://doi.org/10.7326/M20-2567">recommended cloth masks</a> as a worthwhile additional effort to reduce transmission of COVID-19, some of the masks that we had identified in the literature were <a href="https://doi.org/10.1128/jb.83.3.663-667.1962">three-</a> and <a href="https://doi.org/10.1002/bjs.1800621203">four-layer masks</a>: in an experimental setting, they were very effective at blocking particles exhaled by the wearer. </p>
<p>We are a group of epidemiologists and engineers who have been working <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">to summarize what is known</a> about the filtration properties of textiles, to maintain a plain-language website <a href="https://www.clothmasks.ca/">clothmasks.ca</a>, and to create new knowledge about the best textiles to use and the best mask designs.</p>
<p>On the basis of our research review, <a href="https://theconversation.com/covid-19-masks-faqs-how-can-cloth-stop-a-tiny-virus-whats-the-best-fabric-do-they-protect-the-wearer-146822">we recommended two- to four-layer masks</a>, and provided <a href="https://www.clothmasks.ca/how-to-make-a-cloth-mask">a pattern for making a four-layer mask</a>. Four layers is a challenge, though, in terms of design, particularly for the home or artisanal sewer, and few commercial masks have four layers. To sew a four-layer mask, stitching may have to go through eight layers of material after turning seams, multiplied by three for darts or pleats. </p>
<p>The simple action of wearing two multi-layer masks together gets around this problem. It seems to have arisen, like many good ideas, in a number of places at the same time.</p>
<h2>Filtration efficiency</h2>
<figure class="align-right ">
<img alt="Man wearing two cloth face masks" src="https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=720&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=720&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=720&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=904&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=904&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=904&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wearing two fabric face masks together improves filtration efficiency.</span>
<span class="attribution"><span class="source">(Catherine Clase)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We summarize the protective function of a mask or mask material in terms of the percentage of small particles that it filters out — the <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">filtration efficiency</a>. Every extra layer worn increases the overall filtration efficiency of the mask, though not in a simple way. This was first <a href="https://www.jstor.org/stable/30082047">shown in a laboratory setting in 1919</a> and confirmed in <a href="https://doi.org/10.1021/acsnano.0c04897">studies conducted in aerosol labs</a> in Chicago and from the <a href="https://doi.org/10.1021/acsnano.0c05025">U.S. National Institute of Standards and Technology</a> during the current pandemic. </p>
<p>Nurses working in the 1919 influenza pandemic double masked, wearing two three-layer gauze masks. During the first SARS outbreak in 2003, health-care workers in China made twelve- to sixteen-layer masks when they ran out of certified personal protective equipment. Studies that included people wearing these masks suggested that <a href="https://doi.org/10.1016/S0140-6736(20)31142-9">they did provide protection for the wearer</a>.</p>
<p>Increasing the filtration efficiency is our goal whether we are trying to achieve source control (my mask protects you, your mask protects me) or protection of the wearer (my mask protects me). <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html">Health Canada recommends</a> a middle layer of non-woven polypropylene in masks to improve filtration efficiency. </p>
<p>We think that this non-woven material, which can be sewn and washed like a textile, is <a href="https://theconversation.com/polypropylene-the-material-now-recommended-for-covid-19-mask-filters-what-it-is-where-to-get-it-149613">likely to be a useful addition</a>. Probably the best way to improve the filtration efficiency of masks is to <a href="https://www.clothmasks.ca/polypropylene">add a layer of polypropylene</a>, either when the mask is made or as a washable filter insert into a pocket masks.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=527&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=527&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=527&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=662&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=662&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=662&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pocket mask with an insert of washable spunbond industry-grade polypropylene.</span>
<span class="attribution"><span class="source">(Jonathan Clase)</span></span>
</figcaption>
</figure>
<p>Wearing two such masks together, or one mask with polypropylene with another that you are less sure about, is likely to be a good way to further improve filtration. You can even layer two masks without polypropylene and place a rectangle of polypropylene between masks. The tension of the outer mask will keep it in place. </p>
<p>The non-standardized community masks that we have bought, made or been given, imperfect and varied though they are, are proving effective at reducing transmission in the pandemic. Studies of mask mandates in <a href="https://doi.org/10.1377/hlthaff.2020.00818">the United States</a>, <a href="https://doi.org/10.3386/w27891">Canada</a> and <a href="https://doi.org/10.1073/pnas.2015954117">Germany</a>, and <a href="https://doi.org/10.4269/ajtmh.20-1015">between-country comparisons</a>, all consistently show associated reductions in transmission when masks are worn. </p>
<p>Improving filtration further is also likely to be a worthwhile goal: modelling studies show that <a href="https://doi.org/10.1016/j.idm.2020.04.001">improving filtration reduces transmission of COVID-19</a>. Adding layers by double masking is a way of using the masks that we already have, possibly to better effect. And we need all the leverage we can find at this point.</p>
<h2>Breathability</h2>
<p>There is an important caveat. Every layer added also affects breathability, or how it feels to wear the mask in term of the effort of breathing. This is important for comfort and helps keep the mask safe for the wearer. </p>
<p>If you feel short of breath in a double mask, it may be too many layers for you. If you are <a href="https://theconversation.com/joggers-and-cyclists-should-wear-masks-if-they-cant-maintain-a-physical-distance-from-pedestrians-153110">exercising in a double mask</a>, be alert for the feeling of breathlessness and monitor how it feels; don’t push yourself further than you normally would.</p>
<figure class="align-center ">
<img alt="Red cloth face masks" src="https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More layers provide more protection, but it’s difficult to sew masks with more than three layers. Wearing two multi-layer masks together gets around this problem.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>The other problem with the extra layers is that when breathability decreases, it means that the resistance of the mask to the passage of air has increased. This increases the pressure inside the mask and may cause leaking around the edge. Sometimes the double mask, with two sets of head fastenings, will get around this problem because the fit to the face is more snug and held in place by more points. </p>
<p>But there will be diminishing returns if the breathability is so poor that there is significant airflow around the edges of the mask. The aim is to minimize this completely unfiltered air. You can watch out for this when you add the second mask — does the amount of leakage feel less, or more, than when you wore one of the masks alone? And can you breathe comfortably enough for the task you are planning?</p>
<p>At McMaster’s <a href="https://www.eng.mcmaster.ca/centre-excellence-protective-equipment-and-materials-cepem">Centre of Excellence in Protective Equipment and Materials</a>, our group is working with commercial mask manufacturers, textile experts, quilters and other home sewers to create alternative designs for masks and test them in the laboratory. Until such studies are done, double masking is a creative innovation that is worth trying out with the masks that you have.</p><img src="https://counter.theconversation.com/content/154564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Clase is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article. Catherine has received consultation, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter. In 2018 she co-chaired a KDIGO potassium controversies conference sponsored at arm's length by Fresenius Medical Care, AstraZenec, Vifor Fresenius Medical Care, relypsa, Bayer HealthCare and Boehringer Ingelheim.</span></em></p><p class="fine-print"><em><span>Prof. Charles-François de Lannoy is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article.
Charles has received research funding from the Natural Sciences and Engineering Research Council (NSERC), Canada First Research Excellence Fund (CFREF), Global Water Futures (GWF), Canadian Foundation for Innovation (CFI), Ontario Centres of Excellence (OCE), Southern Ontario Water Consortium (SOWC), MITACS, ECO Canada, the France-Canada Research Fund, McMaster University, and the North American Membrane Society (NAMS). </span></em></p><p class="fine-print"><em><span>Scott Laengert is the recipient of an NSERC scholarship.</span></em></p><p class="fine-print"><em><span>Juan Jesus Carrero and Roberto Pecoits-Filho do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Are two face masks better than one? Adding layers of filtration by double masking is a way of using the masks that we already have, possibly to better effect.Catherine Clase, Physician, epidemiologist, associate professor, McMaster UniversityCharles-Francois de Lannoy, Assistant Professor, Chemical Engineering, McMaster UniversityJuan Jesus Carrero, Professor of Epidemiology, Karolinska InstitutetRoberto Pecoits-Filho, Professor of Medicine, Pontificia Universidade Católica do ParanáScott Laengert, PhD Student, Chemical Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1543752021-02-02T05:08:53Z2021-02-02T05:08:53ZPerth is the latest city to suffer a COVID quarantine breach. Why does this keep happening?<p>Here’s a <a href="https://7news.com.au/lifestyle/health-wellbeing/employee-at-melbourne-hotel-hosting-returned-travellers-tests-positive-for-covid-19-c-1062913">newspaper headline</a> from May 27, 2020: “Worker at Melbourne quarantine hotel tests positive for COVID-19”. And here’s <a href="https://www.abc.net.au/news/2021-01--c-106291331/covid-quarantine-hotel-worker-tests-positive-in-perth-wa/13106968">one from yesterday</a>: “Coronavirus lockdown announced for Perth and South West after quarantine hotel worker tests positive.”</p>
<p>Melbourne, Sydney, Adelaide, Brisbane and now Perth have all seen the coronavirus escape from quarantine. Why does this keep happening, especially given the harsh lessons learned from Melbourne’s outbreak? The short answer is there is no national standard, and a stubborn resistance to taking aerosol transmission seriously.</p>
<p>In Melbourne back in May, several more hotel staff and security guards tested positive at two hotels over the ensuing days, triggering Victoria’s severe second coronavirus wave. The hotel quarantine system was cancelled on June 30 as the number of new cases accelerated, peaking at almost 700 per day. Genomic testing showed that <a href="https://www.theage.com.au/national/victoria/returned-travellers-caused-99-per-cent-of-second-wave-20200817-p55mky.html">99% of Victoria’s second wave</a> of COVID-19 cases in the community came from transmission events related to returned travellers infecting people working at the two hotels.</p>
<p>Much media attention focused on why poorly trained and supervised private security guards were employed at hotels hosting recently arrived overseas travellers. On July 2, the Victorian government announced a <a href="https://www.premier.vic.gov.au/judicial-inquiry-hotel-quarantine-program">judicial inquiry</a> into the state’s hotel quarantine system, headed by Judge Jennifer Coate. An interim report was published in early November with recommendations to guide the planning of a new system, and a <a href="https://www.quarantineinquiry.vic.gov.au/covid-19-hotel-quarantine-inquiry-final-report-0">final report</a> was issued in late December.</p>
<p>The inquiry noted that if the recommendations of a <a href="https://www1.health.gov.au/internet/publications/publishing.nsf/Content/review-2011-l/%24File/lessons%20identified-oct11.pdf">2009 federal review</a> of the H1N1 influenza epidemic had been followed, there would already have been a set of guiding principles and a framework for the COVID hotel quarantine program, avoiding the need to set it up on a hasty, ad hoc basis.</p>
<p>Crucially, the report also concluded that casually employed security guards were not appropriate for quarantine hotels, which should instead be staffed by dedicated, appropriately remunerated staff who should not work at more than one location.</p>
<h2>Groundhog Day</h2>
<p>Fast forward to February 2021. Over the past three months, we have seen breaches of hotel quarantine in Adelaide, Sydney, Brisbane and now Perth. Short, hard lockdowns stopped the spread of the virus in Adelaide and Brisbane, although Sydney’s clusters continued for a month, with a total of around 180 cases. Perth has entered a <a href="https://theconversation.com/perths-5-day-circuit-breaker-lockdown-isnt-an-overreaction-to-a-single-case-its-basic-common-sense-154348">circuit-breaker lockdown</a>, prompted by a guard who was infected at a CBD quarantine hotel and then visited well over a dozen locations across the city, reportedly including other casual security gigs.</p>
<p>It seems hard to believe that private security guards are still employed on casual contracts in quarantine hotels. </p>
<p>Lessons have not been learned, neither from Victoria’s extensive inquiries nor from the subsequent <a href="https://www.health.gov.au/sites/default/files/documents/2020/10/national-review-of-hotel-quarantine.pdf">national review of hotel quarantine</a> led by former Department of Health chief Jane Halton.</p>
<p>Given the very low number of community-transmitted COVID cases in Australia, our number-one priority should be the quality of our border health security system, and crucially our quarantine arrangements. This is more vital than ever now that more dangerous variants of the virus that originated in the UK and South Africa have arrived in Australia. </p>
<p>What’s more, although National Cabinet authorised daily testing of quarantine hotel and transport staff on January 8, it was not implemented in Western Australia until January 29, so the infected hotel security guard was not tested until at least four days after he was infected.</p>
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Read more:
<a href="https://theconversation.com/victorias-hotel-quarantine-overhaul-is-a-step-in-the-right-direction-but-issues-remain-151101">Victoria’s hotel quarantine overhaul is a step in the right direction, but issues remain</a>
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<h2>Urgently needed: a national quarantine standard</h2>
<p>It’s time for a coordinated, standardised national hotel quarantine strategy. This should be based on the recommendations in the two reports previously cited as well as lessons learned — both positive and negative — from the current systems in states and territories. Victoria had the benefit of designing a new system from scratch, which is often an easier task than modifying an old system. </p>
<p>The key elements of the Victorian system that could inform national standards include:</p>
<ul>
<li><p>a high level of attention to the ventilation systems in hotels and transport vehicles</p></li>
<li><p>all staff are employed by a central government agency and are prohibited from having second jobs</p></li>
<li><p>all staff who have close contact with an infected guest or anyone who may be infected must wear adequate PPE, including a respiratory mask</p></li>
<li><p>all staff are tested daily using a PCR test</p></li>
<li><p>hotel guests cannot leave their room for any reason.</p></li>
</ul>
<p>It’s not yet clear exactly how the Perth security guard became infected. He worked on the same floor as quarantine guests but reportedly did not enter their rooms.</p>
<p>But regardless of the specific details of this case, attention to ventilation and adequate PPE is more important than ever, given the growing body of <a href="https://www.nature.com/articles/d41586-020-02058-1">evidence</a> the coronavirus can spread via small particles (aerosols). </p>
<p>The <a href="https://www.abc.net.au/news/2020-12-15/ventilation-system-may-have-caused-hotel-quarantine-transmission/12984280">security guard in Adelaide</a> and the hotel cleaner in Brisbane were almost certainly infected via aerosols, as was likely the case for the driver of a Sydney shuttle bus for flight crew. Moreover, when the virus was imported from Sydney’s Northern Beaches to suburban Melbourne, the initial cluster of cases in a Thai restaurant were probably infected via aerosols.</p>
<p>Quarantine protocols need to take account of the fact that aerosols can travel further than larger droplets, and should ensure proper PPE precautions are taken. Ventilation ducts should also not be positioned in a way that allows contaminated air to flow through indoor public areas such as corridors or lobbies.</p>
<p>As we await the vaccine rollout, our primary line of defence against a resurgence of infections is the quarantine system for international arrivals. This needs to be urgently raised to the highest level of federal and state and territory decision-makers, and implemented on a consistent basis nationwide, based on Victoria’s new best-practice standards. Otherwise there will be more groundhog days.</p><img src="https://counter.theconversation.com/content/154375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Toole receives funding from the National Health and Medical Research Council.</span></em></p>With no national standard, casually employed staff, a lack of PPE and a refusal to account for aerosol transmission, infections such as the one that prompted Perth’s lockdown will keep happening.Michael Toole, Professor of International Health, Burnet InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1522192021-01-10T13:47:38Z2021-01-10T13:47:38ZCOVID-19 face masks represent a chance to restore Canadian manufacturing<figure><img src="https://images.theconversation.com/files/377427/original/file-20210106-21-80ka95.JPG?ixlib=rb-1.1.0&rect=0%2C254%2C5851%2C3380&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Face masks are seen in the window of a shop during the COVID-19 pandemic in Montréal in December 2020.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Paul Chiasson</span></span></figcaption></figure><p>It didn’t take long for COVID-19 to race around the world after it emerged in late 2019.</p>
<p>The rapid spread of the coronavirus revealed how efficiently international travel and commerce had flattened distances and erased borders, proving harshly that progress has its negative repercussions. COVID-19 has had the same impact on global economics.</p>
<p>By the time the pandemic struck, it seemed the principles of specialization and division of labour that Adam Smith had expressed in <em><a href="https://www.adamsmith.org/the-wealth-of-nations">The Wealth of Nations</a></em> back in 1776 had played out to their fullest. Globalization and trade has led to the concentration of manufacturing of consumer goods in parts of Asia.</p>
<p>Manufacturing shifted to places where large factories and low wages allowed makers of clothing, steel, cars and many other products to maximize the gap between per-unit cost and selling price.</p>
<p>In the process, North America lost much of its industrial base to globalization. Manufacturing cities — including the city of Hamilton, Ont., where I live — have yet to overcome the devastation of the industrial landslide. Entire manufacturing ecosystems have vanished, together with <a href="https://munkschool.utoronto.ca/mowatcentre/how-ontario-lost-300000-manufacturing-jobs/">the jobs they sustained</a>.</p>
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Read more:
<a href="https://theconversation.com/gm-closures-oshawa-needs-more-than-thoughts-and-prayers-107714">GM closures: Oshawa needs more than 'thoughts and prayers'</a>
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<p>All of it played out as Smith’s principles had predicted, but one problem even the brilliant economist could not have seen coming was that globalization might one also day threaten our physical health.</p>
<p>That became glaringly apparent in the early weeks of the pandemic, when hospitals, clinics and long-term care facilities suddenly <a href="https://www.nejm.org/doi/full/10.1056/NEJMp2006141">lost access</a> to their regular supply of vital masks, gloves and other protective equipment, almost all of it imported from overseas. Global supply chains are highly efficient <a href="https://doi.org/10.1136/bmj.m1910">but are also fragile</a>. </p>
<p>And yet the news, at least in economic terms, may not all be bad.</p>
<h2>Silver lining?</h2>
<p>Though the pandemic has become the world’s dominant health concern, it may catalyze recovery from some of the economic consequences of globalization.</p>
<p>Even before COVID-19, globalization’s counterpoint, “localization,” was beginning take hold. Localization brings smaller, more agile and more profitable forms of manufacturing back to places where conditions warrant, adding resilience to the economies of post-industrial countries like Canada. </p>
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<strong>
Read more:
<a href="https://theconversation.com/keeping-it-local-the-story-behind-a-made-in-saskatchewan-covid-19-emergency-use-ventilator-151819">Keeping it local: The story behind a made-in-Saskatchewan COVID-19 emergency-use ventilator</a>
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<p>What localized or <a href="https://doi.org/10.1108/IJOPM-08-2019-0600">distributed manufacturing</a> may lack in brutal efficiency it makes up in value. <a href="https://www.rd.com/article/why-canada-goose-jackets-expensive/">Canada Goose</a> and <a href="https://digital.hbs.edu/platform-rctom/submission/lululemon-from-niche-market-pioneer-to-apparel-ubiquity/">Lululemon</a> thrive because their products are perceived to have higher value than their competitors, allowing them to command higher prices.</p>
<figure class="align-center ">
<img alt="A woman looks at her phone as she walks along a street wearing a Canada Goose coat." src="https://images.theconversation.com/files/377458/original/file-20210106-23-ujs0n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/377458/original/file-20210106-23-ujs0n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/377458/original/file-20210106-23-ujs0n1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/377458/original/file-20210106-23-ujs0n1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/377458/original/file-20210106-23-ujs0n1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=526&fit=crop&dpr=1 754w, https://images.theconversation.com/files/377458/original/file-20210106-23-ujs0n1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=526&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/377458/original/file-20210106-23-ujs0n1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=526&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In this February 2019 photo, a woman in New York wears a Canada Goose coat.</span>
<span class="attribution"><span class="source">(AP Photo/Frank Franklin II)</span></span>
</figcaption>
</figure>
<p>This allows them to shift from the continuous minimization of manufacturing costs — particularly wages — to continuous improvement of product quality and value, without sacrificing profitability.</p>
<p>This dynamic can help to restore at least some of our lost share of manufacturing. Since we pay workers more, they must produce products that bring higher prices, so Canada needs to be in this area of high value.</p>
<p>How does this relate to personal protective equipment, known as PPE?</p>
<h2>PPE market changed dramatically</h2>
<p>The pandemic changed the condition of the market. Previously, the sale of gloves, masks and other PPE were all based on price. Whoever made functional, disposable products at the lowest cost <a href="https://doi.org/10.1136/bmj.m1910">captured the market</a> by selling them by the millions to hospitals, long-term care homes and clinics.</p>
<p>Today, masks are necessary for everyone, and in the consumer marketplace, they’ve become personal wearable devices, like cell phones and eyeglasses. Users are prepared to invest more in something that meets their everyday needs, stands up to daily use, is comfortable and looks good.</p>
<p>A typical <a href="https://multimedia.3m.com/mws/media/1862179O/get-the-facts-n95-respirator-pricing.pdf">N95 mask from 3M</a>, which offers the best quality filtration, might cost between one and two dollars.</p>
<p>Reusable, <a href="https://www.gapcanada.ca/browse/category.do?cid=1157839">non-medical cloth masks</a> that The Gap sells are not as efficient as 3M’s, but they look much better, can be washed and sell for about $5 apiece. Elsewhere, someone can pay $25 or more for a mask, not because it necessarily offers more protection, but because it looks and feels better.</p>
<p>This consumer demand for higher-priced masks makes it easier to introduce new technologies with better breathability, fit, filtration capability, lifetime and appealing style. These options all have value, which create opportunities for Canadian manufacturers. </p>
<h2>Answering the call for face masks, shields</h2>
<p>Back in March, my colleagues and I at McMaster University created the <a href="https://www.eng.mcmaster.ca/centre-excellence-protective-equipment-and-materials-cepem">Centre of Excellence in Protective Equipment and Materials</a> (CEPEM) in response to a call from Hamilton Health Sciences to start locally manufacturing face masks and face shields to address anticipated shortages.</p>
<p>In just over a month, the CEPEM team created designs, identified suitable materials and developed tests for filtration and fit. </p>
<p>Now, with assistance from the centre, <a href="https://whitebird.ca/">Whitebird</a>, a Hamilton packaging company, is producing 20,000 face shields per day. <a href="https://nikoapparel.ca">Niko Apparel</a>, also in Hamilton, is making 20,000 masks per day. <a href="https://vitacore.ca">Vitacore</a> in British Columbia has started producing hundreds of thousands of “Made in Canada” N95 masks. <a href="https://www.unifor.org/en/whats-new/news/woodbridge-foam-members-make-surgical-grade-masks-combat-covid-19">Woodbridge</a> has already produced millions of <a href="https://www.halyardhealth.com/industry-news/2019/july/choosing-the-right-face-mask-3-things-to-know.aspx">level 3 masks</a> in Ontario.</p>
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<img alt="A woman wears a face mask and shield." src="https://images.theconversation.com/files/377461/original/file-20210106-21-n2ghuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/377461/original/file-20210106-21-n2ghuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/377461/original/file-20210106-21-n2ghuq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/377461/original/file-20210106-21-n2ghuq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/377461/original/file-20210106-21-n2ghuq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/377461/original/file-20210106-21-n2ghuq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/377461/original/file-20210106-21-n2ghuq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman wears a face mask and shield to curb the spread of COVID-19 while walking in North Vancouver, B.C., on Jan. 6, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>The CEPEM continues to grow and support the nascent PPE manufacturing ecosystem across Canada so it can create high value, next-generation products.</p>
<p>Whether the end users are health-care workers, kids in school or people running errands, they need masks. There’s no reason they shouldn’t be made here at home.</p><img src="https://counter.theconversation.com/content/152219/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>P. Ravi Selvaganapathy receives funding from various federal and provincial research sources including the Natural Sciences and Engineering Research Council of Canada, the Ontario Research Fund, Ontario Centers of Excellence, Canada Foundation for Innovation, the Canada Research Chairs Program, Department of National Defense. MITACS and Ontario Ministry of Research and Innovation.</span></em></p>Whether it’s health-care workers, kids in school or people running errands, Canadians need face masks during COVID-19. There’s no reason they shouldn’t be made here at home.P. Ravi Selvaganapathy, Professor, Mechanical and Biomedical Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1506752020-12-14T15:38:39Z2020-12-14T15:38:39ZSilenced and sacrificed: COVID-19 health-care workers’ secret suffering unveiled<figure><img src="https://images.theconversation.com/files/373634/original/file-20201208-16-14d34ty.jpg?ixlib=rb-1.1.0&rect=549%2C120%2C3476%2C2836&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health-care workers need public support. Hospital workers outside Sick Kids hospital in Toronto, July 17, 2020
</span> <span class="attribution"><span class="source">(OCHU-CUPE)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Health-care workers in Ontario — a workforce that is <a href="https://policyoptions.irpp.org/fr/magazines/may-2020/concern-about-pandemic-differs-across-gender-and-race-lines/">predominantly women, many of whom are racialized</a> — have been made especially <a href="https://btlbooks.com/book/sick-of-the-system">vulnerable during the COVID-19 pandemic</a>. </p>
<p>The <a href="https://theconversation.com/heath-care-workers-lacking-ppe-suffer-from-more-anxiety-and-depression-145612">risk of being infected with COVID-19</a>, the <a href="https://financialpost.com/pmn/press-releases-pmn/business-wire-news-releases-pmn/health-minister-misinformed-87-per-cent-of-ontario-health-care-staff-polled-say-not-enough-ppe-on-hand-to-keep-them-safe">lack of preparedness by governments</a>, little success in arguing for better protection and being barred from speaking publicly have left health-care workers feeling angry, <a href="https://doi.org/10.1177%2F0706743720961729">fearful</a> and sacrificed. The vulnerability and physical and mental health impact on health-care workers also affects health-care delivery to the public.</p>
<p>The COVID-19 pandemic changed the landscape of the health-care system. Health-care workers have been disproportionately infected, making up nearly <a href="https://www.thestar.com/news/canada/2020/09/19/nearly-20-per-cent-of-covid-19-infections-in-canada-among-health-care-workers-by-late-july.html">20 per cent of cases</a>, higher than the global rate among health-care workers. Meanwhile, worldwide <a href="https://www.cbc.ca/news/politics/ppe-shortages-slow-response-1.5684962">shortages of N95 masks influence local protection guidelines</a>. </p>
<p>After the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, an <a href="http://www.archives.gov.on.ca/en/e_records/sars/report/v1.html">independent commission provided a roadmap for handling future pandemics</a>. Recommendations included that N95 masks be available to health-care workers at all times. But governments <a href="https://www.cbc.ca/news/canada/saskatchewan/heath-minister-emergency-stockpile-1.5530081">disposed of expired N95s and other medical supplies and failed to replace them</a>. </p>
<p>Health-care workers in need of protection from COVID-19 and other risky working conditions in their jobs confidentially reported the impact of these decisions in our <a href="https://doi.org/10.1177%2F1048291120974358">recent study</a>. The research, a collaboration between University of Windsor occupational health researchers and the Ontario Council of Hospital Unions (OCHU-CUPE), which funded the study, unveils the stories behind the statistics of the thousands of health-care workers who have been infected with COVID-19.</p>
<h2>Study gives voice to health-care workers</h2>
<p>Health-care workers are not allowed to talk publicly about their working conditions. They are <a href="https://amnesty.ca/news/global-health-workers-silenced-exposed-and-attacked">systematically silenced</a> — disciplined or fired — for speaking out about unsafe working conditions. </p>
<p>We conducted anonymous telephone interviews in April and May 2020 with 10 health-care workers recruited with the assistance of the OCHU-CUPE provincial office. Another five participants cancelled, with two specifically citing fear of discipline or job loss if identified. </p>
<p>Prevalent themes in interviews included psychological distress, inadequacy of protection, inconsistencies in policy, government failings and barriers to agency. The stress and anxiety experienced by health-care workers were most prominent.</p>
<figure class="align-center ">
<img alt="Health-care workers in protective equipment" src="https://images.theconversation.com/files/371130/original/file-20201124-21-m861ip.jpg?ixlib=rb-1.1.0&rect=72%2C0%2C1205%2C628&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/371130/original/file-20201124-21-m861ip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/371130/original/file-20201124-21-m861ip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/371130/original/file-20201124-21-m861ip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/371130/original/file-20201124-21-m861ip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/371130/original/file-20201124-21-m861ip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/371130/original/file-20201124-21-m861ip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health-care workers in Ontario fear workplace risks due to government inaction on COVID-19.</span>
<span class="attribution"><span class="source">(OCHU-CUPE)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>During study recruitment, potential interviewees said they were too afraid to participate for fear of losing their jobs. A hospital clerical staff person interviewed for the study said,</p>
<blockquote>
<p>All the front-line workers fear reprisal. We are told, “You can’t talk to the media."… It’s just such a travesty and these issues need to be said and people need to know what’s really going on.</p>
</blockquote>
<p>The study safely and anonymously gives health-care workers a public voice and provides insight into their working conditions.</p>
<figure class="align-right ">
<img alt="An N95 mask that reads 'Help us'" src="https://images.theconversation.com/files/371324/original/file-20201125-16-k9cjep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/371324/original/file-20201125-16-k9cjep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=462&fit=crop&dpr=1 600w, https://images.theconversation.com/files/371324/original/file-20201125-16-k9cjep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=462&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/371324/original/file-20201125-16-k9cjep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=462&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/371324/original/file-20201125-16-k9cjep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=581&fit=crop&dpr=1 754w, https://images.theconversation.com/files/371324/original/file-20201125-16-k9cjep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=581&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/371324/original/file-20201125-16-k9cjep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=581&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health-care workers are at risk of COVID-19 exposure, yet left without adequate protections such as personal protective equipment, including N95 masks.</span>
<span class="attribution"><span class="source">(OCHU-CUPE)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Health-care workers share society’s background mental distress as well as stressors related to their work. An authoritarian and hierarchical culture in health-care work is described by health-care workers as contributing to risk and adverse mental health effects. </p>
<p>Interviewees reported that the risk of contracting COVID-19 and infecting family members or patients created intense anxiety. With under-staffing and increased workloads as well, health-care workers are suffering from exhaustion and burnout.</p>
<blockquote>
<p>There’s a lot of anxiety. When COVID-19 is over, the employer won’t have enough counsellors on hand to handle what I think is going to hit. Because people are anxious; people are fearful. They come to work; they don’t know if they have the illness or not, because sometimes you’re asymptomatic. They’re afraid to go home; their families are scared of them. It is just horrendous. And the morale is as low as it can be.</p>
</blockquote>
<p>A personal support worker (PSW) in a long-term care facility described difficulty coping with added stress, increased workload and making the sacrifice of working longer hours to keep up care:</p>
<blockquote>
<p>There’s definitely extra stress, and some days, you just break down and start crying.… Our workload is crazy, and the girls are just running on the floor to keep up.… Before the pandemic, we had a shortage of PSWs, and now we have more and more people going off work because they’re afraid. A lot of the staff are working double shifts.</p>
</blockquote>
<h2>Government failures create risks for health-care workers</h2>
<p>Ontario’s health-care system has been eroded by <a href="https://toronto.ctvnews.ca/ontario-spent-466m-less-on-healthcare-than-planned-ahead-of-covid-19-pandemic-1.5042104?cache=ftdpqpcfvtwjihs%3FclipId%3D104062">economic strains, understaffing and diminished capacity</a>. Interviewees divulged regulatory inadequacies. Health-care workers are at risk of COVID-19 exposure, yet left without adequate protections — including personal protective equipment (PPE) and <a href="https://www.ccohs.ca/images/products/infographics/download/hierarchy-covid.png">administrative and engineering controls</a> — as well as a lack of adherence to the <a href="http://www.archives.gov.on.ca/en/e_records/sars/report/v1-pdf/Vol1Chp3.pdf">precautionary principle, as explicitly recommended in the SARS Commission Report</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1318933702228008966"}"></div></p>
<p>The <a href="https://www.nytimes.com/article/coronavirus-masks.html">controversy around the aerosol transmission of SARS-CoV-2</a> affected health-care workers’ safety. N95 masks, considered the best protection against virus transmission, have not been available to health-care workers as authorities debated the science that <a href="http://doi.org/10.1001/jama.2020.12897">established airborne transmission</a>. Several health-care workers said requests for N95s were ignored. Supervisors warned nurses, saying:</p>
<blockquote>
<p>You are not to wear an N95 mask; you do not need it, you are fine to be wearing the mask with a shield, and if I catch you with one on again, you can be fined.</p>
</blockquote>
<p>Another nurse, told she couldn’t wear her own N95, resorted to hiding one she had purchased herself under a medical mask.</p>
<p>There is little trust in government decisions and policies for protection. A long-term care PSW explained:</p>
<blockquote>
<p>It makes it difficult when we feel that the best decisions for our safety — especially in regard to PPE — are not truly the best practice.… That’s a big concern for us on the front line.</p>
</blockquote>
<p>Another health-care worker interviewed put it very simply:</p>
<blockquote>
<p>All we are asking is, please protect us!</p>
</blockquote>
<figure class="align-center ">
<img alt="Women health-care workers in face masks holding up signs featuring N95 masks reading 'Help us'" src="https://images.theconversation.com/files/371321/original/file-20201125-18-16jcxtp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/371321/original/file-20201125-18-16jcxtp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=295&fit=crop&dpr=1 600w, https://images.theconversation.com/files/371321/original/file-20201125-18-16jcxtp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=295&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/371321/original/file-20201125-18-16jcxtp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=295&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/371321/original/file-20201125-18-16jcxtp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=371&fit=crop&dpr=1 754w, https://images.theconversation.com/files/371321/original/file-20201125-18-16jcxtp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=371&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/371321/original/file-20201125-18-16jcxtp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=371&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health-care workers seek public support for their safety and health.</span>
<span class="attribution"><span class="source">(OCHU-CUPE)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Protecting health-care workers and the public</h2>
<p>Our study uncovers implications for health-care workers and health-care provision, and concludes with recommendations that include:</p>
<ol>
<li><p>Increased staffing levels in Ontario’s hospitals and in long-term care. </p></li>
<li><p>Changes to the workplace culture so health-care workers are heard. </p></li>
<li><p>Strong management support to mitigate mental distress. </p></li>
<li><p>Improved working conditions and PPE.</p></li>
<li><p>Legislated protection to allow staff to speak without reprisal.</p></li>
</ol>
<p><em>This article was co-authored by James T. Brophy, University of Windsor, University of Stirling, Athabasca University; Margaret M. Keith, University of Windsor, University of Stirling; and Michael Hurley, president OCHU-CUPE.</em></p><img src="https://counter.theconversation.com/content/150675/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane E. McArthur received funding for her doctoral research through a SSHRC Doctoral Fellowship, SWS Barbara Rosenblum Cancer Dissertation Award, Gail Rosenblum Memorial Breast Cancer Research Scholarship and Elena Loaring Memorial Award for Breast Cancer Research.</span></em></p>Ontario health-care workers confidentially reported feeling sacrificed on the job and needing protection from COVID-19 and other risky working conditions in a recent study.Jane E. McArthur, Doctoral Candidate, Sociology-Social Justice, University of WindsorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1496132020-11-19T18:53:35Z2020-11-19T18:53:35ZPolypropylene, the material now recommended for COVID-19 mask filters: What it is, where to get it<figure><img src="https://images.theconversation.com/files/368470/original/file-20201110-14-16u9mjj.jpg?ixlib=rb-1.1.0&rect=209%2C0%2C4943%2C3406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">New recommendation advise using an additional layer of polypropylene fabric in cloth masks to act as a filter.</span> <span class="attribution"><span class="source">(Sara Alas/Niko Apparel)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Adding a third layer to cloth face masks is now recommended for preventing the spread of COVID-19. Non-woven polypropylene fabric is the material of choice for this third layer, but many people may not know what this material is, or where to get it. </p>
<p>With masks being made at home and by local clothing companies, here’s what you need to know about Public Health Agency of Canada’s <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html#a2">new recommendations</a>.</p>
<p>Every study that has examined layering has found that using additional layers in face masks <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">improves filtration, but some fabrics provide more filtration than others</a>. We support the public health recommendation, and specifically recommend the use of industry-grade “spunbond” polypropylene as a middle layer in washable cloth masks. </p>
<p>Spunbond polypropylene destined for the clothing and furniture industries has a fabric-like feel. It is washable and will not divert supply of medical-grade polypropylene from the manufacture of formal personal protective equipment. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/368410/original/file-20201109-15-zwsa6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368410/original/file-20201109-15-zwsa6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368410/original/file-20201109-15-zwsa6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368410/original/file-20201109-15-zwsa6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368410/original/file-20201109-15-zwsa6b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368410/original/file-20201109-15-zwsa6b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368410/original/file-20201109-15-zwsa6b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pleated cloth mask with the bottom seam opened and a rectangle of washable industry-grade spunbond polypropylene inserted as a filter.</span>
<span class="attribution"><span class="source">(Sara Alas/Niko Apparel)</span></span>
</figcaption>
</figure>
<p>Our <a href="https://www.eng.mcmaster.ca/centre-excellence-protective-equipment-and-materials-cepem">research group</a>, with expertise in epidemiology, chemistry, textiles and the mask industry, seeks to improve cloth masks for community use.</p>
<h2>Types of non-woven polypropylene</h2>
<p>Traditional materials for clothing and furniture have a woven or knitted structure. Non-woven materials, by contrast, have a random arrangement of fibres, like spaghetti on a plate. This randomness enables <a href="https://www.nytimes.com/interactive/2020/10/30/science/wear-mask-covid-particles-ul.html">high particle filtration</a> while remaining highly breathable.</p>
<p>There are many types of non-woven polypropylene. The most common are spunbond, meltblown and spunlace materials. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/368412/original/file-20201109-14-15pbkrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/368412/original/file-20201109-14-15pbkrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=550&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368412/original/file-20201109-14-15pbkrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=550&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368412/original/file-20201109-14-15pbkrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=550&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368412/original/file-20201109-14-15pbkrw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=691&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368412/original/file-20201109-14-15pbkrw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=691&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368412/original/file-20201109-14-15pbkrw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=691&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The regular pattern of tiny point welds can be seen in this sample of washable, industry-grade white spunbond polypropylene.</span>
<span class="attribution"><span class="source">(Mark Diamond/Veratex Lining Ltd.)</span></span>
</figcaption>
</figure>
<p>In some spunbond polypropylene the randomly oriented fibres are compressed and melted together in a pattern of small, closely spaced welds, called point bonds. </p>
<p>Lightweight medical-grade spunbond polypropylene, found in the outer layers of three-layer certified medical masks, has been tailored for medical uses. But as a single-use material, it is not designed to be washed. </p>
<p>Washable spunbond polypropylene is used in the clothing and furniture industry. It is one of several materials used as interfacing, to give structure to waistbands and collars, and around zippers. It is also used to seal the bottom of couches and chairs. It is readily available from fabric distributors and is not currently in short supply since it is not part of the supply chain for personal protective equipment. This material likely aligns with public health recommendations. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/IvZkSInterg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Industry-grade spunbond polypropylene has a fabric-like feel and cuts without fraying.</span></figcaption>
</figure>
<h2>Recommended material</h2>
<p>For community mask manufacture, we suggest using industry-grade spunbond polypropylene.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/369344/original/file-20201113-17-1rpg4kq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/369344/original/file-20201113-17-1rpg4kq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369344/original/file-20201113-17-1rpg4kq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369344/original/file-20201113-17-1rpg4kq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369344/original/file-20201113-17-1rpg4kq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369344/original/file-20201113-17-1rpg4kq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369344/original/file-20201113-17-1rpg4kq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A three-layer pleated mask using cotton outer layers and a fully-integrated middle layer of 68 gsm (two ounces per square yard) polypropylene. The mask is quite structured but comfortable, because of the cotton, and completely washable.</span>
<span class="attribution"><span class="source">(Catherine Clase)</span></span>
</figcaption>
</figure>
<p>Manufacturers produce single and double layers of spunbond. There are few published data on its filtration properties, but we suggest using a fabric with a rating of 68 grams per square metre, or two layers of a less dense one. </p>
<p>The material can be integrated as a middle layer when masks are being made. </p>
<p>Alternatively, a rectangle of spunbond polypropylene can be inserted between the two outer layers of a cloth mask. The material does not fray easily. If using two layers of polypropylene, we suggest folding the material in half and sewing it together with a simple stitch or an overlock, to make a washable filter. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/r6pNOqQi1YA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Two layers of 34-51 gsm polypropylene can be stitched together to make a washable filter. Hang or lay flat to dry.</span></figcaption>
</figure>
<p>The polypropylene can be cleaned as recommended by Health Canada: <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/how-put-remove-clean-non-medical-masks-face-coverings.html#_Cleaning_and_disposing">a hot wash with detergent</a>. It can be washed with the mask or separately. It should not be tumble dried: it should be removed from the mask and hung or laid flat to dry before reinserting. Do not iron it: it is plastic and will melt. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/368458/original/file-20201110-17-dxcxq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/368458/original/file-20201110-17-dxcxq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368458/original/file-20201110-17-dxcxq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368458/original/file-20201110-17-dxcxq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368458/original/file-20201110-17-dxcxq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368458/original/file-20201110-17-dxcxq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368458/original/file-20201110-17-dxcxq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Two layers of black industry-grade spunbond sewn to make a washable filter.</span>
<span class="attribution"><span class="source">(Mark Diamond/Veratex Lining Ltd.)</span></span>
</figcaption>
</figure>
<p><a href="https://www.clothmasks.ca/">Our website</a> and <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">previous research</a> summarize what is known about choosing suitable material for the other layers.</p>
<p>Fabric distributors have these materials in bulk and are working to get them to retail. Mask makers can expect to see them in stores by late November.</p>
<h2>Unsuitable materials</h2>
<p>It is important to recognize that not all interfacing is polypropylene. Many brands are polyester or polyester-rayon blends. This is a completely different material. In the retail market, interfacing is sometimes sold as a fusible product. This means that it is pre-glued to help with accurate placement before it is stitched into place. These pre-glued fabrics should not be used for face coverings because the glue may affect filtration and breathability. </p>
<p>Some reusable shopping bags made from spunbond have a shiny plastic coating. These are not breathable and should not be used.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/368430/original/file-20201109-16-vtaxzk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/368430/original/file-20201109-16-vtaxzk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368430/original/file-20201109-16-vtaxzk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368430/original/file-20201109-16-vtaxzk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368430/original/file-20201109-16-vtaxzk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368430/original/file-20201109-16-vtaxzk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368430/original/file-20201109-16-vtaxzk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some shopping bags made from spunbond polypropylene have a shiny plastic surface: they are not breathable and should not be used.</span>
<span class="attribution"><span class="source">(Jonathan Clase)</span></span>
</figcaption>
</figure>
<p>Meltblown polypropylene is used as the middle layer of many certified medical masks and in the manufacture of respirators such as N95s: it filters very well. It remains in short supply, with many distributors in Canada fully committed to July 2021. It is not intended to be washed, though novel programs for <a href="https://doi.org/10.1503/cmaj.201203">limited reuse of respirators</a> have been developed for hospitals. </p>
<p>Because of the supply issue and because it is not washable, we do not recommend using meltblown polypropylene for reusable non-medical masks. </p>
<p>Disposable non-medical filters intended to be inserted into pocket masks are sold commercially and may contain meltblown, spunbond and other components; it is not always possible to determine their composition from the packaging or advertisements. Currently no standards define their use in Canada. They are designed to be discarded after each use.</p>
<p>Spunlace polypropylene tends to be naturally springy and in contrast to spunbond and meltblown, it absorbs liquids. Some wet wipes are produced by spunlace methods. However, the material used is often not polypropylene but rather viscose-polyester blend, to increase absorbency. The composition of the wet ingredients is clearly specified on packaging, but many wipes do not include the fibre composition of the material. These materials are not intended to be laundered and reused. Some wipes contain active ingredients that might be harmful if inhaled. For all these reasons, we do not recommend using dried-out wipes as filters.</p>
<p>Non-woven polypropylene made with a needle-punch method is a continuous material that is completely perforated by thousands of fine needles on a roller. These holes offer a low-resistance path for airflow without fibres projecting into the gap. We predict they would filter poorly and do not recommend them.</p>
<h2>Imperfect does not mean unhelpful</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/368456/original/file-20201110-20-173eoo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/368456/original/file-20201110-20-173eoo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368456/original/file-20201110-20-173eoo4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368456/original/file-20201110-20-173eoo4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368456/original/file-20201110-20-173eoo4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368456/original/file-20201110-20-173eoo4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368456/original/file-20201110-20-173eoo4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some existing cloth masks can be adapted, even if they don’t have a pocket. In a pleated design, the bottom seam can be opened to allow a washable filter to be inserted.</span>
<span class="attribution"><span class="source">(Catherine Clase)</span></span>
</figcaption>
</figure>
<p>Imperfect use of imperfect masks has the potential to <a href="https://royalsocietypublishing.org/doi/10.1098/rspa.2020.0376">help control the spread of COVID-19</a>. Important <a href="https://doi.org/10.1377/hlthaff.2020.00818">decreases in transmission</a> have been observed following mask mandates, using the masks currently available. Industry is working to respond to the <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html#a2">new guidelines</a> by increasing the availability of polypropylene fabrics. </p>
<p>At the <a href="https://www.eng.mcmaster.ca/centre-excellence-protective-equipment-and-materials-cepem">Centre of Expertise in Protective Equipment and Materials</a>, engineering faculty and graduate students are working to identify the best materials to use for cloth masks. We hope to be able to describe textiles that are likely to filter well and be breathable using standard industry descriptors such as the type of material and the weight. </p>
<p><em>Barry Diamond, managing director of Veratex Lining Ltd., co-authored this article. He is a member of the Cloth Mask Knowledge Exchange.</em></p><img src="https://counter.theconversation.com/content/149613/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Clase is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article.
Catherine has received consultation, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter. In 2018 she co-chaired a KDIGO potassium controversies conference sponsored at arm's length by Fresenius Medical Care, AstraZenec, Vifor Fresenius Medical Care, relypsa, Bayer HealthCare and Boehringer Ingelheim.</span></em></p><p class="fine-print"><em><span>Prof. Charles-François de Lannoy is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article.
Charles has received research funding from the Natural Sciences and Engineering Research Council (NSERC), Canada First Research Excellence Fund (CFREF), Global Water Futures (GWF), Canadian Foundation for Innovation (CFI), Ontario Centres of Excellence (OCE), Southern Ontario Water Consortium (SOWC), MITACS, ECO Canada, the France-Canada Research Fund, McMaster University, and the North American Membrane Society (NAMS).</span></em></p><p class="fine-print"><em><span>Scott Laengert is the recipient of an NSERC scholarship.</span></em></p>Everything you need to know about non-woven polypropylene, the fabric now recommended for use as a filter in cloth face masks: What it is, what to look for and where to find it.Catherine Clase, Physician, epidemiologist, associate professor, McMaster UniversityCharles-Francois de Lannoy, Assistant Professor, Chemical Engineering, McMaster UniversityScott Laengert, PhD Student, Chemical Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1476482020-10-27T12:15:07Z2020-10-27T12:15:07ZHealth insurers are starting to roll back coverage for telehealth – even though demand is way up due to COVID-19<figure><img src="https://images.theconversation.com/files/365052/original/file-20201022-19-13fhf1y.jpg?ixlib=rb-1.1.0&rect=120%2C0%2C6277%2C4406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Private insurers saw telehealth claims increase over 4,000% from 2019 to 2020.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-woman-having-online-meeting-with-female-royalty-free-image/1224685401">Solskin/DigitalVision via Getty Images</a></span></figcaption></figure><p>In less than a year, telehealth has gone from a niche rarity to a common practice. Its ability to ensure physical distance, preserve personal protective equipment and prevent the spread of infection among health care workers and patients has been <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html">invaluable during the COVID-19 pandemic</a>.</p>
<p>As health care specialists and <a href="https://scholar.google.com/citations?hl=en&user=5Zl62KMAAAAJ&view_op=list_works&sortby=pubdate">researchers</a>, we have long seen the <a href="https://doi.org/10.1186/s12912-020-0400-9">potential of telehealth, providing health care remotely with technology</a>, which has been around for several decades. Despite evidence it could <a href="https://theconversation.com/is-telehealth-as-good-as-in-person-care-a-telehealth-researcher-explains-how-to-get-the-most-out-of-remote-health-care-142230">safely treat and manage a range of health conditions</a> in a cost-effective manner, widespread adoption of the practice had been limited by issues including insurance coverage, restrictions on prescribing and technology access.</p>
<p>On March 27, 2020, The Coronavirus Aid, Relief and Economic Security Act, or <a href="https://www.ama-assn.org/delivering-care/public-health/cares-act-ama-covid-19-pandemic-telehealth-fact-sheet">CARES Act</a>, removed many of the barriers to widespread telehealth use. Soon after, the <a href="https://www.medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit.pdf">Centers for Medicare & Medicaid released a toolkit</a> encouraging state Medicaid agencies to adopt CARES policy changes to promote the expansion of telehealth. Many <a href="https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/">private insurers followed suit</a>. Collectively, these policy changes facilitated the explosion of telehealth. Now, due to the financial strain on health care systems and insurers, the increase in telehealth use may be forced to shrink even though the public health crisis remains. </p>
<h2>Sudden changes</h2>
<p>At the very beginning of the pandemic, the use of telehealth went from <a href="https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/">13,000 to 1.7 million</a> visits per week among Medicare recipients. Between mid-March and mid-June 2020, during the height of the national lockdown, over 9 million telehealth visits were conducted for Medicare recipients. Private insurers, who mimicked the CARES Act policy changes, also reported exponential increases – with <a href="https://www.ahip.org/telehealth-growth-during-covid-19/">telehealth claims increasing over 4,000%</a> from the previous year. </p>
<p>Telehealth is typically used for new health concerns like a sore throat, psychotherapy and in-home monitoring with mobile devices for chronic conditions like diabetes, high blood pressure or heart failure. Telehealth is convenient because it can be done from anywhere and more frequently than in-person visits. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Family consulting with their doctor from the comfort of their kithen table via laptop." src="https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365059/original/file-20201022-14-a97hs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The doctor will see you now.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/family-consulting-with-their-doctor-royalty-free-image/1245085857">Geber86/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>The changes triggered by the CARES Act were intended to last only until the <a href="https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/PHE-Questions-and-Answers.pdf">public health emergency was considered over</a>. Making telehealth coverage expansions permanent could lead people to use their insurance coverage more often by making care more convenient, thus <a href="https://www.penguinrandomhouse.com/books/318776/an-american-sickness-by-elisabeth-rosenthal/">costing private insurance companies more money</a>. </p>
<p><a href="https://www.acponline.org/advocacy/state-health-policy/new-primary-care-codes-for-payment">Provider compensation</a> is traditionally based on the amount of time spent with the patient and how complicated and risky the exam and procedures are to perform. Historically, telehealth was reimbursed at a lower rate than in-person care. The CARES Act had addressed this payment disparity by mandating the same rate for telehealth visits as in-person visits for those insured by Medicare, with more than 80 new telehealth services being reimbursed at the <a href="https://codingintel.com/telemedicine-and-covid-19-faq/">same rate</a> as in-person services. </p>
<p><a href="https://www.wsj.com/articles/as-covid-19-cases-rise-insurers-reduce-coverage-for-virtual-doctors-visits-11601494901">Many private insurers</a> followed suit and paid providers who conducted telehealth visits at the same rate as office visits.
Now, that’s all <a href="https://www.usatoday.com/story/news/2020/07/03/despite-covid-19-increase-insurance-companies-pull-back-telehealth/5352297002/">changing due to financial loss by insurance companies</a>. As of Oct. 1, telehealth visits are not always paid at the same rate as in-person visits by these private insures. </p>
<p>Several big private insurers are <a href="https://www.wsj.com/articles/as-covid-19-cases-rise-insurers-reduce-coverage-for-virtual-doctors-visits-11601494901">pulling back some of their coverage of telehealth</a> for non-COVID issues. Companies including <a href="https://www.uhc.com/health-and-wellness/health-topics/covid-19/telehealth-options">UnitedHealthcare</a> have already rolled back policies that waived co-pays and other fees for non-COVID-related appointments. Other plans such as <a href="https://www.anthem.com/coronavirus/individual-and-family/">Anthem BlueCross BlueShield</a> have extended their coverage through the end of the year, but only the first two sessions are free for the consumer. </p>
<p>Further complicating matters is that <a href="https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/#C">every private insurance plan and many state-funded Medicaid plans</a> have different sets of rules and dates for what telehealth treatments they cover. This means some patients are paying more. Costs are getting confusing. Patients may end up with <a href="https://theconversation.com/surprise-medical-bills-increase-costs-for-everyone-not-just-for-the-people-who-get-them-146476">a surprise bill</a> – or they may delay care due to cost. </p>
<h2>A system under pressure</h2>
<p>Health care providers and hospital systems are also in limbo. They don’t know whether they’ll lose telehealth payments when the federal public health emergency for the pandemic lapses or what to expect from private health insurance companies. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Dozens of medical beds are unloaded at a hospital loading dock." src="https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365062/original/file-20201022-14-1ss6dol.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Hospitals have faced many shortages this year, including beds.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/workers-prepare-dozens-of-extra-medical-beds-as-they-are-news-photo/1215975178">Spencer Platt/Getty Images News via Getty Images</a></span>
</figcaption>
</figure>
<p>Hospitals and health systems have had to meet <a href="https://www.oig.hhs.gov/oei/reports/oei-06-20-00300.pdf">unprecedented challenges in 2020</a> – increasing testing, treating infected patients, expanding intensive care unit capacity, safeguarding staff and non-COVID-19 patients, procuring personal protective equipment and canceling nonemergency procedures. These challenges have created <a href="https://www.aha.org/fact-sheets/2020-04-24-fact-sheet-financial-challenges-facing-hospitals-and-health-systems-result">historic financial pressures</a> for health care offices and hospitals. The American Hospital Association estimates that the country’s health care systems are <a href="https://www.aha.org/guidesreports/2020-05-05-hospitals-and-health-systems-face-unprecedented-financial-pressures-due">losing an average of US$50.7 billion per month</a>. </p>
<p>This financial crisis puts telehealth in jeopardy. Providers and health systems still have to pay salaries and purchase expensive technological equipment, making it difficult to accept a reduced rate for telehealth visits. Without payment parity, in the current financial crisis, health care systems will not be able to continue to offer telehealth services.</p>
<h2>What’s next</h2>
<p>A continued <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/first-and-second-waves-of-coronavirus">increase in COVID-19 cases is expected this fall</a>, just as insurance providers are starting to diminish coverage for telehealth visits. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Our team – and teams across every state – will undertake rigorous evaluation of each of the CARES Act policy changes (and similar Medicaid and private insurer changes) and their impact. These evaluations will provide information on how telehealth affects cost and cost effectiveness in the future. </p>
<p>Clearly, telehealth is in jeopardy now as patients are paying more, health care practices are receiving less and the risk of infections increases. While the diminished risk of infection through the use of telehealth seems positive, it is clear to us that insurers are trying to drive patients back to the in-person care model. How will vulnerable populations and the fragile health care system respond? Will patients and providers still have a choice in how they receive and provide care, or will we lose the innovation gained during this period?</p><img src="https://counter.theconversation.com/content/147648/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer A. Mallow receives funding from the US DHHS-Centers for Medicare & Medicaid Services & National Institutes of Health/National Cancer Institute. </span></em></p><p class="fine-print"><em><span>Steve Davis receives funding from the WV DHHR-Bureau for Medical Services & the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. </span></em></p>Widely adopted in the US when pandemic precautions kept people home, telehealth faces a challenge as insurance coverage changes, right when its popularity had surged.Jennifer A. Mallow, Associate Professor of Nursing, West Virginia UniversitySteve Davis, Associate Professor of Health Policy, Management and Leadership, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1471342020-10-19T13:04:49Z2020-10-19T13:04:49ZHow do coronavirus researchers avoid catching COVID-19?<figure><img src="https://images.theconversation.com/files/363714/original/file-20201015-23-ez6dp6.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C5455%2C3637&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scientist-experimented-laboratory-728262253">Eugene Lu/Shutterstock</a></span></figcaption></figure><p>Around the world, virologists in labs are constantly handling samples of SARS-CoV-2, the virus that causes COVID-19, as part of our global quest to understand, and hopefully overcome, this pandemic. We know that SARS-CoV-2 is <a href="https://www.ecdc.europa.eu/en/covid-19/latest-evidence/transmission">highly infectious</a> and can be lethal if it gets inside our bodies. So it’s vital these scientists are protected from becoming infected.</p>
<p>This is nothing new. Virologists regularly handle large quantities of virus in much more concentrated forms than we would encounter in the outside world. So how do we stay safe from these pathogens? </p>
<p>There are a lot of different levels of protection we use, but what it all comes down to is trust and responsibility. </p>
<h2>Procedure and protocols</h2>
<p>Before anyone gets near new viruses in the lab, we need permission from the relevant government authority. We inform them of what we intend to do with the virus and demonstrate we can work with it in a safe and secure environment.</p>
<p>When it comes to working with the virus in the lab, we have carefully written documents detailing how to handle the pathogens so that everyone stays safe. This includes using specialist screw-top lids to store virus samples to prevent spills, and treating all liquids in the facility as infectious – even if it’s a newly opened bottle of sterile water.</p>
<p>Scientists who work on hazardous viruses have also undergone significant training. This includes academic qualifications and laboratory experience, but also specific instruction in handling pathogens safely. Each user must have a minimum number of hours of training, covering all procedures used in the facility, and eventually signed off by an experienced virologist and biosafety officer.</p>
<h2>Equipment</h2>
<p>A lot of the physical protection from the viruses we work on comes from the environment in which they are handled. We have separate rooms for virus work and non-virus work to prevent contamination. </p>
<p>Hazardous viruses are handled in <a href="https://ehs.umich.edu/research-clinical/equipment-tools/biological-safety-cabinets/">specialist cabinets</a> that have controlled sterile airflow. This protects the user from the pathogens as air is restricted from leaving the cabinet, and protects samples inside the cabinet from the user. There are many microbes in the air and on our skin, and we don’t want our experimental samples getting contaminated with any of these.</p>
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Read more:
<a href="https://theconversation.com/my-new-life-as-a-coronavirus-tester-a-scientists-story-141646">My new life as a coronavirus tester – a scientist's story</a>
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<p>In higher containment facilities, like those used for SARS-CoV-2, the entire room is maintained under <a href="https://www.news-medical.net/health/What-are-Negative-Pressure-Rooms.aspx">negative pressure</a> – the air pressure inside the lab is lower than the air pressure outside it. No air can leave these rooms without going through a specialist filter that removes potential pathogens.</p>
<h2>Cleaning</h2>
<p>A large amount of virology revolves around cleaning up. Cabinets are cleaned with alcohol before and after use, as is anything taken in or out of them. In addition to cleaning surfaces, anything used inside virus labs must be disinfected before removal. All tubes, flasks and so on are chemically disinfected and then cleaned with an autoclave – an industrial sterilisation unit that uses high pressure and temperature to remove pathogens.</p>
<p>As an extra precaution in higher containment facilities, regular fumigation is performed where the entire room is sealed and pumped full of formaldehyde gas to neutralise any lingering pathogens.</p>
<h2>Personal protective equipment</h2>
<p>I’ve deliberately left personal protective equipment, or PPE, quite low down this list. That’s because PPE is considered the final barrier of protection. If protocols are followed and equipment used correctly, there should be no instances of a lab user being exposed to a virus sample. Unfortunately we cannot foresee all incidents and scientists are only human, so PPE is crucial to safe lab work. PPE also protects our samples from us. We have lots of microbes and enzymes on our skin that we don’t want in our experiments.</p>
<p>In labs handling mild risk pathogens, scientists wear lab coats and gloves (sometimes also eye protection where necessary). Pathogens are unlikely to leave the cabinet but if they do, they would only cause mild illness to healthy individuals so no more PPE is required.</p>
<p>Working in higher containment where pathogens are more likely to be transmitted or cause more serious illness (or both), significantly more PPE is used. Rules in these facilities vary as they are tailored specifically to the pathogens handled, but in general, full biohazard suits are worn which are sealed at the ankles and wrists. Specialist footwear is worn, gloves are doubled up (in case one layer of glove becomes compromised). </p>
<p>For viruses such as SARS-CoV-2 that infect the respiratory system, goggles and <a href="https://www.nhsggc.org.uk/working-with-us/hr-connect/health-safety/policies-guidance-documents-forms/personal-protective-equipment/respiratory-protection-equipment-ffp3-masks/">FFP3 masks</a> which are specifically fitted to individual users are worn to protect from exposure via inhalation or through the eyes. All these items of PPE are worn so that, in the unlikely case of a spill, workers have time to exit the facility without exposing themselves to infection.</p>
<h2>It all comes down to responsibility</h2>
<p>No matter the pathogen, regulations, or set-up of a laboratory, our main form of protection from viruses is the scientists themselves. Everything discussed in this article is only effective if every scientist in the lab follows all the regulations and has the right training.</p>
<p>There is little point donning all your PPE if the person who used the lab before you did not follow procedure – for example, if there was an unreported spill or a used scalpel blade left out on the benchtop. It is up to all of us to keep ourselves, our colleagues, and the outer world safe.</p>
<p>This ethos is also relevant to our daily lives during the pandemic. It is important to notify the lab of spills in the lab, just as it is important that we report COVID-19 symptoms or a positive test result. It’s important that we leave our lab space clean and tidy for other uses, much like it is important to regularly wash our hands. It’s important we wear PPE in the lab to protect ourselves and our samples, much like we need to wear masks properly to protect those around us in public.</p>
<p>Finally, like in the lab where we treat any and all liquids used in the virus facility as infectious, in the outer world we must treat ourselves and those around us as potentially infectious at all times. If we want to beat this pandemic, we all need to think a little more like virologists.</p><img src="https://counter.theconversation.com/content/147134/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace C Roberts works at Queen's University, Belfast and receives funding from The Wellcome Trust.</span></em></p>Scientists handle virus samples every day but infections are incredibly rare – here’s why.Grace C Roberts, Research Fellow in Virology, Queen's University BelfastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1468222020-10-12T13:22:09Z2020-10-12T13:22:09ZCOVID-19 masks FAQs: How can cloth stop a tiny virus? What’s the best fabric? Do they protect the wearer?<figure><img src="https://images.theconversation.com/files/360752/original/file-20200930-18-wwkpvt.jpg?ixlib=rb-1.1.0&rect=258%2C0%2C5691%2C4104&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Although cloth masks have been widely adopted, many people still have questions about them. </span> <span class="attribution"><span class="source">(Usplash/Vera Davidova)</span></span></figcaption></figure><p>Face masks <a href="https://doi.org/10.1016/S0140-6736(20)31142-9">reduce the spread of viruses</a> passed on from respiratory secretions. While cloth masks are imperfect, widespread use of an imperfect mask has the potential to make a big difference in transmission of the virus. </p>
<p>We started reading the research on cloth masks and face coverings at the start of the pandemic, looking for ways to protect our <a href="https://doi.org/10.1177%2F2054358120944298">vulnerable dialysis patients</a> and our dialysis staff. We found a total of 25 studies, <a href="https://doi.org/10.7326/M20-2567">advocated for mask use</a> and <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">summarized our findings</a> in a peer-reviewed publication. We also created an evidence-based, plain-language website (<a href="https://www.clothmasks.ca">www.clothmasks.ca</a>) to help people navigate this area. </p>
<p>Although mask use has been widely adopted, many people still have questions about them. </p>
<h2>I see spaces in the cloth. How can it stop particles?</h2>
<p>The virus that causes COVID-19 is about <a href="https://doi.org/10.1016/s0140-6736(20)31185-5">0.1 micrometer in diameter</a>. (A micrometer (µm) is one one-thousandth of a millimeter.) The holes in woven cloth are visible to the naked eye and may be <a href="https://pubs.acs.org/doi/abs/10.1021/acsnano.0c03252#notes1">five to 200 micrometers in diameter</a>. It is counter-intuitive that cloth can be useful in this setting — it’s been compared to putting up a chain-link fence to stop mosquitoes. However, that analogy is wrong in many ways. </p>
<p>According to aerosol science, whenever liquid hangs in air it is technically an aerosol, but other disciplines use the word “droplet” to mean a coarse particle five micrometers or larger, and reserve “aerosol” for fine particles smaller than five micrometers in effective diameter. </p>
<p>When we breathe, talk, eat, cough, sneeze or sing, we emit particles across <a href="https://doi.org/10.1098/rsif.2013.0560">a range of sizes</a>, both coarse and fine, and <a href="https://doi.org/10.1016/S2213-2600(20)30323-4">the virus is in those particles</a>. Even though there are gaps between the threads in cloth, the threads are usually wider than the gaps. </p>
<p>Also, at this microscopic level, the thread has thickness, or depth, so the gap is more a tunnel than a window. Microfilaments from broken or irregular threads <a href="https://www.semlab.com/services/materials-analysis/fiberanalysis/">project into the gap</a>. The particle is not like a mosquito, which can redirect itself to avoid obstacles. A particle with momentum will run into a fibre, even though the air stream is diverted around it, like a ball hitting a wall — this is called impaction. </p>
<figure class="align-center ">
<img alt="Québec Premier François Legault holds a face mask with the Montréal Canadiens logo in front of his face as he puts it on." src="https://images.theconversation.com/files/360755/original/file-20200930-14-kr4qba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/360755/original/file-20200930-14-kr4qba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=471&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360755/original/file-20200930-14-kr4qba.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=471&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360755/original/file-20200930-14-kr4qba.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=471&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360755/original/file-20200930-14-kr4qba.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=592&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360755/original/file-20200930-14-kr4qba.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=592&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360755/original/file-20200930-14-kr4qba.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=592&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Québec Premier François Legault puts on a Montréal Canadiens face mask as he finishes the daily COVID-19 press briefing on May 21, 2020 in Montréal.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Ryan Remiorz</span></span>
</figcaption>
</figure>
<p>But at the microscopic level, there are two additional processes in play. Particles also fall out of the air — called sedimentation. Some particles are moving randomly and this random motion brings them into contact with fibres — called diffusion. Finally, cloth can be used in multiple layers, adding a second and third gauntlet for the particle to run before it reaches the other side.</p>
<p>The point is not that some particles may penetrate the cloth, but that some are blocked.</p>
<h2>What are the best materials for cloth face masks?</h2>
<p>Based on our <a href="https://www.clothmasks.ca/plain-language-summary-of-evidence">summary of 25 different studies</a>, <a href="https://www.clothmasks.ca/guidance">woven cotton, at least 100 threads per inch; flannel, either cotton or poly-cotton blend, at least 90 threads per inch; tea towel material; and heavy, good quality, cotton T-shirt material all performed well</a>. This recommendation is based on the published data available, which doesn’t cover all possible mask materials: we didn’t find a lot of information on synthetic materials, for example, so we don’t know how they compare. </p>
<figure class="align-left ">
<img alt="Four cloth masks hanging on a clothesline." src="https://images.theconversation.com/files/360756/original/file-20200930-24-ganl1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/360756/original/file-20200930-24-ganl1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360756/original/file-20200930-24-ganl1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360756/original/file-20200930-24-ganl1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360756/original/file-20200930-24-ganl1z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360756/original/file-20200930-24-ganl1z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360756/original/file-20200930-24-ganl1z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Although the SARS-CoV-2 virus is smaller than the spaces between the threads of many types of cloth, wearing a cloth mask is not like trying to contain a mosquito with a chain-link fence.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Every study that looked at layering found that it made a difference, so we recommend that masks be made of at least two layers; three or four may be even better. We found evidence for multiple layers of the same fabrics and for sandwiches of different materials. We did not find good evidence of useful levels of filtration for disposable filters, like coffee filters, so we suggest not using them.</p>
<p>For example, a <a href="https://www.researchgate.net/publication/340023785_facemask_instructions_COVID-19doc">two-layer T-shirt mask with a sewn edge</a> — which prevents stretching — <a href="https://doi.org/10.1017/dmp.2013.43">prevented 79 per cent of mouth bacteria reaching the environment during coughing</a>. In the same experiment, a modern disposable medical mask performed in the same range at 85 per cent.</p>
<p>Two studies of surgical masks from the 1960s and 1970s distinguished between coarse particles (sometimes called droplets) and fine particles (sometimes called aerosols). A <a href="https://doi.org/10.1002/bjs.1800621203">four-layer cotton mask</a> and a mask made of a <a href="https://doi.org/10.1128/jb.83.3.663-667.1962">sandwich of cotton and flannel</a> both reduced mouth bacteria in particles of all sizes reaching the environment during talking by 99 per cent and mouth bacteria in fine particles by <a href="https://doi.org/10.1002/bjs.1800621203">89 per cent</a>.</p>
<p>This is all good evidence that cloth face coverings can prevent respiratory secretions from reaching the environment. Every coarse or fine particle trapped in a mask is not available to hang in the air or fall to a surface and contaminate it. “My mask protects you, your mask protects me”: if many people wear face coverings we expect the probability of transmission to fall.</p>
<h2>Can a cloth mask protect the person wearing it?</h2>
<p>We found four studies of inward filtration, all of which showed useful levels of filtration, all using the same widely-accepted technology that measures salt particles in the fine particle (0.02 to 1.0 micrometer) range. A <a href="https://doi.org/10.1371/journal.pone.0002618">study of one-layer tea-towel masks</a> and <a href="https://doi.org/10.1017/dmp.2013.43">a study of two-layer masks made of T-shirt material</a> both showed at least 50 per cent protection for fine particles. <a href="https://doi.org/10.1038/jes.2016.42">Two cloth masks of unknown materials</a> randomly purchased from street vendors performed just as well. For comparison, two of these studies — using exactly the same methods — examined how well modern disposable medical masks worked when tested on volunteers: they filtered around 80 per cent of fine particles.</p>
<p>Three researchers from the University of Pittsburgh made complex masks with <a href="https://doi.org/10.3201/eid1206.051468">eight layers of pre-shrunk high-quality cotton T-shirts</a> fitted to their own faces: each filtered more than 90 per cent of inward aerosol-sized fine particles, offering proof-of-concept for the idea of designing better cloth masks.</p>
<figure class="align-center ">
<img alt="Illustration of a black face mask with a coronavirus in a red circle with a line through it." src="https://images.theconversation.com/files/360758/original/file-20200930-24-kfdwjv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/360758/original/file-20200930-24-kfdwjv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=430&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360758/original/file-20200930-24-kfdwjv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=430&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360758/original/file-20200930-24-kfdwjv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=430&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360758/original/file-20200930-24-kfdwjv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360758/original/file-20200930-24-kfdwjv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360758/original/file-20200930-24-kfdwjv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many of the cloth masks in current use are likely producing useful levels of filtration to the person wearing them.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>An <a href="https://www.atsjournals.org/doi/pdf/10.1164/art.1949.59.1.1">animal experiment</a> with tuberculosis bacteria provides further insight. Tuberculosis is usually considered an “airborne” disease, that is, one with an important transmission route through aerosols or fine particles. When caring for tuberculosis patients, health-care workers wear N95 masks, a high level of respiratory protection, to protect themselves and prevent onward transmission to others. When rabbits were exposed to aerosols of tuberculosis in controlled conditions, tuberculomas (infected abscesses) were reduced by 95 per cent in rabbits that wore close-fitting three- to six-layer gauze masks compared with those that did not.</p>
<p>Many of the cloth masks in current use, therefore, are likely producing useful levels of filtration to the person wearing them, and we have proof-of-concept for improved cloth mask materials and design.</p>
<h2>At what rate of use do masks become beneficial?</h2>
<p>Two modelling studies predict that 50 per cent adoption of a 50 per cent effective mask will have an important effect on transmission, and that if either percentage is increased, transmission is further reduced. We need to work on making cloth masks more effective, but the masks that we have on hand have the potential to change the course of the pandemic, particularly if we almost all wear them.</p>
<p>Mask mandates were imposed at different times in different states in the United States, creating a natural experiment. The COVID-19 daily growth rate <a href="https://doi.org/10.1377/hlthaff.2020.00818">fell by one per cent in the first five days and by two per cent at 21 days after a mask mandate was imposed</a>. These effects are not small: they represent <a href="https://doi.org/10.1377/hlthaff.2020.00608">16 to 19 per cent of the effects of other much more invasive measures</a> (school closures, bans on large gatherings, shelter-in-place orders and closures of restaurants, bars and entertainment venues).</p>
<p>Taken together, this suggests that cloth face coverings of the type currently available have the potential to reduce transmission, and that when cloth face coverings are mandated, the growth rate decreases. The Institute for Health Metrics and Evaluation in Seattle <a href="https://www.healthdata.org/sites/default/files/files/Projects/COVID/briefing_Global_09.03.2020.pdf">projected on Sept. 3</a> that an increase in mask usage from the current 60 per cent to 95 per cent, combined with enhanced local social distancing as needed, would reduce global deaths by three-quarters of a million people before the end of 2020.</p>
<h2>Are there any other benefits to wearing a mask?</h2>
<figure class="align-center ">
<img alt="Dr. Bonnie Henry wearing a cloth mask featuring bees and embroidered with the words 'kind calm safe'" src="https://images.theconversation.com/files/360757/original/file-20200930-24-1nwuali.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/360757/original/file-20200930-24-1nwuali.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=418&fit=crop&dpr=1 600w, https://images.theconversation.com/files/360757/original/file-20200930-24-1nwuali.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=418&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/360757/original/file-20200930-24-1nwuali.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=418&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/360757/original/file-20200930-24-1nwuali.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=525&fit=crop&dpr=1 754w, https://images.theconversation.com/files/360757/original/file-20200930-24-1nwuali.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=525&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/360757/original/file-20200930-24-1nwuali.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=525&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">British Columbia provincial health officer Dr. Bonnie Henry wears a face mask as she views the Murals of Gratitude exhibition in Vancouver, on July 3, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>A <a href="https://doi.org/10.1007/s11606-020-06067-8">new hypothesis</a> advanced by researchers at the University of California San Francisco suggests that cloth masks don’t just reduce the probability of infectious organisms reaching a person, but also the number of infectious organisms — and that a lower number of infecting organisms leads to less severe disease. </p>
<p><a href="http://doi.org/10.1056/NEJMp2026913">Accumulating epidemiologic evidence</a> from this pandemic suggests that when masks are worn, the overall severity of illness is lower. The proportion of those infected who remain asymptomatic is higher, and the probability of dying is lower. In animal experiments it is <a href="https://doi.org/10.1093/oxfordjournals.aje.a118408">well known</a> that the inoculum (the infecting dose) is related to disease severity. The threshold at which 50 per cent of animals in a group receiving the same dose die of infection is called the <a href="https://doi.org/10.1093/oxfordjournals.aje.a118408">lethal-dose 50 (LD50)</a>. </p>
<p>Experiments on mice using the coronaviruses <a href="https://doi.org/10.1128/jvi.02009-15">MERS-CoV (Middle East respiratory syndrome)</a> and <a href="https://doi.org/10.1128/jvi.78.7.3572-3577.2004">SARS-CoV-1, which caused the 2003 SARS outbreak,</a> showed dose-response and in MERS-CoV established LD50. In hamsters separated by surgical masks between cages from hamsters infected with SARS-CoV-2, the <a href="https://doi.org/10.1093/cid/ciaa644">severity of infection was reduced</a> compared with hamsters unprotected by masks.</p>
<p>Further research on better cloth masks will be helpful. At the <a href="https://www.eng.mcmaster.ca/centre-excellence-protective-equipment-and-materials-cepem">Centre of Excellence for Protective Equipment and Materials</a> at McMaster, we hope to play a role in that work. However, even imperfect uptake and imperfect use of imperfect masks has the potential to have a surprisingly large impact during this pandemic. We should not let the perfect be the enemy of the good.</p><img src="https://counter.theconversation.com/content/146822/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Epidemiologists reviewed 25 studies of cloth face masks. Here’s what they found out about how well they work, why they work, who they protect and why the mosquito and chain-link fence analogy is wrong.Catherine Clase, Physician, epidemiologist, associate professor, McMaster UniversityEdouard Fu, MD/PhD Candidate in Clinical Epidemiology, Leiden UniversityJuan Jesus Carrero, Professor of Epidemiology, Karolinska InstitutetLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1456122020-09-28T20:08:55Z2020-09-28T20:08:55ZHeath-care workers lacking PPE suffer from more anxiety and depression<figure><img src="https://images.theconversation.com/files/358517/original/file-20200917-16-xad5y.jpg?ixlib=rb-1.1.0&rect=4%2C8%2C2645%2C2110&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A health-care worker is seen wearing full personal protective equipment outside the Royal Columbian Hospital in New Westminster, B.C. on April 3, 2020.</span> <span class="attribution"><span class="source"> THE CANADIAN PRESS/Jonathan Hayward</span></span></figcaption></figure><p>While all workers across Canada and around the world are being affected by COVID-19, health-care workers as a group are most heavily feeling its impact. This is because of their pivotal role in the treatment of people infected with the virus and their high COVID-19 exposure as part of their job. As such, maximizing efforts to enable the health-care workforce to remain free of COVID-19 infection, and stay in good physical and mental health, is essential to the response and management of COVID-19.</p>
<p>Including mental health in these efforts is important. Consider the situation of many health-care workers during the pandemic: their increased workload, the moral dilemmas they may face when providing patient care, their heightened personal exposure to COVID-19 infection, and their associated worries about infecting family and household members. It’s no surprise that <a href="https://doi.org/10.1136/bmj.m1642">previous studies</a> have shown increases in mental health symptoms among health-care workers during disease outbreaks and pandemics. </p>
<p>It is also important to identify workplace factors linked to mental health that can be changed. While personal protective equipment (PPE) and infection control procedures are often discussed as measures to reduce virus transmission, we also need to understand their importance in the context of mental health, especially since the <a href="https://doi.org/10.1136/bmj.m1211">mental health impacts</a> of COVID-19 may linger beyond the pandemic. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A cart holding PPE, including surgical masks, N95 masks, gloves, gowns and caps" src="https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/358984/original/file-20200921-24-qsxoax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Personal protective equipment in the COVID-19 intensive care unit at St. Paul’s Hospital in downtown Vancouver on April 21, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Our team of work and health researchers recently examined the association between the perceived adequacy of PPE and infection control procedures, and symptoms of anxiety and depression among health-care workers. As reported in our <a href="https://doi.org/10.1177/0706743720961729">paper</a> in the <a href="https://journals.sagepub.com/home/cpa"><em>Canadian Journal of Psychiatry</em></a>, we found greater levels of mental health symptoms among workers who indicated their needs for PPE and infection control procedures were not met.</p>
<h2>Assessing mental health and protection measures</h2>
<p>About 6,000 health-care workers in hospitals, long-term care homes and other community care settings were recruited across Canada through the networks of an ad-hoc pandemic survey group. Responses were collected by the <a href="https://www.ohcow.on.ca/">Occupational Health Clinics for Ontario Workers</a> and then analyzed at the <a href="https://www.iwh.on.ca/">Institute for Work & Health</a>. Surveys were conducted between April 7 and May 13, 2020, during the height of the first wave of COVID-19 infections in Canada.</p>
<p>To assess symptoms of anxiety and depression among health-care workers, we asked questions from two validated screening instruments: the General Anxiety Questionnaire (GAD-2) and the Patient Health Questionnaire (PHQ-2). </p>
<p>We also asked about eight different types of PPE that might be needed such as gloves, hand sanitizer, face shields, procedural masks and N95 masks. For each type of PPE, respondents indicated if these were needed and adequately supplied (both in terms of appropriate type and adequate amounts), needed but not adequately supplied, or not needed. </p>
<p>We further asked about 10 different types of infection control procedures such as screening patients, isolating symptomatic patients from other patients and staff, frequent cleaning, and using engineering controls such as ventilation systems. Again, respondents told us whether these were appropriate and adequately implemented, required but inadequately implemented or not required. </p>
<p>We then grouped respondents based on the proportion of their needs for PPE or infection control procedures that were met, and ran statistical models to estimate the proportion of respondents in each of these groups with symptoms of anxiety and depression. Our models took into account a variety of factors about each respondent (age, gender and visible minority status), where they lived (province and urban/suburban/rural setting), the type of health-care facility they worked in, the hours of work per week and how long they had worked there, their level of exposure to COVID-19 patients, level of infections in their workplace, if they had experienced COVID-19 symptoms and training on PPE. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two health-care professionals, one of whom is adjusting a face shield and the other is putting on a yellow protective gown." src="https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/358987/original/file-20200921-14-q0qn3z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Health-care workers put on personal protective equipment before testing at a drive-through COVID-19 assessment centre at the Etobicoke General Hospital in Toronto on April 7, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>We found that, among respondents with 100 per cent of their PPE needs met, 42.9 per cent reported symptoms consistent with anxiety; this increased to 60.4 per cent among respondents with none of their needs met. This was after taking into account the factors listed above which might also be related to anxiety symptoms. Similar differences were observed in anxiety symptoms between workers with none or all of their needs for infection control procedures met (43.4 per cent of workers with all their infection control needs met had anxiety symptoms compared to 60.6 per cent of workers with none of these needs met). We also observed differences in the prevalence of depression symptoms among these same groups (differences of 11 percentage points for PPE needs, and 19 percentage points for infection control procedures). </p>
<h2>Implications for health-care workers</h2>
<p>While no silver bullet will adequately address the increased mental health needs of health-care workers during COVID-19, our study demonstrates that the perceived adequacy of PPE and infection control procedures in health-care workplaces is associated with important differences in anxiety and depression symptoms. As such, it is important that health-care workplaces provide adequate and appropriate PPE and institute effective infection control procedures — not just to reduce COVID-19 infection, but to help reduce the mental health strain faced by health-care workers.</p><img src="https://counter.theconversation.com/content/145612/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Smith has received project funding from The Canadian Institutes of Health Research, The Ontario Workplace Safety & Insurance Board, WorkSafe BC, Alberta Futures, and the Australian Research Council</span></em></p>Health-care workers’ access to personal protective equipment, along with appropriate infection control procedures, affected their mental health during the first wave of the COVID-19 pandemic.Peter Smith, Senior Scientist, Institute for Work & Health. Associate professor, Dalla Lana School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1441812020-09-08T12:16:34Z2020-09-08T12:16:34ZHow the Civil War drove medical innovation – and the pandemic could, too<figure><img src="https://images.theconversation.com/files/354135/original/file-20200821-18-1jj8kww.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bernard Tobey, a double amputee, and his son, wearing Union sailor uniforms, standing beside a small wagon displaying Secretary of War Edwin Stanton's dispatch on the fall of Fort Fisher.</span> <span class="attribution"><a class="source" href="https://www.loc.gov/pictures/item/2017659614/"> Fetter's New Photograph Gallery/Library of Congress</a></span></figcaption></figure><p>The current COVID-19 pandemic, the largest public health crisis in a century, threatens the health of people across the globe. The U.S. has had the most diagnosed cases – <a href="https://www.worldometers.info/coronavirus/">surpassing 6 million</a> – and <a href="https://www.worldometers.info/coronavirus/">more than 180,000 deaths</a>. </p>
<p>But six months into the pandemic, the U.S. still faces <a href="https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/faqs-shortages-surgical-masks-and-gowns-during-covid-19-pandemic">shortages</a> of personal protective equipment for both front-line medical workers and the general public. There is also great need for widely available <a href="https://theconversation.com/will-the-new-15-minute-covid-19-test-solve-us-testing-problems-145285">inexpensive, rapid tests</a>; the infrastructure to administer them; and most importantly, safe, effective vaccines. </p>
<p>Moving forward, medical innovation can play a substantial role in controlling and preventing infection – and treating those who have contracted the virus. But what’s the best way to catalyze and accelerate public health developments? Research and history show that the federal government can play a major role in spurring private-sector innovation.</p>
<h2>Lessons from the Civil War</h2>
<p>Governments play far-reaching roles in health care. The U.S. Food and Drug Administration approves new treatments. Public and private insurance administrators determine what treatments to cover. The Medicare program sets prices that have <a href="https://www.journals.uchicago.edu/doi/pdfplus/10.1086/689772">effects across the heath care system</a>. By determining if and when competitors can enter the market, the U.S. patent system shapes pharmaceutical prices, which impacts companies’ financial returns. The National Institutes of Health and the National Science Foundation allocate funding for both basic and applied medical research.</p>
<p>Taken together, the government has substantial influence on medical innovation. That’s because private industry requires well-defined quality standards and clear financial incentives to speed forward – performance depends critically on the government agencies that often make the rules and set the payments.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354137/original/file-20200821-16-tujihc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Portraits of Civil War veteran amputees, Left to right: G.L. Burnette, Richard D. Dunphy and Henry A. Seaverns.</span>
<span class="attribution"><a class="source" href="https://www.loc.gov/pictures/resource/bellcm.15657">Library of Congress</a></span>
</figcaption>
</figure>
<p>In my <a href="https://scholar.google.com/citations?user=wFv_COwAAAAJ&hl=en">research as an economist</a>, I investigate the effects of government insurance programs on patient care, pricing and innovation across the health system. My colleague Parker Rogers and I recently <a href="https://econweb.ucsd.edu/%7Ej1clemens/pdfs/ProstheticsPaperLatest">analyzed</a> innovations in the design and manufacture of artificial limbs during the U.S. Civil War. The example resonates because wars, like pandemics, create dramatic, unanticipated needs for medical innovations. </p>
<p>With advances in weaponry, destructive Minié bullets and a lack of surgical experience among doctors, many Civil War soldiers with leg or arm wounds required amputation. Roughly <a href="https://www.rehab.research.va.gov/jour/07/44/4/Gailey.html">70,000 veterans</a> who survived the bloody, four-year conflict lost limbs.</p>
<p>As disabled veterans returned home, the government launched the “Great Civil War Benefaction” to provide prostheses. Officials <a href="http://www.siupress.com/books/978-0-8093-3131-4">examined and certified</a> inventors’ prototypes, and wounded veterans then chose from approved products, which the government then acquired at preset prices: US$75 per leg and $50 per arm. </p>
<p>The program’s cost-conscious approach shaped inventors’ efforts, leading them to emphasize simplicity in design and low-cost production. While prosthetic arms and legs remained quite primitive by modern standards, inventors emphasized improvements in comfort and modest gains in functionality. In total, 87 patents for prostheses were granted from 1863 through 1867, compared with 15 new patents between 1858 and 1862.</p>
<p>Production responded dramatically to the unprecedented needs. Just prior to the war, in 1860, <a href="https://econweb.ucsd.edu/%7Ej1clemens/pdfs/ExpandingHealthSystemCapacity.pdf">five manufacturers</a> sold an estimated 350 prostheses in the U.S. By 1865, production had increased tenfold. That year, the Union Army <a href="http://www.siupress.com/books/978-0-8093-3131-4">furnished</a> some 2,020 artificial legs and 1,441 artificial arms to its soldiers. By 1870, there were <a href="https://econweb.ucsd.edu/%7Ej1clemens/pdfs/ExpandingHealthSystemCapacity.pdf">24 manufacturers</a> in the industry. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354738/original/file-20200825-23-kyneen.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A researcher holding vials of COVID-19 vaccine that will be used in clinical trials.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/healthcare-professional-in-protective-gloves-royalty-free-image/1254511513">Tang Ming Tung/GettyImages</a></span>
</figcaption>
</figure>
<h2>The economics of medical innovation</h2>
<p>Most research into the economics of medical innovation has focused on pharmaceuticals. This research has showcased the power of incentives. </p>
<p>For example, with the introduction of guidelines, mandates or other government policies that increased projected profits, <a href="https://economics.mit.edu/files/7894">vaccine development</a> accelerated. Clinical trial activity increased during the years immediately following these changes. </p>
<p>Additional evidence has shown that the introduction of <a href="https://doi.org/10.1016/j.jpubeco.2012.10.003">Medicare’s drug benefit</a> (passed in 2003 and enacted in 2005) sped pharmaceutical research for diseases that impact the elderly. Diseases that offer robust or expanding drug <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1756-2171.12113">markets</a> <a href="https://economics.mit.edu/files/4464">receive particular attention</a>. Economists have also found that drug development responds to incentives created by the <a href="https://pubs.aeaweb.org/doi/pdfplus/10.1257/aer.20131176">patent system</a>. Finally, when insurers begin to exclude drugs for a particular disease, <a href="https://cpb-us-e1.wpmucdn.com/sites.dartmouth.edu/dist/c/1998/files/2020/07/Agha-Kim-Li-Insurance-Design-Innovation-_-July-2020.pdf">R&D for that disease tends to slow</a>. </p>
<h2>Failures during the COVID-19 pandemic</h2>
<p>During the COVID-19 pandemic the U.S. government has, unfortunately, not provided the sort of certainty required for medical innovation to flourish as well as it could. By creating uncertainty, the federal government discouraged both states and private companies from acting on their own initiative, which has delayed our national response. </p>
<p>Early on, for example, the federal government equivocated over contractual commitments to companies that came forward to <a href="https://www.nytimes.com/2020/03/26/us/politics/coronavirus-ventilators-trump.html">produce ventilators</a>. State officials who prudently expanded stocks of <a href="https://www.vanityfair.com/news/2020/05/how-the-federal-government-took-control-of-the-ppe-pipeline">personal protective equipment</a> were unsure whether supplies would be commandeered by the federal government. </p>
<p>Federal actions also impacted testing. The FDA thwarted efforts to implement <a href="https://medium.com/@rzadek/unprepared-government-failure-at-the-cdc-fda-e157d2ca25c">new testing infrastructure</a> supported by <a href="https://www.businessinsider.com/bill-gates-backed-coronavirus-testing-program-stopped-by-fda-2020-5">the Gates Foundation</a>. The error was compounded by the <a href="https://www.sciencemag.org/news/2020/02/united-states-badly-bungled-coronavirus-testing-things-may-soon-improve">botched early rollout</a> of testing kits and rejection of tests manufactured in other countries. The result: Months into the pandemic, tests can still be difficult to obtain, and <a href="https://www.nytimes.com/2020/08/04/us/virus-testing-delays.html">results are often backlogged</a> to the point of uselessness.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/355171/original/file-20200827-16-j71bs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Catrina Rugar, 34, a traveling nurse from Florida, responded first to hospitals in New York City, then to Texas’ Rio Grande Valley, where she was treating COVID-19 patients. Rather than coordinate purchases of PPE to help drive innovation in the field, the federal government created uncertainty among states and other purchasers.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/july-20-2020-catrina-rugar-a-traveling-nurse-from-florida-news-photo/1227737165">Carolyn Cole/Getty Images</a></span>
</figcaption>
</figure>
<h2>A recipe for progress</h2>
<p>So what is the best way forward for spurring private industry to fight the pandemic? To me it’s clear that the government has a straightforward role to play in setting the stage. </p>
<p>As a narrow example, governments can increase demand for masks by issuing clear guidance and informing the public. The resulting demand creates strong financial incentives for companies to innovate and expand production.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Further, the federal government can propel the development and distribution of <a href="https://www.nytimes.com/2020/07/03/opinion/coronavirus-tests.html">tests</a> and vaccines through “<a href="https://www.nytimes.com/2020/05/04/opinion/coronavirus-vaccine.html">advance purchase commitments</a>” that guarantee a market for newly approved products. The U.S. government has <a href="https://www.nytimes.com/2020/07/22/upshot/vaccine-coronavirus-government-purchase.html">taken a major step</a> in this direction by committing to purchase large quantities of COVID-19 vaccines upon approval.</p>
<p>While the science of medical innovation is difficult, policy is relatively simple: Set clear standards, establish clear incentives and let the scientists and entrepreneurs do their work. Vaccine development, rapid testing and widely available protective gear all have important roles to play in saving lives and getting the economy back on its feet.</p><img src="https://counter.theconversation.com/content/144181/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey Clemens does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Lessons from history make clear that the federal government can spur medical innovation in a crisis, including this pandemic. Providing certainty and clarity is critical.Jeffrey Clemens, Associate Professor of Economics, University of California, San DiegoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1451402020-09-07T13:13:34Z2020-09-07T13:13:34ZCoronavirus nanoscience: the tiny technologies tackling a global pandemic<figure><img src="https://images.theconversation.com/files/356743/original/file-20200907-16-7xd8as.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/antibodies-attacking-sarscov2-virus-conceptual-3d-1700617951">Kateryna Kon/Shutterstock</a></span></figcaption></figure><p>The world-altering coronavirus behind the COVID-19 pandemic is thought to be just <a href="https://www.sciencedirect.com/science/article/pii/S2090123220300540">60 nanometres to 120 nanometres</a> in size. This is so mind bogglingly small that you could fit more than 400 of these virus particles into the width of a single hair on your head. In fact, coronaviruses are so small that <a href="https://theconversation.com/five-techniques-were-using-to-uncover-the-secrets-of-viruses-144363">we can’t see them</a> with normal microscopes and require much fancier electron microscopes to study them. How can we battle a foe so minuscule that we cannot see it?</p>
<p>One solution is to fight tiny with tiny. <a href="https://www.nano.gov/nanotech-101/what/definition">Nanotechnology</a> relates to any technology that is or contains components that are between 1nm and 100nm in size. Nanomedicine that takes advantage of such tiny technology is used in everything from plasters that contain anti-bacterial nanoparticles of silver to <a href="https://www.eurekaselect.com/132451/article">complex diagnostic machines</a>. </p>
<p>Nanotechnology also has an impressive record against viruses and has been used since the <a href="https://www.longdom.org/open-access/history-and-possible-uses-of-nanomedicine-based-on-nanoparticles-and-nanotechnological-progress-2157-7439-1000336.pdf">late 1880s</a> to separate and identify them. More recently, nanomedicine has been used to develop treatments for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5507392/">flu, Zika and HIV</a>. And now it’s joining the fight against the COVID-19 virus, SARS-CoV-2.</p>
<h2>Diagnosis</h2>
<p>If you’re suspected of having COVID, swabs from your throat or nose will be taken and tested by reverse transcription polymerase chain reaction (<a href="https://www.iaea.org/newscenter/news/how-is-the-covid-19-virus-detected-using-real-time-rt-pcr">RT-PCR</a>). This method checks if genetic material from the coronavirus is present in the sample. </p>
<p>Despite being highly accurate, the test can take <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/testing-and-tracing/what-your-test-result-means/">up to three days</a> to produce results, requires high-tech equipment only <a href="https://www.tandfonline.com/doi/full/10.1080/14787210.2020.1776115">accessible in a lab</a>, and can only tell if you have an active infection when the test is taken. But antibody tests, which check for the presence of <a href="https://www.ouh.nhs.uk/patient-guide/leaflets/files/66122Pantibody.pd">coronavirus antibodies</a> in your blood, can produce results immediately, wherever you’re tested. </p>
<p><a href="https://www.livescience.com/antibodies.html">Antibodies</a> are formed when your body fights back against a virus. They are tiny proteins that search for and destroy invaders by hunting for the chemical markers of germs, called antigens. This means antibody tests can not only tell if you have coronavirus but if you have previously had it. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7241732/">Antibody tests use</a> nanoparticles of materials such as gold to capture any antibodies from a blood sample. These then slowly travel along a small piece of paper and stick to an antigen test line that only the coronavirus antibody will bond to. This makes the line visible and indicates that antibodies are present in the sample. These tests are more than <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295501/">95% accurate</a> and can give results <a href="https://www.briancolemd.com/wp-content/themes/ypo-theme/pdf/fast-portable-tests-come-online-to-curb-coronavirus-pandemic.pdf">within 15 minutes</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/YdvFhIF1QEw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Vaccines and treatment</h2>
<p>A major turning point in the battle against coronavirus will be the development of a <a href="https://www.bbc.co.uk/news/health-51665497">successful vaccine</a>. Vaccines often contain an inactive form of a virus that acts as an antigen to train your immune system and enable it develop antibodies. That way, when it meets the real virus, your immune system is ready and able to resist infection. </p>
<p>But there are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180194/">some limitations</a> in that typical vaccine material can prematurely break down in the bloodstream and does not always reach the target location, reducing the efficiency of a vaccine. One solution is to enclose the vaccine material inside a nanoshell by a process called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464443/">encapsulation</a>. </p>
<p>These shells are made from fats called lipids and can be as thin as <a href="https://www.sciencedirect.com/science/article/pii/S154996341200754X?casa_token=MLdBN28OW80AAAAA:pUBR_sctSnKf52ryvEY_gTDb22AdCHHzc71DVcpFADw7OYEogopmjVs5kx-sIoytavAitMWxAA">5nm in diameter</a>, which is 50,000 times thinner than an egg shell. The nanoshells protect the inner vaccine from breaking down and can also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180194/">be decorated</a> with molecules that target specific cells to make them more effective at delivering their cargo. </p>
<p>This can improve the immune <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325519/#ref233">response of elderly people</a> to the vaccine. And critically, people typically need lower doses of these encapsulated vaccines to develop immunity, meaning you can more quickly produce enough to vaccinate an <a href="https://pubmed.ncbi.nlm.nih.gov/19059004/">entire population</a>. </p>
<p>Encapsulation can also improve viral treatments. A major contribution to the deaths of virus patients in intensive care is “acute respiratory distress syndrome”, which occurs when the immune system produces an <a href="https://pubs.acs.org/doi/10.1021/acsnano.0c03697">excessive response</a>. Encapsulated vaccines can target specific areas of the body to deliver immunosuppressive drugs directly to targeted organs and helping regulate our immune system response.</p>
<h2>Transmission reduction</h2>
<p>It’s hard to exaggerate the importance of wearing face masks and washing your hands to reducing the spread of COVID-19. But typical face coverings can have trouble stopping the most penetrating particles of respiratory droplets, and many can only be used once. </p>
<p>New fabrics made from nanofibres 100nm thick and coated in titanium oxide can catch droplets smaller than 1,000nm and so they can be destroyed by <a href="https://link.springer.com/article/10.1007/s11051-009-9820-x">ultraviolet (UV) radiation</a> from sunlight. <a href="https://news.kaist.ac.kr/newsen/html/news/?mode=V&mng_no=6530&skey=&sval=&list_s_date=&list_e_date=&GotoPage=1">Masks</a>, gloves and other personal protective equipment (PPE) made from such fabrics <a href="https://phys.org/news/2020-04-mask-material-virus-size-nanoparticles.html">can also be</a> washed and reused, and are more breathable.</p>
<figure class="align-center ">
<img alt="Close-up of intricately woven fibres." src="https://images.theconversation.com/files/356749/original/file-20200907-18-1q0r6kr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356749/original/file-20200907-18-1q0r6kr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356749/original/file-20200907-18-1q0r6kr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356749/original/file-20200907-18-1q0r6kr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356749/original/file-20200907-18-1q0r6kr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356749/original/file-20200907-18-1q0r6kr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356749/original/file-20200907-18-1q0r6kr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">New fabrics made from coated nanofibres could produce better PPE.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/blue-3d-texturised-technological-seamless-breathing-1074160988">AnnaVel/Shutterstock</a></span>
</figcaption>
</figure>
<p>Another important nanomaterial is
<a href="https://pubs.acs.org/doi/10.1021/acsnano.0c03697">graphene</a>, which is formed from a single honeycomb layer of carbon atoms and is <a href="https://newscenter.lbl.gov/2016/02/08/graphene-is-strong-but-is-it-tough/">200 times stronger</a> than steel but lighter than paper. Fabrics laced with graphene can capture viruses and <a href="https://pubmed.ncbi.nlm.nih.gov/28266670/">block them</a> from passing through. PPE containing graphene could be more <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/admi.201900622">puncture, flame, UV and microbe resistant</a> while also being light weight. </p>
<p>Graphene isn’t reserved for fabrics either. Nanoparticles could be placed on surfaces <a href="https://www.sciencedirect.com/science/article/pii/S266608652030014X?via%253Dihub">in public places</a> that might be particularly likely to facilitate transmission of the virus.</p>
<p>These technologies are just some of the ways nanoscience is contributing to the battle against COVID-19. While there is no one answer to a global pandemic, these tiny technologies certainly have the potential to be an important part of the solution.</p><img src="https://counter.theconversation.com/content/145140/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Josh Davies-Jones does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Nanotechnology has an impressive record against viruses.Josh Davies-Jones, PhD Candidate in Chemistry, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1437872020-08-23T14:39:22Z2020-08-23T14:39:22ZHeroes, or just doing our job? The impact of COVID-19 on registered nurses in a border city<figure><img src="https://images.theconversation.com/files/353499/original/file-20200818-14-116rlqs.jpg?ixlib=rb-1.1.0&rect=203%2C1%2C868%2C716&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some nurses who live in Windsor, Ont. work at hospitals in Detroit, just across the Ambassador Bridge.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The <a href="https://www.who.int/campaigns/year-of-the-nurse-and-the-midwife-2020">Year of the Nurse</a> brought increased attention to the “heroes of health care”: nurses working on the front lines of COVID-19. However, despite <a href="https://windsor.ctvnews.ca/thank-you-windsor-health-care-workers-feel-the-love-1.4871787">public displays of thanks</a>, it’s becoming clear that many nurses are not getting the support they need to feel safe on the job and to maintain their own health and well-being.</p>
<p>As researchers in psychology and nursing at the University of Windsor, we sought an in-depth understanding of how nurses in a border city felt about working during the pandemic. </p>
<p>Evidence from SARS in 2003 indicated that <a href="https://doi.org/10.1093/alcalc/agn073">nurses may experience significant, long-term mental health effects from working during the pandemic</a>. <a href="https://doi.org/10.1111/jonm.13014">Early research</a> from <a href="https://doi.org/10.1016/j.jpainsymman.2020.04.008">China</a> and <a href="https://doi.org/10.1016/j.psychres.2020.113129">Italy</a> found that nurses working during the surge of COVID-19 cases in those countries reported <a href="https://doi.org/10.1016/j.ajic.2020.03.018">high rates of depression, anxiety and sleep disturbances</a>. </p>
<h2>Commuting in a border city</h2>
<p>As a border city, Windsor, Ont., is home to nurses who reside and work locally, but also a significant number who commute daily to hospitals in Detroit, Mich. Early in the pandemic, Detroit emerged as a “hot spot” partly due to significant <a href="https://doi.org/10.7759/cureus.7405">racial inequalities and health disparities</a> in the city’s population. </p>
<p>Detroit hospitals depend on their Canadian nurse employees. In 2016, <a href="https://www.workforcewindsoressex.com/wp-content/uploads/2017/12/Cross-Border-Employment-Report.pdf">20 per cent of the nurses working at Henry Ford Hospital were Canadian, and a total of 1,600 Windsor residents</a> reported working in health-care settings in Detroit. The continued ability of these hospitals to operate during and after the pandemic depends on the retention of Canadian personnel. </p>
<figure class="align-center ">
<img alt="A Canadian flag and an American flag in the foreground with a suspension bridge over a river behind them." src="https://images.theconversation.com/files/353478/original/file-20200818-24956-v85r41.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353478/original/file-20200818-24956-v85r41.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=385&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353478/original/file-20200818-24956-v85r41.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=385&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353478/original/file-20200818-24956-v85r41.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=385&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353478/original/file-20200818-24956-v85r41.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=484&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353478/original/file-20200818-24956-v85r41.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=484&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353478/original/file-20200818-24956-v85r41.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=484&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canadian and American flags fly near the Ambassador Bridge at the Canada-United States border crossing in Windsor, Ont., on March 21, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Rob Gurdebeke</span></span>
</figcaption>
</figure>
<p>In May and June 2020, our team interviewed 32 female and five male nurses living in Windsor and working in health-care settings in Windsor (20 nurses) or Detroit (17 nurses). They worked on intensive care units, COVID-specific units, labour and delivery units, in emergency departments and field hospitals, with experience in nursing ranging from 1.5 to 36 years. </p>
<h2>Concerns about family and mental health</h2>
<p>Nurses consistently reported increased mental health concerns, difficulties coping and substantial dissatisfaction with the level of support provided by their hospitals. </p>
<p>The support that nurses felt from their organization and managers varied from workplace to workplace and unit to unit. A few felt well supported, but many reported they were not valued, citing organizations that furloughed them, stopped employer contributions to retirement funds or did not provide adequate PPE. One participant noted: </p>
<blockquote>
<p>“I didn’t sign up for not having myself protected, you know, I think I deserve as a nurse to at least have that.” </p>
</blockquote>
<p>Despite increasing levels of depression and anxiety, there was a strong sense that referrals to employee assistance plans (EAPs) were not sufficient. Overall, we found that nurses were surprisingly resistant to the idea of formal mental health supports. They felt more comfortable seeking support from their coworkers or “work family” than non-nurse family/friends or organizational supports. Many expressed fears that seeking help from hospital administration would be perceived as a sign of weakness. One participant stated: </p>
<blockquote>
<p>“Heaven forbid, you say mental health or stress … because then they’ll take you from your unit, and say, put you at the front door as a greeter.”</p>
</blockquote>
<p>Nurses also expressed concerns about their own health and the health of family members. They described difficulties balancing quality patient care with “cluster care,” which limited their time in patient rooms, and the emotional toll of “death over Facetime” as one participant called it: holding electronic tablets as dying patients said their goodbyes to family. </p>
<p>They experienced difficulties navigating rapidly changing hospital policies (sometimes during a single shift), discrepancies between governmental and hospital recommendations, do not resuscitate orders that were either avoided or forced, and inadequate access to PPE. </p>
<p>Many reported sleep issues, nightmares, fatigue, increased irritability, increased alcohol consumption, unhealthy eating habits and use of sleep aids and cannabis. Many self-isolated from their families and missed out on the day-to-day moments and key developmental milestones of their children. One participant recounted: </p>
<blockquote>
<p>“I missed my kid’s entire crawling stage.”</p>
</blockquote>
<p>Many nurses spoke of inequity and moral injury. They expressed frustration about doctors and men with facial hair receiving better PPE, temporary employees (that is, travel nurses) getting better pay and/or hours, being reassigned to multiple units and doing non-nursing tasks like cleaning COVID-19 positive rooms. Nurses felt better prepared to be reassigned if they volunteered, but not if it was forced (and some were). </p>
<p>Some nurses were encouraged to purchase their own PPE to use at work, for example, face shields from Amazon or even dollar store raincoats. Almost everyone we interviewed expressed concern about second and third waves and whether the hospitals would be prepared.</p>
<h2>Heroes … but stigmatized</h2>
<p>Nurses expressed appreciation regarding the community responses (for example, clapping, food donations, skipping lines at businesses) but also felt a lot of stigma as potential “disease carriers.” One participant shared:</p>
<blockquote>
<p>“[The public] keep saying: ‘Oh, nurses are heroes. Doctors are heroes. They’re doing so much for us.’ You’re out in scrubs and they’re like, ‘They’re contaminated, get them away, they’re infectious.’” </p>
</blockquote>
<p>There were some differences in responses between nurses employed in Detroit and those working in Windsor. Overall, nurses working on the Michigan side of the border reported greater patient mortality, PPE shortages, community stigma and dissatisfaction with hospital administration. However, these findings are complicated by the much more rapid onset and greater intensity of the COVID-19 pandemic in Detroit compared to Windsor, and therefore can’t be interpreted with confidence.</p>
<p>Most nurses said that they were not planning on leaving nursing, but several are considering changing units or looking to a career change if the pandemic continues for many months or even years. Nurses also highlighted issues that the public may not be aware of: a moratorium on organ donation, decreased quality of care or risk of family-patient online meetings getting hacked.</p>
<p>Rapid intervention and availability of supports are needed to quickly address symptoms of mental health issues and reduce loss in the nursing workforce that has been observed after previous outbreaks, such as SARS, which could exacerbate a pre-pandemic shortage of nurses in Canada. </p>
<p>Nursing is a profession with a reputation for trustworthiness and dedication to quality care. As a community, we need solutions that go beyond a pat on the back and “hero” label, and instead address unsafe working conditions and offer practical effective support.</p><img src="https://counter.theconversation.com/content/143787/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jody Ralph receives funding from WE-SPARK Health Institute and the University of Windsor. </span></em></p><p class="fine-print"><em><span>Dana Ménard receives funding from WE-SPARK Health Institute and the University of Windsor.</span></em></p><p class="fine-print"><em><span>Kendall Soucie receives funding from WE-SPARK Health Institute and the University of Windsor.</span></em></p><p class="fine-print"><em><span>Laurie A. Freeman receives funding from WE-SPARK Health Institute and the University of Windsor</span></em></p>Nurses on both sides of the border report that they aren’t getting the support they need to feel safe on the job and maintain their own health and well-being during the COVID-19 pandemic.Jody Ralph, Associate Professor, Nursing, University of WindsorDana Ménard, Assistant professor of clinical psychology, University of WindsorKendall Soucie, Assistant Professor of Psychology, University of WindsorLaurie A. Freeman, Associate Professor, Nursing, University of WindsorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1439942020-08-20T20:16:15Z2020-08-20T20:16:15ZFriday essay: vizards, face gloves and window hoods – a history of masks in western fashion<figure><img src="https://images.theconversation.com/files/353787/original/file-20200820-22-c50i1h.jpg?ixlib=rb-1.1.0&rect=54%2C36%2C5898%2C3971&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/woman-wearing-stylish-protective-black-600w-1794076177.jpg">Shutterstock</a></span></figcaption></figure><p>Masks have emerged as unlikely fashion heroes as the COVID-19 pandemic has developed. Every conceivable colour and pattern seems to have become available, from <a href="https://www.syfy.com/syfywire/alien-facehugger-coronavirus-mask">facehuggers</a> to <a href="https://www.etsy.com/listing/800546489/star-wars-darth-vader-face-mask-with?source=aw&awc=10781_1596684726_ebd56f193b252d97cbc2ddf5fa6123f1&zanpid=10781_1596684726_ebd56f193b252d97cbc2ddf5fa6123f1&utm_medium=affiliate&utm_source=affiliate_window&utm_campaign=au_buyer&utm_content=78888&utm_term=141123">Darth Vader</a> to <a href="https://www.news.com.au/lifestyle/fashion/brides-wear-intricate-wedding-day-face-masks-amid-pandemic-photos/news-story/d821ddbfcc3c20f37ba1583fc5973bef">bejewelled bridal numbers</a>. </p>
<p>Many show how brevity and style can combine to protect the wearer, offsetting the fear the sight of a respiratory or surgical mask usually inspires. </p>
<p>Some, like those produced by not-for-profit enterprises including the <a href="https://www.thesocialstudio.org/">Social Studio</a> and <a href="https://www.secondstitch.org.au/product-page/fabric-face-mask">Second Stitch</a>, use on-trend fabrics and benefit both the wearer and the makers. Meanwhile, an Israeli jeweller has designed a <a href="https://www.independent.co.uk/life-style/coronavirus-face-mask-most-expensive-jeweller-israel-diamonds-yvel-a9665476.html">white gold, diamond-encrusted mask</a> worth US$1.5 million (A$2.1 million).</p>
<p>Yet, masks remain fundamentally unnerving. Mostly intended to either protect or disguise, they are designed to cover all or part of the face. In societies where emotions are <a href="https://www.nature.com/articles/srep22049">read through both eyes and mouth</a>, they can be disorienting. </p>
<p>In many places around the globe, masks have played an important role in conveying style, spirituality and culture for thousands of years. They have been a part of western fashion for centuries. Here are some of the highlights (and lowlights) of masks as fashion items.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-should-i-clean-my-cloth-mask-143974">How should I clean my cloth mask?</a>
</strong>
</em>
</p>
<hr>
<h2>Silenced by the vizard</h2>
<blockquote>
<p>“And make our faces vizards to our hearts/Disguising what they are”
– Macbeth </p>
</blockquote>
<p>One of the most bizarre accessories in 16th-century fashion was the vizard, an oval-shaped mask made from black velvet worn by women to protect their skin whilst travelling. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=879&fit=crop&dpr=1 600w, https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=879&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=879&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1105&fit=crop&dpr=1 754w, https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1105&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/351271/original/file-20200805-22-ifinzx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1105&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A woman wearing a vizard, c.1581, France.</span>
<span class="attribution"><span class="source">Wikimedia</span></span>
</figcaption>
</figure>
<p>In an age where unblemished skin was a sign of gentility, European women took pains to avoid sunburn or significant sun tan. Two holes were cut for the eyes, sometimes fitted with glass, and an indentation was created to accommodate the nose. Disturbingly, they did not always have an opening for the mouth. </p>
<p>To hold the mask in place, wearers gripped a bead or button between their teeth, prohibiting speech. To the contemporary feminist, the mask raises associations with the <a href="http://www.historyofmasks.net/famous-masks/scolds-bridle/">scold’s bridle</a>: a method of torture and public humiliation for gossiping women and suspected witches. </p>
<p>During the following century, masks continued to be fashionable although the guise of protection gave way to mystique and desire. The small “domino” mask – seen in a 17th century Netherlands example below and still worn by superheroes from Batman to Harley Quinn – <a href="https://enacademic.com/dic.nsf/enwiki/5634899#:%7E:text=Since%20the%2018th%20century%2C%20the,lord%22%20or%20%22master.%22">covered the eyes and tip of the nose</a>. It was usually made from a strip of black fabric. For warmer months, <a href="https://lh5.ggpht.com/qLmqR1dTpPwCsQVdjeLzan_MrgarWLemmWC7rGH1726niY2jcKrLrRyG3Dj0s-fh_U7M4NRHgec_frfG7mjq5YNzdMcE=s0">a lighter veiling</a> could be substituted.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="17th century engraving of woman wearing black eye mask and period clothing." src="https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=846&fit=crop&dpr=1 600w, https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=846&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=846&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1064&fit=crop&dpr=1 754w, https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1064&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/351258/original/file-20200805-493-1i3xlf0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1064&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The look for Winter by Wenceslaus Hollar (1643).</span>
<span class="attribution"><a class="source" href="https://lh4.ggpht.com/EFWFDmGMt2Fdio1emzvdfIXoO9J502nlD7b3JvZtkAPmddwg85nGbfVGqz5qGDxwYjIrJTx1Qeu12ishn30ZmWLjo-ag=s0">Rijksmuseum</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/beware-of-where-you-buy-your-face-mask-it-may-be-tainted-with-modern-day-slavery-142672">Beware of where you buy your face mask: it may be tainted with modern day slavery</a>
</strong>
</em>
</p>
<hr>
<h2>Masquerade and desire</h2>
<p>Venice has long been associated with masks, thanks to its <a href="https://www.venice-carnival-italy.com/what-is-the-venice-carnival/#/cart">history of carnival and masquerade</a>. Their theatrical nature might lead to an assumption masks were always worn to deceive or seduce. Travellers expecting a masked amoral free-for-all in the early 18th century <a href="https://www.google.com.au/books/edition/Venice_Incognito/EbUwDwAAQBAJ?hl=en&gbpv=1">were surprised</a> at how “innocent” the accessory really was in everyday life. </p>
<p>When worn at a masquerade, masks encouraged “safe” contact between the sexes – bringing them close enough to mingle but maintaining the social distance between strangers that etiquette required. In this scenario, masks also encouraged a kind of egalitarianism by allowing people of disparate <a href="https://www.jstor.org/stable/2738282?seq=1">social classes to mix</a> – a freedom never allowed in normal social gatherings. </p>
<p>The <a href="https://theculturetrip.com/europe/italy/articles/a-guide-to-the-masks-of-venice/">gnaga mask</a>, with its cat shape, allowed men to dress as women and skirt Venetian homosexuality laws. Venetian prostitutes were <a href="https://www.google.com.au/books/edition/Venice_Incognito/EbUwDwAAQBAJ?hl=en&gbpv=1">at various times prohibited from wearing or required to wear masks</a> in public, yet married women were required to wear masks to the theatre, fostering an association between masks and sex. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Venetian masks" src="https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353116/original/file-20200817-14-1l8dfw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Masquerades encouraged contact between the sexes while maintaining acceptable social distance.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1533022586528-2e09bde0959b?ixlib=rb-1.2.1&ixid=eyJhcHBfaWQiOjEyMDd9&auto=format&fit=crop&w=3142&q=80">Unsplash/Llanydd Lloyd</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Conversely, the infamous <a href="https://books.google.com.au/books?id=RMPZ76R-VqcC&printsec=frontcover">Harris’s List of Covent Garden Ladies</a>, published annually between 1757 and 1795, provided a catalogue of prostitutes to hire in London. One entry from 1779 described a woman who … </p>
<blockquote>
<p>by her own confession has been a votary to pleasure these thirty years, she wears a substantial mask upon her face, and is rather short. </p>
</blockquote>
<p>John Cleland’s controversial 1748 book <a href="https://www.gutenberg.org/files/25305/25305-h/25305-h.htm">Memoirs of Fanny Hill</a> describes Louisa, a prostitute, being made “violent love to” by a “gentlemen in a handsome domino” as soon as her own mask was removed. </p>
<h2>Charming possibilities</h2>
<p>“A mask tells us more than a face”, wrote Oscar Wilde in his 1891 dialogue <a href="https://www.gutenberg.org/files/887/887-h/887-h.htm">Intentions</a>, yet by the 19th century the mask as fashion accessory was <em>démodé</em>. Masks were generally only mentioned in newspapers and fashion magazines when referring to fancy dress and masked balls, which still took place in the homes of the wealthy. </p>
<p>“Society is a masked ball”, wrote <a href="https://cdnc.ucr.edu/?a=d&d=WBR18610209.2.8.6&srpos=1&e=-------en--20-WBR-1--txt-txIN-%22society+is+a+masked+ball%22-------1">one American columnist in 1861</a> mirroring Wilde’s famous quote, “where everyone hides his real character, and reveals it by hiding”. </p>
<p>Although masks were no longer recommended for maintaining a pale complexion, women’s faces were still covered by veiling in certain situations: including, for the first time, weddings. Ironically, <a href="http://nla.gov.au/nla.news-article227206624">one Australian fashion column</a> in 1897 decried the fashion, stating: </p>
<blockquote>
<p>Veils are largely responsible for poor complexions … This fine lace mask – for it is nothing else – hinders the circulation … but does far more injury by keeping the face heated.</p>
</blockquote>
<p>As if this were not enough, veils blew dust from the street into “open pores” and retained dirt, redistributing it onto the skin every time it was worn.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Advertisement for Rowley's Toilet Mask shows woman with rubber face shield." src="https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=473&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=473&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=473&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=595&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=595&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353756/original/file-20200820-20-143sc2g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=595&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A precursor to today’s sheet beauty treatments.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/sv/editorial/image-editorial/advert-for-madame-p-rowleys-toilet-mask-1895-9805233a">Shutterstock</a></span>
</figcaption>
</figure>
<p>Veiling still had some fans, who touted its health and beauty benefits, and connotations of intrigue and excitement. <a href="http://nla.gov.au/nla.news-article138628599">“It suggests such charming possibilities beneath it”</a>, a columnist in The Australasian wrote in 1897.</p>
<p>Fashionable or not, some masks were still worn behind closed doors. Enter the most bizarre masked accessory since the vizard: the toilet mask or “face glove”.</p>
<p>Devised by a Madame Rowley in the 1870s-80s, the rubberised full-face covering was <a href="http://nla.gov.au/nla.news-article102705392">advertised as an</a>: </p>
<blockquote>
<p>aid to complexion beauty … treated with some medicated preparation … the effects of the mask when worn at night two or three times in the week are described as marvellous. </p>
</blockquote>
<p>Advertisements for these <a href="https://www.beautifulwithbrains.com/beauty-history-madame-rowleys-toilet-mask/">precursors to today’s sheet mask beauty treatments</a> contained testimonials from women who claimed to be cured of freckles and wrinkles. </p>
<h2>Veils and visors</h2>
<p>The advent of the automobile in the early 20th century brought a whole new fashion range into the public arena. Motorists needed protection from weather, dust and fumes, so accessories had to be practical. For women, protection took the fashionable form of coats and face coverings.</p>
<p>Veils and hoods were wrapped around stylish large hats of the day, and fastened under the chin so that the entire face was safely covered. </p>
<p>Advertisements in the early 1920s describe a “<a href="https://cdnc.ucr.edu/?a=d&d=SDI19210814.2.115&srpos=1&e=-------en--20-SDI-1--txt-txIN-%22complete+face+mask%22-------1">complete face mask</a>” for drivers – ostensibly men as the accessory “buttoned to the cap and [is] equipped with an adjustable eye shield against glaring headlights”. </p>
<p>A design for women in 1907 was described as a <a href="https://digitalcollections.nypl.org/items/510d47e1-1ea0-a3d9-e040-e00a18064a99">“window hood”</a>, which completely engulfed the hat beneath and closed with a drawstring around the neck. It had a gauze “window” for the eyes and another smaller opening at the mouth.</p>
<p>By the swinging 1960s, the cultural and sartorial landscape couldn’t have been more different – and yet, masks made an unlikely appearance in “<a href="https://www.vogue.com/article/60s-space-age-fashion#:%7E:text=The%20space%20race%20in%20the,envisioned%20as%20the%20next%20frontier.&text=Chin%2Dstrap%20space%20bonnets%2C%20flat,for%20a%20new%20sartorial%20stratosphere.">space age</a>” fashion championed by designers such as André Courrèges and Pierre Cardin. Metallic mini dresses and one-piece suits were topped with “space helmets” that left an opening for the entire face or eyes. </p>
<p>More commonly adopted were plastic visors worn separately or as part of a hat, sometimes covering forehead to chin and taking on the appearance of a welders’ shield – or indeed, the <a href="https://www.health.gov.au/resources/publications/coronavirus-covid-19-face-shields-a-quick-guide">face shields worn by health workers</a> today. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/WoT2z14YemI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Plastic fantastic looks of the sixties.</span></figcaption>
</figure>
<p>Sunglasses, a kind of mask in their own right, were taken to the extreme by Courrèges with his infamous solid white shades with only a slit for light. Life described this as a <a href="https://books.google.com.au/books?id=8VIEAAAAMBAJ&printsec=frontcover">“built-in squint”</a> in 1965 - a design that “dangerously narrows the field of vision”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-fashionable-history-of-social-distancing-134464">The fashionable history of social distancing</a>
</strong>
</em>
</p>
<hr>
<h2>What goes around …</h2>
<p>Discussions during the 1918-19 Spanish flu pandemic around whether masks would be a fad, how long they would be required, and how to create your own at home, seem eerily prescient now. </p>
<p>This darkly comic mask from 1918 demonstrates the same wish for ingenuity and levity that exists today: </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Man wears white face mask with black skull and cross." src="https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=896&fit=crop&dpr=1 600w, https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=896&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=896&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1126&fit=crop&dpr=1 754w, https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1126&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/351353/original/file-20200805-22-grtbgf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1126&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The skulls and cross bones embellishment was a joke, rather than standard issue in 1919.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/statelibraryofnsw/3481163841/">State Library of NSW/Flickr</a></span>
</figcaption>
</figure>
<p>Lebanese fashion designer Eric Ritter has sported <a href="https://www.insider.com/most-creative-face-masks-people-have-designed-2020-5#people-have-hid-their-lower-faces-behind-graphics-like-a-skull--17">a similarly macabre aesthetic</a>. He was already thinking and <a href="https://www.instagram.com/p/B7CDivfJPZJ/?utm_source=ig_embed">writing about masks</a> on Instagram in January before coronavirus spread around the world …</p>
<blockquote>
<p>On growing up without a mask</p>
<p>On being forced to wear a mask</p>
<p>On ecstatically removing a mask</p>
<p>On picking a mask back up</p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person in pink hood with decorative face covering" src="https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=601&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=601&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=601&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=755&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=755&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353769/original/file-20200820-24-xa4cav.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=755&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Beirut designer Eric Ritter.</span>
<span class="attribution"><a class="source" href="https://www.instagram.com/p/B7CDivfJPZJ/">ericmathieuritter/Instagram</a></span>
</figcaption>
</figure>
<p>In Australia, entertainer Todd McKenney has launched an <a href="https://toddmasks.com/todd-masks-launches/">online marketplace</a> for costume designers to make and sell one-of-a-kind masks directly to the public. </p>
<p>Face masks don’t have to be created by artists, designers or couture fashion houses to make them appealing. But a look through our fashion history shows that ingenuity and humanity have long influenced our face wear – whether for the purposes of allure, space travel or pandemic protection.</p><img src="https://counter.theconversation.com/content/143994/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lydia Edwards does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Masks have a chequered history in western fashion. Some silenced women in the name of beauty, others provoked sexual desire.Lydia Edwards, Fashion historian, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1432372020-08-19T12:20:31Z2020-08-19T12:20:31ZSketchy darknet websites are taking advantage of the COVID-19 pandemic – buyer beware<figure><img src="https://images.theconversation.com/files/353477/original/file-20200818-24815-1ex4lpu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5304%2C3594&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Black markets thrive online and flourish during pandemics and other crises.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/protective-surgical-masks-on-white-backrgound-money-royalty-free-image/1216144535?adppopup=true">Marko Klaric/EyeEm via Getty Images</a></span></figcaption></figure><p>Underground markets that sell illegal commodities like drugs, counterfeit currency and fake documentation tend to flourish in times of crisis, and the <a href="https://impakter.com/black-markets-shaped-the-covid-19-crisis/">COVID-19 pandemic is no exception</a>. The online underground economy has responded to the current crisis by exploiting demand for COVID-19-related commodities. </p>
<p>Today, some of the most vibrant underground economies exist in <a href="https://www.investopedia.com/insights/what-dark-net/">darknet markets</a>. These are internet websites that look like ordinary e-commerce websites but are accessible only using special browsers or authorization codes. Vendors of illegal commodities have also formed dedicated group-chats and channels on encrypted instant messaging services like WhatsApp, Telegram and ICQ. </p>
<p>The <a href="https://ebcs.gsu.edu/project/darknet-analysis/">Darknet Analysis</a> project at the <a href="https://ebcs.gsu.edu/">Evidence-Based Cybersecurity Research Group</a> here at Georgia State University collects data weekly from 60 underground darknet markets and forums. My colleagues <a href="https://scholar.google.com/citations?user=Ussl738AAAAJ&hl=en">Yubao Wu</a>, <a href="https://scholar.google.com/citations?user=px5AJoYAAAAJ&hl=en">Robert Harisson</a> and <a href="https://www.researchgate.net/profile/David_Maimon">I</a> have analyzed this data and found that three major types of COVID-19 offerings have emerged on darknet markets since late February: protective gear, medications and services that help people commit fraud.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Darknet website product page showing COVID-19 antibody test" src="https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=355&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=355&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=355&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=446&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=446&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353459/original/file-20200818-24-1of2iwp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=446&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">If it’s an in-demand COVID-19 commodity, chances are it’s available on darknet markets.</span>
<span class="attribution"><span class="source">Screenshot by David Maimon</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Using these darknet markets is risky business. First, there’s the built-in risk of becoming the victim of a scam or <a href="https://theconversation.com/buyer-beware-counterfeit-markets-can-flourish-during-a-public-health-crisis-134492">buying counterfeit products</a> when purchasing products from underground vendors. There are also health and legal risks. Inadvertently buying ineffective COVID-19 protective gear and dangerous remedies from unregulated sellers could physically harm buyers. And purchasing information and services with the aim to defraud people and the government is a criminal offense that carries legal penalties.</p>
<h2>Personal protective equipment</h2>
<p>Several vendors have added protective gear such as face masks, protective gowns, COVID-19 test kits, thermometers and hand sanitizer to their list of products for sale. The effectiveness of this protective gear is questionable. Underground vendors typically do not disclose their products’ sources, leaving consumers with no way to judge the products. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Darknet website product page showing protective gown" src="https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353455/original/file-20200818-16-njmabz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">COVID-19 protective gear is a common product type on darknet e-commerce sites.</span>
<span class="attribution"><span class="source">Screenshot by David Maimon</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>One example of the uncertainties that surround protective gear effectiveness comes from one of the encrypted channel platforms we monitored during the first few days of the pandemic. Vendors on the channel offered facemasks for sale. Demand for facemasks was very high at that time, and people around the world were scrambling to find facemasks for personal use. </p>
<p>While governments and suppliers faced difficulties in meeting demand for facemasks, several vendors on these platforms posted ads offering large quantities of facemasks. One vendor even uploaded a video showing many boxes of facemasks in storage. </p>
<p>Given the global shortage of facemasks at the time, our research team found it difficult to understand how this vendor in Thailand could offer so many for sale. One disturbing possibility is that they sold used facemasks. Indeed, authorities in Thailand <a href="https://www.youtube.com/watch?v=k92TTXZe77E&feature=youtu.be">broke up an operation</a> that washed, ironed and boxed used facemasks and supplied them to underground markets.</p>
<h2>Treatments</h2>
<p>Darknet vendors are also selling medications and cures, including effective treatments, like <a href="https://theconversation.com/remdesivir-explained-what-makes-this-drug-work-against-viruses-137751">Remdesivir</a>, and ineffective treatments, like <a href="https://theconversation.com/why-hydroxychloroquine-and-chloroquine-dont-block-coronavirus-infection-of-human-lung-cells-143234">Hydroxychloroquine</a>. They’re are also selling various purported COVID-19 antidotes and serums. Some vendors even offer to sell and ship oxygen ventilators.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Darknet website product page showing Hydroxychloroquine pills" src="https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=258&fit=crop&dpr=1 600w, https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=258&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=258&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=324&fit=crop&dpr=1 754w, https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=324&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/353456/original/file-20200818-18-18na4f4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=324&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Darknet markets offer ineffective and potentially dangerous COVID-19 therapies, including hydroxychloroquine, which studies have shown is not an effective treatment.</span>
<span class="attribution"><span class="source">Screenshot by David Maimon</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Using COVID-19 medications purchased on darknet platforms could be dangerous. Uncertainties about the true identity of medication manufacturers and the ingredients of other cures leaves patients vulnerable to a wide array of potentially detrimental side effects. </p>
<p>[<em><a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=experts">Expertise in your inbox. Sign up for The Conversation’s newsletter and get expert takes on today’s news, every day.</a></em>]</p>
<h2>DIY fraud</h2>
<p>Government efforts to relieve the financial stress on individuals and businesses from the economic impact of the pandemic has led to a third category of products on these markets. We have observed many vendors offering to sell online fraud services that promise to improve customers’ financial circumstances during this crisis. </p>
<p>These vendors offer to either support customers in putting together fake websites that allow them to lure victims into disclosing their personal information, or simply provide stolen personal information. The stolen information can be <a href="https://www.fbi.gov/news/pressrel/press-releases/fbi-sees-spike-in-fraudulent-unemployment-insurance-claims-filed-using-stolen-identities">used to file for unemployment benefits</a> or obtain loans. Some vendors go a step further and offer support in the fraudulent benefits application process. </p>
<p>COVID-19-related fraud could have grave consequences for individuals whose identities have been stolen and used to apply for government benefits or loans, including the loss of future government assistance and damage to credit scores. Fraudulent requests for COVID-19 relief funds filed using stolen personal information also puts additional strain on federal, state and local governments. </p>
<h2>Digging up the data</h2>
<p>The size of the online illicit market of COVID-19 essentials is unknown. We aim to collect enough data to provide an empirical assessment of this underground economy. </p>
<p>There are several challenges to understanding the scope of the COVID-19 underground market, including measuring the magnitude of the demand, the extent supply meets that demand and the impact of this underground economy on the legitimate market. The unknown validity of darknet customers’ and vendors’ reports about the products they purchased and sold also makes it difficult to assess the underground market. </p>
<p>Our systematic research approach should allow us to overcome these issues and collect this data, which could reveal how online underground markets adjust to a worldwide health crisis. This information, in turn, could help authorities develop strategies for disrupting their activities.</p><img src="https://counter.theconversation.com/content/143237/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Maimon receives funding from the National Science Foundation. </span></em></p>The global pandemic has fueled illicit online sales of COVID-19 commodities, some of which are dangerous or illegal. Researchers are assessing the size and reach of this underground market.David Maimon, Associate Professor of Criminal Justice and Criminology, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.