A group of public health and infection
prevention doctors in South Africa have urged the National Coronavirus Command
Council to add the wearing of homemade masks by members of the public as an
additional essential tool to fight the spread of COVID-19 in South Africa.

The doctors from TB Proof and the Public
Health Action Team (PHACT) have started the #Masks4allinAfrica
campaign which forms part of the global #Masks4All initiative aimed at
encouraging governments to follow  scientific evidence that shows that the spread
of the virus can be slowed down if everyone wear homemade masks when they leave
their homes.

In the letter (below) to the South Africa’s
Cornavirus Command Council, Drs Helene-Mari van der Westhuizen (TB Proof), Dr
Nathan Green (PHACT), Dr Atiya Mosam (PHACT), Dr Dirk von Delft (TB Proof), Dr
Jesse L Werner (PHACT) and Dr Arne von Delft (TB Proof) explain how adding
homemade masks to the current tools such as regular handwashing, social distancing,
sanitising and widespread testing could assist in flattening the curve.


A rapidly changing world and rapidly
changing research

The COVID-19 pandemic has caught the world
and South Africa off guard. What started out as a seemingly mild disease
in a distant land, has become a formidable threat to our health
system, our economy, our societies and every South African. As the pandemic
exponentially changed gears, opinions and evidence about the disease and
how to control it have shifted too. This has been complex for decision makers,
as ‘evidence-based’ statements made confidently one day, turned out to be less
clear or even incorrect the next. This is not due to poor decision-making but
reflects the rapid influx of new and changing information. What usually takes
years, is happening in days. Some of the sweeping interventions implemented in
South Africa seemed unthinkable just weeks before. Closing borders, restricting
movement, closing schools and business and physical distancing have all been
instituted based-on expert opinion, learning from other countries, or rapidly
developed scientific models.

Public mask use has been a specific bone of
contention. Countries like China, Hong Kong, Korea, Japan and very
recently the Czech Republic, are advocating for widespread mask use in the
general population, and others have given exactly the opposite advice. Many,
like the United States, are at a point where they are reconsidering their
recommendation. This has been further complicated by the impact of the general
public stockpiling masks, contributing to severe shortages for healthcare
workers on the frontline of combating this pandemic.

Health facilities have the greatest need
for masks

In health facilities across South Africa,
health workers depend on N95 respirators, surgical masks, goggles and gloves to
keep them safe at work, not only from COVID-19, but also from diseases like
tuberculosis (TB) and HIV. There is a critical global shortage of protective
equipment, which means all N95 respirators and surgical masks should be
reserved for use in healthcare settings. We are heartened to see organisations
and individuals donating any stock they have to their nearest health facility
and strongly encourage more people to do the same.

But what about everybody else?

When looking at mask use in public it is
important to consider two perspectives. Firstly, as a healthy member of the
public, does wearing a mask decrease my risk of becoming infected? Secondly, as
somebody who may already be infected (even if I don’t know it), does a mask
help me to prevent spreading my infection to others?

Considering the first instance, the
research is limited, but masks appear to be helpful if you are in very close
contact with someone who is infectious. When the roles are reversed, the
evidence is much stronger. Hence the #Masks4All slogan: I protect you, you
protect me. Wearing a mask reduces the spread of infectious droplets,
especially when someone coughs or sneezes, for diseases like COVID-19, influenza and TB.
The WHO and other experts are in agreement and advise anyone with respiratory
symptoms to wear a mask. However, a growing body of evidence suggests that
nearly half of people with SARS-CoV-2 (i.e. the virus that causes COVID-19
disease) do not have symptoms. In China and Singapore they have shown between
6.4 – 12.6% of people who developed COVID-19, were infected by someone who
did not show any symptoms.

The risk of asymptomatically and
unknowingly spreading COVID-19 is the main reason for considering public mask
wearing. If we ask South Africans to wear masks in public, they can protect
each other. This is in keeping with the principle of physical distancing, where
everyone considers themselves infectious and behaves in a manner aimed at
reducing the spread of the disease. Masks can help us protect each other, when
visiting the grocery store, taking a sick relative for healthcare, collecting a
social grant, or using public transport.

Furthermore, masks in South Africa would
have added benefits. We are facing a concurrent major health crisis, TB, which
is our leading cause of death. The COVID-19 pandemic is predicted to have a
very negative impact on TB prevention and care. This may lead to increased
deaths, with TB patients, whether cured or currently under treatment, having
an increased risk of severe COVID-19 disease. There is evidence that surgical masks help
reduce the spread of TB by 56% if worn by somebody with symptoms. We will
take any additional help we can get to curb our TB epidemic.

Another potential benefit of encouraging
widespread community mask use is that it could destigmatise mask wearing in
countries like South Africa, where masks are commonly associated with feared
illnesses like drug-resistant TB. This may encourage people who have symptoms
of any respiratory illness, to wear a mask in public. This is based on TB
Proof’s experience with past #UnmaskStigma campaigns
and echoed by global public health experts: “If everyone
wears a mask, no stigma is attached

We have made the argument that masks are
important for health workers and could also help the public to limit
symptomatic and asymptomatic spread, but we currently have a global shortage.
So, where does this leave us?

Homemade masks as a compromise

Homemade masks have been suggested as
 to scarce medical masks for members of the public,
but what does the evidence say about them? In short – they are not as effective
as surgical masks – but cloth masks can protect others by reducing the spread
of contagious droplets from infected individuals to uninfected people.

 Studies tested cloth masks in
comparison to surgical masks in healthy volunteers to see whether they help to
capture infectious droplets. They concluded that:

type of general mask use is likely to decrease viral exposure and infection
risk on a population level, in spite of imperfect fit and imperfect adherence

A hand-fashioned
mask can provide a good fit and a measurable level of protection

homemade mask …would be better than no protection

Only one randomized control trial (one
of the most authoritative forms of evidence) has been done comparing cloth
masks to surgical masks and this has found that surgical masks are superior to
cloth masks in a healthcare setting to protect healthcare workers. Some experts
have pointed to this finding to advise against the use of cloth masks by the public,
but this is missing the point. Compared to no masks at all, cloth masks are the
better option. This is in a context where the public are being urged to
wear masks on public transport. If we want to keep healthcare supplies from
being used outside of healthcare facilities where they are essential equipment,
we need to provide the public with the best possible alternative. The details
around how to make cloth masks safely remain very important. Thankfully there
are numerous guides available to help members of the public, including
information on designs, safe use and appropriate cleaning.

This is something you can do

Our Minister of Health, Dr Zweli Mkhize,
has endorsed the use of masks for people who have a cough, or in
situations where physical distancing is difficult. While this is a step in the
right direction, it does not highlight the importance of considering everybody
as potentially infectious, and the subsequent need for masks for all.

Fortunately, an about-face is upon
us. TB
Proof and PHACT are leading a 
 calling on President Ramaphosa to commit to #Masks4All. It
has already been signed by twelve leading health and civil society
organisations and numerous individuals, committing to help make alternative
masks and protect scarce healthcare resources. On 2 April, in response to
growing evidence, the Western Cape became the first province to recommend
the use of cloth masks for the general publi

We call on South Africa’s National
Coronavirus Command Council to:

Help mobilise South Africa through publicly
encouraging our creative and resourceful citizens to make and share cloth masks
on a mass scale.

Provide technical guidance on the best
materials and designs for making masks at home or places of work or learning.

Use existing communication platforms for
widespread public education on correct and safe use.

Lead by example and appear in public
wearing a cloth mask.

Take all steps necessary to ensure
healthcare settings are safe for all, including uninterrupted access to N95
respirators and surgical masks for health workers.

We call on all South Africans to join
the global #Masks4All movement,
because if I protect you, you protect me.

Authored by Dr Helene-Mari van der
Westhuizen (TB Proof), Dr Nathan Green (PHACT), Dr Atiya Mosam (PHACT), Dr Dirk
von Delft (TB Proof), Dr Jesse L Werner (PHACT) and Dr Arne von Delft (TB