Abstract
The use of masks protects individuals from the spread of COVID-19 and control the source of transmission through droplets, but with limited medical masks, a cloth face mask can be used as an alternative personal protection from COVID-19. This study aimed to describe the use of cloth face mask as an alternative personal protection during the pandemic. WHO recommends the use of non-medical masks both at home and in public places. The use of face masks is a WHO’s recommendation on April 6, 2020. Medical masks are categorized as medical waste, then the disposal must be appropriate to prevent COVID-19 transmission in community. Cloth face mask can be used repeatedly and washed, its use can be adjusted to face. However, using a face mask alone is not enough to provide an adequate protection level. Other steps must be taken, such as washing hands with hand soap in running water, keeping a physical dis- tance of minimum one meter from people, especially from those showing respiratory tract symptoms (coughing, sneezing), cleaning items touched by hands of people such as door handles and handles stairs. Therefore, the use of cloth face mask must be carried out together with clean and healthy living behaviors.
Keywords: cloth face mask, COVID-19, Indonesia, mask crisis, pandemic
The Use of Cloth Face Mask during the Pandemic Period in Indonesian People
Ririh Yudhastuti
Department of Environmental Health, Faculty of Public Health, Universitas Airlangga, Indonesia
Introduction
Coronavirus is a large family of viruses that cause dis- eases, ranging from mild to severe symptoms.
Coronavirus disease 2019 (COVID-19) is a new type of disease that has never been identified before in humans.
In December 31, 2019, the World Health Organization (WHO) China Country Office reported a case of pneu- monia of unknown etiology in Wuhan City, Hubei Province, China. On January 7, 2020, China identified pneumonia of unknown etiology as a new type of corona - virus (coronavirus disease, COVID-19). In January 30, 2020, WHO has designated the Public Health Emergency of International Concern (PHEIC). The increase in the number of COVID-19 cases took place quite quickly and there has been a spread between countries.1
Common signs and symptoms of COVID-19 infection include symptoms of acute respiratory disorders such as fever, coughing, and shortness of breath. The average in- cubation period is 5 - 6 days with the longest incubation period of 14 days. In severe cases, COVID-19 can cause pneumonia, acute respiratory syndrome, kidney failure, and even death.1 As of May 18, 2020, a total of
4,628,903 confirmed cases were reported with a total of 312,009 deaths where cases were reported in 216 coun- tries or regions.2The total number of confirmed cases in Indonesia up to May 19, 2020, was 18,010 cases with a mortality rate of 6.6%.3
Several behaviors have been recommended to limit the spread of COVID-19 to be carried out, which is the same as in the influenza pandemic, such as washing hands, limiting social distance and coughing, and sneez- ing.4In addition, WHO has recommended the commu- nity to use face masks.5,6Several studies also suggest the use of face masks in public places.7,8
Medical masks must be provided for health workers.9 The use of medical masks in the community will cause a shortage of masks for health workers.6The impact of the COVID-19 pandemic, such as people's fear of the dis- ease, causes people flock to buy face masks and some even hoard them. This results in a mask vacuum and sky- rocketing mask prices.10
The Centers for Disease Control and Prevention (CDC) recommends the use of cloth face mask in public settings, especially in significant community-based trans-
DOI: 10.21109/kesmas.v15i2.3945
Correspondence*: Ririh Yudhastuti, Department of Environmental Health Faculty of Public Health, Universitas Airlangga, Airlangga Street, Surabaya City, East Java, Indonesia, E-mail: [email protected], Phone: +62-878-5486-2677
Received : May 30, 2020 Accepted : May 31, 2020 Published : July 31, 2020
mission areas. The CDC also recommends the use of a simple face-covering mask to slow the spread of the virus and help people who might have the virus, but not know it from spreading it to others.11The recommended cloth face mask is not a surgical mask or an N-95 respirator.
Surgical masks or N-95 respirators are critical supplies that must be continuously reserved for health workers and other first medi cal respondents.11
The use of face masks protects individuals from the spread of COVID-19 and control the source of transmis- sion through droplets of others, but with limited medical masks, a cloth face mask can be used as an alternative personal protection from COVID-19. This study aims to describe the use of cloth face mask as an alternative per- sonal protection during the pandemic.
Method
In a commentary, the authors sought to present new views to researchers about certain topics. Commentary can also draw attention to current progress and speculate on the direction of certain topics in the future. Therefore, the authors review scientific texts and messages pub- lished in the mass media and scientific articles as well as social life about the use of face masks during the COVID- 19 pandemic. Also, the authors use prior knowledge and experience, particularly regarding information on the use of cloth face masks during the COVID-19 pandemic in Indonesia. In this commentary, the author attempts to account for any information published during the corona virus crisis.
Results and Discussion
Since the outbreak of the coronavirus (COVID-19), there have been battles related to the use of face masks in the community. Sometime before, WHO is still incon- sistent in the use of masks in the community. On January 2020, WHO did not recommend the use of face masks in healthy individuals in the community (mass making) as a way to prevent the transmission of COVID-19 in the in- terim guidelines dated on April 6, 2020.12,13The United Kingdom Public Health has made similar recommenda- tions, however, the United States Centers for Disease Control and Prevention has recommended the use of cloth face masks outside home or public places and the action is followed by other countries, such as Canada and South Korea. Initially, the purpose of using face masks was to protect oneself, then for reasons of public health, the use of face masks is to protect each other be- tween people from asymptomatic COVID-19 transmis- sion sources.14,15From a workshop organized by WHO in 2019, the workshop concluded that although there was no evidence of trials of effectiveness in reducing corona virus transmission, WHO recommended that the use of a severe influenza pandemic mask wear in the
community should be considered.15,16Concern about the insufficient supply of masks in the community is because a medical mask must be provided for health workers.
While, to control the source of COVID-19 and protect yourself, the use of a cloth face mask (non-medical) is sufficient for protection, especially if everyone uses it.
Fabric masks are easily made at home and reused after washing.16In Indonesia, the need for face masks in the community is increasing, especially after the Indonesian Government recommends to always use masks while do- ing activities outside home.17 It is recommended to at least use a cloth face mask to prevent the coronavirus transmission which is increasing and spreading across provinces and districts in Indonesia.
A research on influenza, influenza-like illness, and coronavirus in humans provides evidence that the use of medical masks can prevent the spread of sparks that can cause transmission from the infected people to other peo- ple and the air contamination due to the sparks. There is an evidence that the use of medical masks by healthy peo- ple at home or by people who come in contact with peo- ple infected with COVID-19, as well as in a crowd, face masks can serve as limited prevention, although there is currently no evidence that using face masks (either med- ical masks or other types) by healthy people in the com- munity at large, including the use of face masks together in the wider community, can prevent people from respi- ratory tract infections, including COVID-19.18 The Indonesian Government’s policies recommend that medi - cal masks should be provided for health workers. The use of medical masks by the public can create a false sense of security, so that other health measures such as maintaining hand hygiene and physical distance are ig- nored, and there is still a practice of touching the face be- hind the mask and under the eyes. Some suggestions such as maintaining a physical distance of approximately one meter, avoiding crowds of people (more than five people) and washing hands in running water with hand soap for 30 seconds is a very helpful role in preventing the trans- mission of COVID-19.19,20
WHO and decision-makers can continue to advocate the use of non-medical masks both outdoors and indoors.19In such places, the following points related to non-medical masks must be considered, such as 1) the number of layers of cloth / tissue, 2) the ease of breathing given to the user of the mask material 3) the waterproof or hydrophobic nature 4) the shape of the mask 5) con- formity to face shape and 6) mask size.
Several types of masks that are available in the com- munity:
1. Cloth face mask,20,21
Cloth face masks can be used to prevent transmission, while anticipating the scarcity of masks that occur in markets such as pharmacies and health stores. Fabric
masks made need to have three layers, namely a water- proof non-woven layer (front), microfiber melt-blown non-woven fabric (middle), and ordinary non-woven fab- ric (rear). Cloth masks need to be washed and can be worn many times. The material used for fabric masks is cotton, scarf, and so on. This type of mask can be used in public places and other facilities while maintaining a safe distance of 1 - 2 meters. A three-layer fabric mask can filter the air and ward off viruses by up to 70%.
Ways and models of fabric masks can be adjusted to the face and not loose. Masks can be sewn manually or using machines, the use of these masks is important, consider- ing the spread of the virus through the nose, mouth, and eyes carried by human fingers. The use of cloth face masks can be indoors or outdoors.22,23
Fabric mask treatments can be washed using deter- gents with less rubbing, so that the fabric pores do not widen and should be used for four hours to prevent con- tamination by other microorganisms like bacteria such as Escherichia coli, Enterobacter aeruginosa, Shigella sp., Staphylococcus aureus, and fungus / fungi Aspergillus sp., Penicillium sp., and Candida sp.because the cloth face mask becomes moist. The average temper- ature of 27oC and 75% relative humidity are preferred by microorganisms including bacteria, viruses, or fungi / fungus.9 It is important to note that cotton cloth face masks are not considered suitable for health workers.
Regarding fabric masks as Personal Protective Equipment (PPE), the production of cloth face masks for use in health service facilities is proposed to be carried out locally if the supplies are inadequate or run out.
WHO stresses that medical masks and respirators must be prioritized for medical workers or health workers.
24,25
2. N95 mask,26
N95 mask is one of the protective or filter particles that are harmful to the users. However, the N95 mask can only function for dirt and dust, not for gas and steam.
Even so, N95 mask can protect its users from droplets, particles which are 0.1 micron in size and have an effec- tiveness of up to 95%. Medical personnel use particulate respirators with at least equivalent protection to N95 cer- tified by the US National Institute of Occupational Safety and Health, code 95 means that it can filter out airborne particles as much as 95%. In the N95 mask, there are three levels of mask filtering which are divided into three levels of filtering, namely FFP1, FFP2, and FFP3. FFP1 means filtering out at least 80% of particles in the air, FFP2 means filtering out at least 94% of particles in the air, and FFP3 means filtering out at least 99% of particles in the air. From this explanation, it can be interpreted that FFP2 has almost the same standard with an N95 mask, whereas FFP3 is the same as an N99 mask.26
Medical personnel use particulate respirators with pro- tection at least equivalent to N95 certified by the US National Institute for Occupational Safety and Health, European Union standard FFP2, or equivalent, when car- rying out or working in the place of carrying out proce- dures that produce aerosols, such as tracheal intubation, ventilation noninvasive, tracheotomy, cardiac pulmonary resuscitation, manual ventilation before intubation, and bronchoscopy.25,26
3. Surgical masks,21,22,26
This type is a mask easily found in the nearest store or pharmacy. Usually, surgical masks are green or blue.
Surgical masks have a function for protecting the users from drops of large particles or splashes of water from a person's mouth. However, it has not been able to protect against airborne particles. Surgical masks have a filtra- tion effectiveness of 0.1 microns 10 to 95%.
4. Facepiece respirator,26
A facepiece respirator or gas mask serves to protect themselves from harmful gases and vapors. This mask does not filter out airborne particles unless it is designed to have a filter to block it. Among others, masks that cov- er almost the entire surface of the face are usually de- signed to protect users from big and small splashes, with- out leakage and effectiveness of up to 99%. This mask can be used repeatedly after disinfection according to rec- ommendations from WHO. Facepiece respirators are rarely encountered every day because they are usually on- ly used by workers in the gas field or jobs with high levels of contamination. In addition to the masks above, there are still N99, N100, and P95 masks.
Management of the use of mask,27,28
The use and disposal of masks regardless of the type are important to be done properly to ensure they are ef- fective and to avoid increased transmission. The follow- ing information on the proper use of masks is taken from practices in health care facilities,28:
1. Place the mask carefully, and ensure the mask covers the mouth and nose and attaches it firmly to minimize the distance between the face and the mask
2. Avoid touching the mask while it is used
3. Take the mask off with the correct technique: do not touch the front of the mask, but remove the mask from the back
4. After removing or whenever you accidentally touch the mask used, clean your hands with alcohol-based antiseptic liquid or soap/detergent with running water if hands look dirty
5. If the mask becomes moist, it must be replaced imme- diately with a new mask that is clean and dry
6. Disposable masks are not used anymore
7. Take off and discard the disposable mask after use Education on proper disposal of the masks must be actively delivered to the community, and people must learn how to properly handle the masks. For this reason, the government urges the public to dispose the used masks to spray disinfectants first. Then you should re- member that, before removing the mask, please cut it first. The waste masks used by the people have been cate - gorized as potential medical waste in toxic and hazardous waste. After that, wrap it in clear plastic as a marker of mask waste. Trash have to be closed if necessary with a prominent logo, so that people can quickly find it. In ad- dition to not polluting the environment and disturbing public health, this is because the waste masks can contain various microorganisms that cause disease in humans. In addition there are other microorganisms as secondary in- fections in mask waste, so that mask waste is categorized as medical waste, so that the management of mask waste is the same as the medical waste standard operating pro- cedure (SOP). It is hoped that by following the stages of management of used masks, the potential risk for trans- mission due to misuse of masks can be avoided. In addi- tion, the habit of washing hands before and after using a mask will minimize the potential for transmission of virus, such as the SARS-CoV-2 virus which causes COVID-19.29,30
Conclusion
During a pandemic, the use of cloth face masks can reduce the COVID-19 transmission and should be fol- lowed by washing hands with hand soap in running wa- ter, physical distancing and avoiding crowds of people.
Abbreviations
COVID-19: Coronavirus Disease 2019; WHO: World Health Organization; PHEIC: Public Health Emergency of International Concern; CDC: Centers for Disease Control and Prevention; PPE:
Personal Protective Equipment; SOP: Standard Operating Procedure.
Ethics Approval and Consent to Participate
Permission to use this data has been approved by the Ministry of Health of the Republic of Indonesia through the COVID-19 Task Force.
Competing Interest
The author states that there are no competing interests to disclose.
Availability of Data and Materials
Data is available in the COVID-19 Task Force text of the Ministry of Health, Republic of Indonesia and existing literature related to the use of masks for literature review.
Authors’ Contribution
The study has been carried out independently by Ririh Yudhastuti, start from designing research, studying design, analysis and composing ma -
nuscripts
Acknowledgment
The author thank the Ministry of Health of the Republic of Indonesia for providing COVID-19’s data that being used in this manuscript.
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