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Why Face Masks Don’t Work: A Revealing Review

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Why Face Masks Don’t Work: A Revealing Review
October 18, 2016
by John Hardie, BDS, MSc, PhD, FRCDC

Yesterday’s Scientific Dogma is Today’s Discarded Fable
Introduction
The above quotation is ascribed to Justice Archie Campbell author of Canada’s SARS Commission Final Report. 1 It is a stark reminder that scientific knowledge is constantly changing as new discoveries contradict established beliefs. For at least three decades a face mask has been deemed an essential component of the personal protective equipment worn by dental personnel. A current article, “Face Mask Performance: Are You Protected” gives the impression that masks are capable of providing an acceptable level of protection from airborne pathogens. 2 Studies of recent diseases such as Severe Acute Respiratory Syndrome (SARS), Middle Eastern Respiratory Syndrome (MERS) and the Ebola Crisis combined with those of seasonal influenza and drug resistant tuberculosis have promoted a better understanding of how respiratory diseases are transmitted. Concurrently, with this appreciation, there have been a number of clinical investigations into the efficacy of protective devices such as face masks. This article will describe how the findings of such studies lead to a rethinking of the benefits of wearing a mask during the practice of dentistry. It will begin by describing new concepts relating to infection control especially personal protective equipment (PPE).




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Trends in Infection Control
For the past three decades there has been minimal opposition to what have become seemingly established and accepted infection control recommendations. In 2009, infection control specialist Dr. D. Diekema questioned the validity of these by asking what actual, front-line hospital-based infection control experiences were available to such authoritative organization as the Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Association (OSHA) and the National Institute for Occupational Safety and Health (NIOSH). 3 In the same year, while commenting on guidelines for face masks, Dr. M. Rupp of the Society for Healthcare Epidemiology of America noted that some of the practices relating to infection control that have been in place for decades, ”haven’t been subjected to the same strenuous investigation that, for instance, a new medicine might be subjected.” 4 He opined that perhaps it is the relative cheapness and apparent safety of face masks that has prevented them from undergoing the extensive studies that should be required for any quality improvement device. 4 More recently, Dr. R. MacIntyre, a prolific investigator of face masks, has forcefully stated that the historical reliance on theoretical assumptions for recommending PPEs should be replaced by rigorously acquired clinical data. 5 She noted that most studies on face masks have been based on laboratory simulated tests which quite simply have limited clinical applicability as they cannot account for such human factors as compliance, coughing and talking. 5
Covering the nose and mouth for infection control started in the early 1900s when the German physician Carl Flugge discovered that exhaled droplets could transmit tuberculosis. 4 The science regarding the aerosol transmission of infectious diseases has, for years, been based on what is now appreciated to be “very outmoded research and an overly simplistic interpretation of the data.” 6 Modern studies are employing sensitive instruments and interpretative techniques to better understand the size and distribution of potentially infectious aerosol particles. 6 Such knowledge is paramount to appreciating the limitations of face masks. Nevertheless, it is the historical understanding of droplet and airborne transmission that has driven the longstanding and continuing tradition of mask wearing among health professionals. In 2014, the nursing profession was implored to “stop using practice interventions that are based on tradition” but instead adopt protocols that are based on critical evaluations of the available evidence. 7
A December 2015 article in the National Post seems to ascribe to Dr. Gardam, Director of Infection Prevention and Control, Toronto University Health Network the quote, “I need to choose which stupid, arbitrary infection control rules I’m going to push.” 8 In a communication with the author, Dr. Gardam explained that this was not a personal belief but that it did reflect the views of some infection control practitioners. In her 2014 article, “Germs and the Pseudoscience of Quality Improvement”, Dr. K Sibert, an anaesthetist with an interest in infection control, is of the opinion that many infection control rules are indeed arbitrary, not justified by the available evidence or subjected to controlled follow-up studies, but are devised, often under pressure, to give the appearance of doing something. 9
The above illustrate the developing concerns that many infection control measures have been adopted with minimal supporting evidence. To address this fault, the authors of a 2007 New England Journal of Medicine (NEJM) article eloquently argue that all safety and quality improvement recommendations must be subjected to the same rigorous testing as would any new clinical intervention. 10 Dr. R. MacIntyre, a proponent of this trend in infection control, has used her research findings to boldly state that, “it would not seem justifiable to ask healthcare workers to wear surgical masks.” 4 To understand this conclusion it is necessary to appreciate the current concepts relating to airborne transmissions.
Airborne Transmissions
Early studies of airborne transmissions were hampered by the fact that the investigators were not able to detect small particles (less than 5 microns) near an infectious person. 6 Thus, they assumed that it was the exposure of the face, eyes and nose to large particles (greater than 5 microns) or “droplets” that transmitted the respiratory condition to a person in close proximity to the host. 6 This became known as “droplet infection”, and 5 microns or greater became established as the size of large particles and the traditional belief that such particles could, in theory, be trapped by a face mask. 5 The early researchers concluded that since only large particles were detected near an infectious person any small particles would be transmitted via air currents, dispersed over long distances, remain infective over time and might be inhaled by persons who never had any close contact with the host. 11 This became known as “airborne transmission” against which a face mask would be of little use. 5
Through the use of highly sensitive instruments it is now appreciated that the aerosols transmitted from the respiratory tract due to coughing, sneezing, talking, exhalation and certain medical and dental procedures produce respiratory particles that range from the very small (less than 5 microns) to the very large (greater than a 100 microns) and that all of these particles are capable of being inhaled by persons close to the source. 6, 11 This means that respiratory aerosols potentially contain bacteria averaging in size from 1-10 microns and viruses ranging in size from 0.004 to 0.1 microns. 12 It is also acknowledged that upon their emission large “droplets” will undergo evaporation producing a concentration of readily inhalable small particles surrounding the aerosol source. 6
The historical terms “droplet infection” and “airborne transmission” defined the routes of infection based on particle size. Current knowledge suggests that these are redundant descriptions since aerosols contain a wide distribution of particle sizes and that they ought to be replaced by the term, “aerosol transmissible.” 4, 5 Aerosol transmission has been defined as “person –to – person transmission of pathogens through air by means of inhalation of infectious particles.” 26 In addition, it is appreciated that the physics associated with the production of the aerosols imparts energy to microbial suspensions facilitating their inhalation. 11
Traditionally face masks have been recommended to protect the mouth and nose from the “droplet” route of infection, presumably because they will prevent the inhalation of relatively large particles. 11 Their efficacy must be re-examined in light of the fact that aerosols contain particles many times smaller than 5 microns. Prior to this examination, it is pertinent to review the defence mechanism of the respiratory tract.
Respiratory System Defences
Comprehensive details on the defence mechanisms of the respiratory tract will not be discussed. Instead readers are reminded that; coughing, sneezing, nasal hairs, respiratory tract cilia, mucous producing lining cells and the phagocytic activity of alveolar macrophages provide protection against inhaled foreign bodies including fungi, bacteria and viruses. 13 Indeed, the pathogen laden aerosols produced by everyday talking and eating would have the potential to cause significant disease if it were not for these effective respiratory tract defences.
These defences contradict the recently published belief that dentally produced aerosols, “enter unprotected bronchioles and alveoli.” 2 A pertinent demonstration of the respiratory tract’s ability to resist disease is the finding that- compared to controls- dentists had significantly elevated levels of antibodies to influenza A and B and the respiratory syncytial virus. 14 Thus, while dentists had greater than normal exposure to these aerosol transmissible pathogens, their potential to cause disease was resisted by respiratory immunologic responses. Interestingly, the wearing of masks and eye glasses did not lessen the production of antibodies, thus reducing their significance as personal protective barriers. 14 Another example of the effectiveness of respiratory defences is that although exposed to more aerosol transmissible pathogens than the general population, Tokyo dentists have a significantly lower risk of dying from pneumonia and bronchitis. 15 The ability of a face mask to prevent the infectious risk potentially inherent in sprays of blood and saliva reaching the wearers mouth and nose is questionable since, before the advent of mask use, dentists were no more likely to die of infectious diseases than the general population. 16
The respiratory tract has efficient defence mechanisms. Unless face masks have the ability to either enhance or lessen the need for such natural defences, their use as protection against airborne pathogens must be questioned.
Face Masks
History: Cloth or cotton gauze masks have been used since the late 19th century to protect sterile fields from spit and mucous generated by the wearer. 5,17,18 A secondary function was to protect the mouth and nose of the wearer from the sprays and splashes of blood and body fluids created during surgery. 17 As noted above, in the early 20th century masks were used to trap infectious “droplets” expelled by the wearer thus possibly reducing disease transmission to others. 18 Since the mid-20th century until to-day, face masks have been increasingly used for entirely the opposite function: that is to prevent the wearer from inhaling respiratory pathogens. 5,20,21 Indeed, most current dental infection control recommendations insist that a face mask be worn, “as a key component of personal protection against airborne pathogens”. 2
Literature reviews have confirmed that wearing a mask during surgery has no impact whatsoever on wound infection rates during clean surgery. 22,23,24,25,26 A recent 2014 report states categorically that no clinical trials have ever shown that wearing a mask prevents contamination of surgical sites. 26 With their original purpose being highly questionable it should be no surprise that the ability of face masks to act as respiratory protective devices is now the subject of intense scrutiny. 27 Appreciating the reasons for this, requires an understanding of the structure, fit and filtering capacity of face masks.
Structure and Fit: Disposable face masks usually consist of three to four layers of flat non-woven mats of fine fibres separated by one or two polypropylene barrier layers which act as filters capable of trapping material greater than 1 micron in diameter. 18,24,28 Masks are placed over the nose and mouth and secured by straps usually placed behind the head and neck. 21 No matter how well a mask conforms to the shape of a person’s face, it is not designed to create an air tight seal around the face. Masks will always fit fairly loosely with considerable gaps along the cheeks, around the bridge of the nose and along the bottom edge of the mask below the chin. 21 These gaps do not provide adequate protection as they permit the passage of air and aerosols when the wearer inhales. 11,17 It is important to appreciate that if masks contained filters capable of trapping viruses, the peripheral gaps around the masks would continue to permit the inhalation of unfiltered air and aerosols. 11
Filtering Capacity:
The filters in masks do not act as sieves by trapping particles greater than a specific size while allowing smaller particles to pass through. 18 Instead the dynamics of aerosolized particles and their molecular attraction to filter fibres are such that at a certain range of sizes both large and small particles will penetrate through a face mask. 18 Accordingly, it should be no surprise that a study of eight brands of face masks found that they did not filter out 20-100% of particles varying in size from 0.1 to 4.0 microns. 21 Another investigation showed penetration ranges from 5-100% when masks were challenged with relatively large 1.0 micron particles. 29 A further study found that masks were incapable of filtering out 80-85% of particles varying in size from 0.3 to 2.0 microns. 30 A 2008 investigation identified the poor filtering performance of dental masks. 27 It should be concluded from these and similar studies that the filter material of face masks does not retain or filter out viruses or other submicron particles. 11,31 When this understanding is combined with the poor fit of masks, it is readily appreciated that neither the filter performance nor the facial fit characteristics of face masks qualify them as being devices which protect against respiratory infections. 27 Despite this determination the performance of masks against certain criteria has been used to justify their effectiveness.2 Accordingly, it is appropriate to review the limitations of these performance standards.
Performance Standards: Face masks are not subject to any regulations. 11 The USA Federal Food and Drug Administration (FDA) classifies face masks as Class II devices. To obtain the necessary approval to sell masks all that a manufacturer need do is satisfy the FDA that any new device is substantially the same as any mask currently available for sale. 21 As ironically noted by the Occupational Health and Safety Agency for Healthcare in BC, “There is no specific requirement to prove that the existing masks are effective and there is no standard test or set of data required supporting the assertion of equivalence. Nor does the FDA conduct or sponsor testing of surgical masks.” 21 Although the FDA recommends two filter efficiency tests; particulate filtration efficiency (PFE) and bacterial filtration efficiency (BFE) it does not stipulate a minimum level of filter performance for these tests. 27 The PFE test is a basis for comparing the efficiency of face masks when exposed to aerosol particle sizes between 0.1 and 5.0 microns. The test does not assess the effectiveness of a mask in preventing the ingress of potentially harmful particles nor can it be used to characterize the protective nature of a mask. 32 The BFE test is a measure of a mask’s ability to provide protection from large particles expelled by the wearer. It does not provide an assessment of a mask’s ability to protect the wearer. 17 Although these tests are conducted under the auspices of the American Society of Testing and Materials (ASTM) and often produce filtration efficiencies in the range of 95-98 %, they are not a measure of a masks ability to protect against respiratory pathogens. Failure to appreciate the limitations of these tests combined with a reliance on the high filtration efficiencies reported by the manufacturers has, according to Healthcare in BC, “created an environment in which health care workers think they are more protected than they actually are.” 21 For dental personnel the protection sought is mainly from treatment induced aerosols.
Dental Aerosols
For approximately 40 years it has been known that dental restorative and especially ultrasonic scaling procedures produce aerosols containing not only blood and saliva but potentially pathogenic organisms. 33 The source of these organisms could be the oral cavities of patients and/or dental unit water lines. 34 Assessing the source and pathogenicity of these organisms has proven elusive as it is extremely difficult to culture bacteria especially anaerobes and viruses from dental aerosols. 34 Although there is no substantiated proof that dental aerosols are an infection control risk, it is a reasonable assumption that if pathogenic microbes are present at the treatment site they will become aerosolized and prone to inhalation by the clinician which a face mask will not prevent. As shown by the study of UK dentists, the inhalation resulted in the formation of appropriate antibodies to respiratory pathogens without overt signs and symptoms of respiratory distress. 14 This occurred whether masks were or were not worn. In a 2008 article, Dr. S. Harrel, of the Baylor College of Dentistry, is of the opinion that because there is a lack of epidemiologically detectable disease from the use of ultrasonic scalers, dental aerosols appear to have a low potential for transmitting disease but should not be ignored as a risk for disease transmission. 34 The most effective measures for reducing disease transmission from dental aerosols are pre-procedural rinses with mouthwashes such as chlorhexidine, large diameter high volume evacuators, and rubber dam whenever possible. 33 Face masks are not useful for this purpose, and Dr. Harrel believes that dental personnel have placed too great a reliance on their efficacy. 34 Perhaps this has occurred because dental regulatory agencies have failed to appreciate the increasing evidence on face mask inadequacies.
The Inadequacies
Between 2004 and 2016 at least a dozen research or review articles have been published on the inadequacies of face masks. 5,6,11,17,19,20,21,25,26,27,28,31 All agree that the poor facial fit and limited filtration characteristics of face masks make them unable to prevent the wearer inhaling airborne particles. In their well-referenced 2011 article on respiratory protection for healthcare workers, Drs. Harriman and Brosseau conclude that, “facemasks will not protect against the inhalation of aerosols.” 11 Following their 2015 literature review, Dr. Zhou and colleagues stated, “There is a lack of substantiated evidence to support claims that facemasks protect either patient or surgeon from infectious contamination.” 25 In the same year Dr. R. MacIntyre noted that randomized controlled trials of facemasks failed to prove their efficacy. 5 In August 2016 responding to a question on the protection from facemasks the Canadian Centre for Occupational Health and Safety replied:
  • The filter material of surgical masks does not retain or filter out submicron particles;
  • Surgical masks are not designed to eliminate air leakage around the edges;
  • Surgical masks do not protect the wearer from inhaling small particles that can remain airborne for long periods of time. 31
In 2015, Dr. Leonie Walker, Principal Researcher of the New Zealand Nurses Organization succinctly described- within a historical context – the inadequacies of facemasks, “Health care workers have long relied heavily on surgical masks to provide protection against influenza and other infections. Yet there are no convincing scientific data that support the effectiveness of masks for respiratory protection. The masks we use are not designed for such purposes, and when tested, they have proved to vary widely in filtration capability, allowing penetration of aerosol particles ranging from four to 90%.” 35
Face masks do not satisfy the criteria for effectiveness as described by Drs. Landefeld and Shojania in their NEJM article, “The Tension between Needing to Improve Care and Knowing How to Do It. 10 The authors declare that, “…recommending or mandating the widespread adoption of interventions to improve quality or safety requires rigorous testing to determine whether, how, and where the intervention is effective…” They stress the critical nature of this concept because, “…a number of widely promulgated interventions are likely to be wholly ineffective, even if they do not harm patients.” 10 A significant inadequacy of face masks is that they were mandated as an intervention based on an assumption rather than on appropriate testing.
Conclusions
The primary reason for mandating the wearing of face masks is to protect dental personnel from airborne pathogens. This review has established that face masks are incapable of providing such a level of protection. Unless the Centers for Disease Control and Prevention, national and provincial dental associations and regulatory agencies publically admit this fact, they will be guilty of perpetuating a myth which will be a disservice to the dental profession and its patients. It would be beneficial if, as a consequence of the review, all present infection control recommendations were subjected to the same rigorous testing as any new clinical intervention. Professional associations and governing bodies must ensure the clinical efficacy of quality improvement procedures prior to them being mandated. It is heartening to know that such a trend is gaining a momentum which might reveal the inadequacies of other long held dental infection control assumptions. Surely, the hallmark of a mature profession is one which permits new evidence to trump established beliefs. In 1910, Dr. C. Chapin, a public health pioneer, summarized this idea by stating, “We should not be ashamed to change our methods; rather, we should be ashamed not to do so.” 36 Until this occurs, as this review has revealed, dentists have nothing to fear by unmasking. OH
 

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Why face mask definitely works especially in hospitals


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SARS: experience from the emergency department, Tan Tock Seng Hospital, Singapore
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  1. E Seow
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http://dx.doi.org/10.1136/emj.20.6.501

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Lessons learnt
The severe acute respiratory syndrome (SARS) entered Singapore through three young women, who were in Hong Kong from 20 to 24 February 2003.1 They were infected by a doctor from Guangzhou by a chance encounter in the lift lobby of the hotel where all were staying.2
Two were admitted to Tan Tock Seng Hospital (TTSH) and one of them was what the World Heath Organisation (WHO) later described as a “super-spreader” (persons who directly infected ⩾10 other persons3).
On the 22 March 2003, the Singapore government made a decision to centralise the care of suspect and probable cases of SARS including paediatric cases in TTSH. This facilitated the management of SARS patients and reduced the risk of secondary transmission of the disease.4 Ambulances were diverted and patients at the emergency department (ED) with non-SARS conditions who required hospitalisation were transferred to other hospitals.
The screening centre was initially at the Centre for Communicable Disease (within the TTSH campus). This moved to the ED on the 26 March 2003. The ED then became the national screening centre.
By the 31 May 2003 when WHO took Singapore off the list of SARS affected countries, we had screened more than 9000 patients.
The aim of this article is to describe our ED experiences in dealing with this outbreak and the lessons learnt.
INITIAL WARNING –THE FIRST WEEK (14 MARCH–20 MARCH 2003)
Retrospectively, the first warning we received was through our emails on the 13 March 2003. The Ministry of Health, Singapore had sent out a medical alert warning of an outbreak of atypical pneumonia in Hong Kong, Vietnam, and Guangdong province in China. The medical alert commented that there were three cases that had returned from Hong Kong who had been treated for pneumonia but were well. Two had been discharged and one was recovering. It also stated that none of the hospital staff attending to these patients had reported ill but advised hospital staff attending to this type of cases to take the necessary infection control measures.


Our response in the ED was to obtain a travel history from febrile patients and give a surgical facemask to at risk patients. There was no sense of danger until the next evening when one of our infectious disease (ID) physicians came to ED to warn us of this unknown entity. It was only then that a decision was made by the ED consultant on duty and the head of ED to physically separate at risk patients from the other patients. They were placed in our decontamination building, which was adjacent to the ED (area D in figure 1). The at risk patients were attended to in area D by staff wearing PPE (personal protection equipment), which consisted of gloves, gown, and a N95 mask. We would add goggles or a visor to this armamentarium a month later.
SARS screening and treatment area.
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Figure 1
SARS screening and treatment area.

Our triage nurses started to don N95 masks at this time as well.
During this visit, the ID physician also informed us that there was a group of ward staff that had been admitted for fever. The ED therefore began categorising TTSH personnel as at risk despite the absence of a formal announcement. As a result a member of staff waiting to be admitted in our observation room was transferred to area D to wait for a bed and another, seen earlier in the day and discharged, was recalled for admission.
TTSH opened its emergency operations room 24 hours a day from the 15 March 2003, day 2 of the crisis. Daily meetings to plan and manage the crisis were chaired by the chief executive officer of TTSH and attended by heads of various areas including the head of ED.
I began to write open letters to my staff on an almost daily basis to keep them updated. These were issued to all grades of staff.
On day 3, all ED staff wore N95 facemasks regardless of work area. We were still managing our regular load of about 380 patients a day (TTSH ED was the busiest ED in Singapore) and were depending on our triage nurses to sieve out at risk patients. Any patients who slipped through triage would be waiting in the same area as other patients.
It was only on day 4 (17 March 2003) that a portable radiograph machine was placed in area D for the dedicated use of at risk patients. Before this, the at risk patients had their chest radiograph taken in the ED in the same area as other patients.
The next day, a screening station was set up outside the department to separate at risk cases from “other patients”. The latter were then triaged inside the ED as per normal practice. It was at the same time that an ED staff presented with fever. Eventually, 10 more would be admitted for observation.
By day 6, one of our epidemiologists began to inform us directly of at risk areas. This enabled us to carry out further revisions of our screening questionnaire in a timely fashion and which by then was into its third draft.
With respect to the hospital, the intensive care units were closed to non-SARS patients but ED was still receiving ambulance cases.
THE SECOND WEEK (21 MARCH–27 MARCH 2003)
By the eighth day all ED staff involved in patient care were in full PPE. We were still operating with our usual load as well as screening a small number of patients.
On 22 March 2003, the Ministry of Health designated TTSH as the SARS hospital. It meant that “we were to stop ED admissions, stop admissions/transfers from other hospitals unless the patients were SARS related. The non-SARS patients still in the hospital, we were to gradually discharge them when they were better, and so empty our wards to only look after SARS related patients. The outpatient clinics were also closed.”6
ED was on ambulance diversion but continued to see walk in patients who were non-SARS.
Interestingly, the ED attendance did not decrease despite the fact we were declared the SARS hospital. A decision was made on the 23 March 2003 to build tents under the car porch in front of the ED entrance (fig 1). Those who had a temperature higher than 38°C were seen in area D and the others in the tents. The tents were operational by the next day (day 11). At the same time, two senior nurses were coopted to form the ED operational team to assist the head of department.
We revised the screening questionnaire again and began preparations to take over from CDC the screening of patients for SARS. We became the national screening centre on 26 March 2003 (day 13). A hotline was started with dedicated phone lines. It was run by vulnerable staff who we wanted to shield from direct patient contact (for example, those who were pregnant or had chronic illnesses). The hotline staff handled inquiries from patients ED had seen and was one of our safety nets. They worked closely with the Home Surveillance Group—our other safety net. This group would phone all the patients we had screened on the first three days after discharge and on alternate days thereafter until day 14. This had allowed us to recall and admit a significant minority for SARS that had not exhibited typical symptoms and signs in the first consultation.
The other responsibilities of the screening centre included keeping the Ministry of Health up to date about patients admitted because of SARS, liaison with officials of various agencies in charge of the country’s borders and the police.
It was only on day 13 that ED was given the authority to actively turn away patients who had non-SARS related conditions unless they were critically ill. However, a safety mechanism was put in place—they had to be vetted by a senior doctor.
Staff were reminded to follow only instructions from the head of department.
WEEK 3 (28 MARCH TO 3 APRIL 2003)
Operations within the ED were moved outdoors to an enlarged tentage area. Administration of medications through the nebuliser route was done outdoors. Only patients who clearly did not have SARS, for example, dislocated shoulders were treated within the ED.
Standard letters were prepared such as fitness for travel, not having SARS, and discharge advisory. Revisions were made as new information was available.
A computerised database of at risk patients and their contacts was created by the information technology team of the organisation and was named the SARSweb. It took some time before this database stabilised.
When this was introduced, our screening nurses asked patients if they had any known contacts with SARS patients and if the answer was yes, the nurse would check the name against the database. However, after one patient did not tell the truth, the workflow changed. The screening nurses now actively checked the patient’s name against the database. This added to the screening time.
The powered air positive respiratory hood was introduced for use in high risk activity like intubations but we did not use it when administering nebulisers until week 9.
WEEK 4, 5 (4 APRIL TO 17 APRIL 2003)
A new cluster of SARS patients from other hospitals emerged.
The names of persons accompanying patients and their contact numbers together with their temperatures were now logged in the screening questionnaire of every patient. This was to facilitate contact tracing.
Admissions from the ED was streamlined to only SARS or non-SARS. No categorisation of SARS patients at ED was permitted (this was an ED decision). It was difficult to categorise them at ED as the definitions given at that point were open to differing interpretations. In not permitting categorisation at ED, we ensured that all patients admitted for SARS or to exclude SARS were admitted to an isolation room for further review by the ID consultant.
Before the outbreak, TTSH ED had admitting rights. However, during the first four weeks of the SARS crisis, only ID physicians could admit to a SARS bed. On week 5, this authority was extended to the ED senior doctor. As a result, the turnaround time was short and streamlined the flow for these patients.
As a precautionary measure, ED admitted non-SARS patients with pneumonia or fever of indeterminate origin to isolation beds. The other group of non-SARS patients admitted to isolation beds were patients on home quarantine orders who were being admitted for non-SARS conditions. We were fortunate to have put this in place as a patient who was on home quarantine order, who was afebrile with no respiratory signs or symptoms on presentation and admitted because of anaemia subsequently manifested signs and symptoms of SARS within 24 hours of her hospitalisation.
A similar policy was adopted by other hospitals and would cause a shortage of hospital beds and strain EDs in the weeks to come.
Despite being a SARS hospital, we were admitting between 5 to 15 non-SARS patients a day. These were TTSH patients who were too ill to be transferred to other hospitals.
WEEK 6 (18–24 APRIL 2003)
We were one of the first to suspect that SARS had spread to the community when a family of eight were referred by a general practitioner for fever. The grandmother of the family had just died from bronchopneumonia. There was no obvious contact history. We admitted all eight of them. They were the herald of the next cluster. Contact history was important but was no longer necessary in suspecting SARS in a patient. Previous to this there had been tenuous links to healthcare institutions like a taxi driver who had ferried passengers to hospitals, visitors to hospitals or staff of hospitals.
We were later to discover that the grandfather had contracted SARS at the biggest wholesale vegetable centre in the country where a SARS victim had worked for several days before seeking medical attention. The government closed the centre for 14 days.
With the spread of SARS into the community, we now categorised the patients we screened into low, moderate or high risks instead of no, low, moderate, or high.
The definition became:

  • Low risk—no definite exposure with or without symptoms
  • Moderate risk—contact or travel with or without symptoms
  • High risk—contact or travel history with a temperature of 38°C or more

WEEK 7 (25 APRIL–1 MAY)
We reorganised and increased the tentage area as the number of patients with low risk increased. (Figure 1 shows the plan for the work area for SARS screening.)
The biggest problem now was the weather, which averaged 34°C. The staff working in the frontline were drenched within minutes of stepping out into the working area. They were instructed to drink water and isotonic fluids before starting their shifts and a “water” break after working 90 minutes was strictly enforced. Two staff were assigned to keep track and despite this, two staff did suffer giddy spells but fortunately recovered very quickly.
WEEK 8, 9, 10 (2 MAY–29 MAY)
There were high hopes that Singapore would be SARS free on the 18 May 2003 but a patient we had admitted on the 11 May 2003 (for whom to date we are unable to obtain a contact history) turned for the worse and tested positive for SARS. Two previous tests for coronavirus had been negative.
WEEK 11
Singapore celebrated as the country was taken off WHO list of SARS affected countries.7 TTSH ED prepares for resumption of its normal functions.
LESSONS LEARNT
Infection control measures
It is the nature of epidemics to be unpredictable.8 This was made worse because SARS was a new disease. In the early days of the outbreak, we were uncertain of which level of infection control measures to adopt and there was a concern about causing unwarranted public panic as well.
It took us five days before we set up a screening centre at the entrance of the ED and a few more days before all staff involved in patient care wore full PPE.
We were fortunate that the institution had in place mask fitting as part of its orientation programme. However, many of the ED staff still had to undergo mask fitting and a check four weeks into the crisis found that a few had not done so. This is crucial for staff protection. Staff must wear the correct size N95 facemask.
Audit is very important. It should be recorded if staff have undergone mask fitting, training in putting on gown and removing them, and in infection control measures such as changing gloves and wiping down their stethoscopes between patients. We assigned senior staff to be our main auditor. This role was very important in enabling us to maintain strict compliance of infection control measures.
We were fortunate to have enough outdoor space to separate the different categories of patients. This we believe was one of the reasons why we did not have any transmission of the disease within the department.
Communication
This was one of the most critical components in our management of the SARS crisis.
At the hospital level, the ED head was kept updated of the latest developments at the daily meetings chaired by the chief executive officer. The ED’s input was taken into consideration during decision making and there was direct access to senior management and this was of importance in obtaining logistical support and in resource management.
The relationship between ED and ID physicians has always been close and the two groups had worked together previously during the Nipah virus outbreak.9
This was why ID physicians were comfortable visiting the ED and sharing any new information that they had available as well as exchanging ideas with the ED staff.
The ED also obtained up to date information especially of at risk areas from the epidemiology team. It also helped that one of them had worked as a medical officer in the ED previously and was familiar with our work processes.
These open channels between the ID, epidemiology, and ED teams allowed for the early identification of new cases and clusters like the family of eight and those from other hospitals. Early identification allowed for contact tracing and isolation to be achieved much faster.
This open channel of communication was also present between the staff who ran the ED hotline and the home surveillance team. There were a few SARS patients who had been discharged initially but were subsequently recalled and admitted because of this close working relationship between the two teams.
At the department level, the open letter issued by the HOD was one form of communication. It is not easy to disseminate ever changing information in an ED as most staff work shifts. Briefings and debriefings by senior staff both medical and nursing became one of the most important lines of communication for the department.
Command and control
In a crisis, the chain of command must be clear to all concern. Fortunately, in ED TTSH the medical, nursing, and support staff have the same head of department. This made it easier for decisions to be made and carried out as the final responsibility belonged to only one person, the head of department. This made it easier for the staff to respond to changes.
Staff were frequently reminded in the first few weeks to follow only instructions from the head of department. The more senior the staff, the harder it was for them to comply and there was a tendency for this group to issue instructions without clearing with the head of department. This can cause confusion to the ground. It is important for the head of department to maintain discipline in such situations.
Staff morale
The fear felt by the staff must be acknowledged. We admitted our ignorance and were open about any information we received. We explained the rationale behind decisions and changes that were made.
The staff were prepared from the start that the SARS crisis would be a marathon and not a sprint. They were warned to expect many changes within a day and that decisions may be reversed frequently depending on whatever information we receive. It was very important to the staff for the head of department and senior staff to be visible in the ED during this period.
The hospital management was very supportive in providing funds for us to provide meals and recreational activities for the staff. Public support was also a great morale booster.
However, the staff did face prejudices. “They were fighting the unknown virus as well as fighting discrimination.”10
Patient behaviour
Contact with a known case is important but this may not be evident at the initial assessment.11 In the case of the family of eight, they did not know but in at least one case, the patient was not forthcoming with the truth. This behaviour is not peculiar to Singapore. It also occurred in Taiwan (L M Wang, personal communication).
We postulate that these patients were in denial.
Fortunately, we learnt this lesson very early during the crisis. We decided to actively search the computerised database of SARS patients and contact for every patient we screened even though this added to the turnaround time at screening.
Community spread
We were expecting the worse from the start of the crisis. We suspected that it would be a matter of time before SARS spread to the community. Even though contact history was an important discriminator11 for us, we did not rely on it too strongly. We admitted all patients who fitted the clinical picture of SARS12 even if they did not have a contact history. To date, we have yet to trace the contact history of the last patient in Singapore diagnosed to have probable SARS.
Clinical expertise
We had 24 hour senior doctor cover. This ensured that the quality of care did not suffer during the crisis. It also allowed us to gain clinical experience of this new disease very quickly. We discovered like Hong Kong that although fever is a cardinal symptom,11 it could be absent in a minority of patients.
The presence of this leadership was very important in giving the staff confidence as they handled multiple changes and new problems.
Conclusion
We have survived the SARS crisis by expecting the worse and hoping for the best. We are now moving from crisis to a transition period.
Acknowledgments
I would like to thank the staff of ED, TTSH for their support during this SARS crisis. They are a great team to work with.
Lessons learnt
REFERENCES

  1. Goh LG. Reflections on the Singapore SARS outbreak, commentary. SMA News2003;35:5.
    Google Scholar

  2. The Straits Times. http://straitstimes.asia1.com.sg/columnist/0,1886,56-178860,00.html.
    Google Scholar

  3. Leo YS, Chen M, Heng BH, et al. Severe acute respiratory syndrome—Singapore 2003. MMWR2003;52:405–11.
    PubMedGoogle Scholar

  4. Ministry of Health, Singapore. Enhanced precautionary measures to break SARS transmission, 22 March 2003; http://www.asia1.com/straitstimes/.
    Google Scholar
  5. Reference withdrawn.
    Google Scholar

  6. Chee YC. SARS (and me) (Part 1). SMA NewsMarch 2003;35:6.
    Google Scholar

  7. WHO. http://www.who.int/csr/don/2003_05_30a/en/.
    Google Scholar

  8. Bloom BR. Lessons from SARS. Science2003;300:701.
    AbstractGoogle Scholar

  9. Tambyah PA. The Nipah virus outbreak—a reminder. Singapore Med J1999;40:329–30.
    PubMedGoogle Scholar

  10. Chee YC. Heroes and heroines of the war on SARS. Singapore Med J44:221–8.
    Google Scholar

  11. Tomlinson B, Cockram C. SARS: experience at Prince of Wales Hospital, HongKong. Lancet2003;361:1486–7.
    CrossRefPubMedWeb of ScienceGoogle Scholar

  12. Hsu LY, Lee CC, Green JA, et al. Severe acute respiratory syndrome (SARS) in Singapore: clinical features of index patient and initial contacts. CDC2003;9:1–7.
    Google Scholar
View Abstract




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Why face mask definitely works especially in hospitals


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Commentary

SARS: experience from the emergency department, Tan Tock Seng Hospital, Singapore
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  1. E Seow
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http://dx.doi.org/10.1136/emj.20.6.501

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Lessons learnt
The severe acute respiratory syndrome (SARS) entered Singapore through three young women, who were in Hong Kong from 20 to 24 February 2003.1 They were infected by a doctor from Guangzhou by a chance encounter in the lift lobby of the hotel where all were staying.2
Two were admitted to Tan Tock Seng Hospital (TTSH) and one of them was what the World Heath Organisation (WHO) later described as a “super-spreader” (persons who directly infected ⩾10 other persons3).
On the 22 March 2003, the Singapore government made a decision to centralise the care of suspect and probable cases of SARS including paediatric cases in TTSH. This facilitated the management of SARS patients and reduced the risk of secondary transmission of the disease.4 Ambulances were diverted and patients at the emergency department (ED) with non-SARS conditions who required hospitalisation were transferred to other hospitals.
The screening centre was initially at the Centre for Communicable Disease (within the TTSH campus). This moved to the ED on the 26 March 2003. The ED then became the national screening centre.
By the 31 May 2003 when WHO took Singapore off the list of SARS affected countries, we had screened more than 9000 patients.
The aim of this article is to describe our ED experiences in dealing with this outbreak and the lessons learnt.
INITIAL WARNING –THE FIRST WEEK (14 MARCH–20 MARCH 2003)
Retrospectively, the first warning we received was through our emails on the 13 March 2003. The Ministry of Health, Singapore had sent out a medical alert warning of an outbreak of atypical pneumonia in Hong Kong, Vietnam, and Guangdong province in China. The medical alert commented that there were three cases that had returned from Hong Kong who had been treated for pneumonia but were well. Two had been discharged and one was recovering. It also stated that none of the hospital staff attending to these patients had reported ill but advised hospital staff attending to this type of cases to take the necessary infection control measures.


Our response in the ED was to obtain a travel history from febrile patients and give a surgical facemask to at risk patients. There was no sense of danger until the next evening when one of our infectious disease (ID) physicians came to ED to warn us of this unknown entity. It was only then that a decision was made by the ED consultant on duty and the head of ED to physically separate at risk patients from the other patients. They were placed in our decontamination building, which was adjacent to the ED (area D in figure 1). The at risk patients were attended to in area D by staff wearing PPE (personal protection equipment), which consisted of gloves, gown, and a N95 mask. We would add goggles or a visor to this armamentarium a month later.
SARS screening and treatment area.
" data-icon-position="" data-hide-link-title="0" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; background-color: transparent; font-weight: normal; text-decoration: none; color: rgb(42, 110, 187); box-shadow: none; border: 0px;">     Figure 1

Figure 1
SARS screening and treatment area.

Our triage nurses started to don N95 masks at this time as well.
During this visit, the ID physician also informed us that there was a group of ward staff that had been admitted for fever. The ED therefore began categorising TTSH personnel as at risk despite the absence of a formal announcement. As a result a member of staff waiting to be admitted in our observation room was transferred to area D to wait for a bed and another, seen earlier in the day and discharged, was recalled for admission.
TTSH opened its emergency operations room 24 hours a day from the 15 March 2003, day 2 of the crisis. Daily meetings to plan and manage the crisis were chaired by the chief executive officer of TTSH and attended by heads of various areas including the head of ED.
I began to write open letters to my staff on an almost daily basis to keep them updated. These were issued to all grades of staff.
On day 3, all ED staff wore N95 facemasks regardless of work area. We were still managing our regular load of about 380 patients a day (TTSH ED was the busiest ED in Singapore) and were depending on our triage nurses to sieve out at risk patients. Any patients who slipped through triage would be waiting in the same area as other patients.
It was only on day 4 (17 March 2003) that a portable radiograph machine was placed in area D for the dedicated use of at risk patients. Before this, the at risk patients had their chest radiograph taken in the ED in the same area as other patients.
The next day, a screening station was set up outside the department to separate at risk cases from “other patients”. The latter were then triaged inside the ED as per normal practice. It was at the same time that an ED staff presented with fever. Eventually, 10 more would be admitted for observation.
By day 6, one of our epidemiologists began to inform us directly of at risk areas. This enabled us to carry out further revisions of our screening questionnaire in a timely fashion and which by then was into its third draft.
With respect to the hospital, the intensive care units were closed to non-SARS patients but ED was still receiving ambulance cases.
THE SECOND WEEK (21 MARCH–27 MARCH 2003)
By the eighth day all ED staff involved in patient care were in full PPE. We were still operating with our usual load as well as screening a small number of patients.
On 22 March 2003, the Ministry of Health designated TTSH as the SARS hospital. It meant that “we were to stop ED admissions, stop admissions/transfers from other hospitals unless the patients were SARS related. The non-SARS patients still in the hospital, we were to gradually discharge them when they were better, and so empty our wards to only look after SARS related patients. The outpatient clinics were also closed.”6
ED was on ambulance diversion but continued to see walk in patients who were non-SARS.
Interestingly, the ED attendance did not decrease despite the fact we were declared the SARS hospital. A decision was made on the 23 March 2003 to build tents under the car porch in front of the ED entrance (fig 1). Those who had a temperature higher than 38°C were seen in area D and the others in the tents. The tents were operational by the next day (day 11). At the same time, two senior nurses were coopted to form the ED operational team to assist the head of department.
We revised the screening questionnaire again and began preparations to take over from CDC the screening of patients for SARS. We became the national screening centre on 26 March 2003 (day 13). A hotline was started with dedicated phone lines. It was run by vulnerable staff who we wanted to shield from direct patient contact (for example, those who were pregnant or had chronic illnesses). The hotline staff handled inquiries from patients ED had seen and was one of our safety nets. They worked closely with the Home Surveillance Group—our other safety net. This group would phone all the patients we had screened on the first three days after discharge and on alternate days thereafter until day 14. This had allowed us to recall and admit a significant minority for SARS that had not exhibited typical symptoms and signs in the first consultation.
The other responsibilities of the screening centre included keeping the Ministry of Health up to date about patients admitted because of SARS, liaison with officials of various agencies in charge of the country’s borders and the police.
It was only on day 13 that ED was given the authority to actively turn away patients who had non-SARS related conditions unless they were critically ill. However, a safety mechanism was put in place—they had to be vetted by a senior doctor.
Staff were reminded to follow only instructions from the head of department.
WEEK 3 (28 MARCH TO 3 APRIL 2003)
Operations within the ED were moved outdoors to an enlarged tentage area. Administration of medications through the nebuliser route was done outdoors. Only patients who clearly did not have SARS, for example, dislocated shoulders were treated within the ED.
Standard letters were prepared such as fitness for travel, not having SARS, and discharge advisory. Revisions were made as new information was available.
A computerised database of at risk patients and their contacts was created by the information technology team of the organisation and was named the SARSweb. It took some time before this database stabilised.
When this was introduced, our screening nurses asked patients if they had any known contacts with SARS patients and if the answer was yes, the nurse would check the name against the database. However, after one patient did not tell the truth, the workflow changed. The screening nurses now actively checked the patient’s name against the database. This added to the screening time.
The powered air positive respiratory hood was introduced for use in high risk activity like intubations but we did not use it when administering nebulisers until week 9.
WEEK 4, 5 (4 APRIL TO 17 APRIL 2003)
A new cluster of SARS patients from other hospitals emerged.
The names of persons accompanying patients and their contact numbers together with their temperatures were now logged in the screening questionnaire of every patient. This was to facilitate contact tracing.
Admissions from the ED was streamlined to only SARS or non-SARS. No categorisation of SARS patients at ED was permitted (this was an ED decision). It was difficult to categorise them at ED as the definitions given at that point were open to differing interpretations. In not permitting categorisation at ED, we ensured that all patients admitted for SARS or to exclude SARS were admitted to an isolation room for further review by the ID consultant.
Before the outbreak, TTSH ED had admitting rights. However, during the first four weeks of the SARS crisis, only ID physicians could admit to a SARS bed. On week 5, this authority was extended to the ED senior doctor. As a result, the turnaround time was short and streamlined the flow for these patients.
As a precautionary measure, ED admitted non-SARS patients with pneumonia or fever of indeterminate origin to isolation beds. The other group of non-SARS patients admitted to isolation beds were patients on home quarantine orders who were being admitted for non-SARS conditions. We were fortunate to have put this in place as a patient who was on home quarantine order, who was afebrile with no respiratory signs or symptoms on presentation and admitted because of anaemia subsequently manifested signs and symptoms of SARS within 24 hours of her hospitalisation.
A similar policy was adopted by other hospitals and would cause a shortage of hospital beds and strain EDs in the weeks to come.
Despite being a SARS hospital, we were admitting between 5 to 15 non-SARS patients a day. These were TTSH patients who were too ill to be transferred to other hospitals.
WEEK 6 (18–24 APRIL 2003)
We were one of the first to suspect that SARS had spread to the community when a family of eight were referred by a general practitioner for fever. The grandmother of the family had just died from bronchopneumonia. There was no obvious contact history. We admitted all eight of them. They were the herald of the next cluster. Contact history was important but was no longer necessary in suspecting SARS in a patient. Previous to this there had been tenuous links to healthcare institutions like a taxi driver who had ferried passengers to hospitals, visitors to hospitals or staff of hospitals.
We were later to discover that the grandfather had contracted SARS at the biggest wholesale vegetable centre in the country where a SARS victim had worked for several days before seeking medical attention. The government closed the centre for 14 days.
With the spread of SARS into the community, we now categorised the patients we screened into low, moderate or high risks instead of no, low, moderate, or high.
The definition became:

  • Low risk—no definite exposure with or without symptoms
  • Moderate risk—contact or travel with or without symptoms
  • High risk—contact or travel history with a temperature of 38°C or more

WEEK 7 (25 APRIL–1 MAY)
We reorganised and increased the tentage area as the number of patients with low risk increased. (Figure 1 shows the plan for the work area for SARS screening.)
The biggest problem now was the weather, which averaged 34°C. The staff working in the frontline were drenched within minutes of stepping out into the working area. They were instructed to drink water and isotonic fluids before starting their shifts and a “water” break after working 90 minutes was strictly enforced. Two staff were assigned to keep track and despite this, two staff did suffer giddy spells but fortunately recovered very quickly.
WEEK 8, 9, 10 (2 MAY–29 MAY)
There were high hopes that Singapore would be SARS free on the 18 May 2003 but a patient we had admitted on the 11 May 2003 (for whom to date we are unable to obtain a contact history) turned for the worse and tested positive for SARS. Two previous tests for coronavirus had been negative.
WEEK 11
Singapore celebrated as the country was taken off WHO list of SARS affected countries.7 TTSH ED prepares for resumption of its normal functions.
LESSONS LEARNT
Infection control measures
It is the nature of epidemics to be unpredictable.8 This was made worse because SARS was a new disease. In the early days of the outbreak, we were uncertain of which level of infection control measures to adopt and there was a concern about causing unwarranted public panic as well.
It took us five days before we set up a screening centre at the entrance of the ED and a few more days before all staff involved in patient care wore full PPE.
We were fortunate that the institution had in place mask fitting as part of its orientation programme. However, many of the ED staff still had to undergo mask fitting and a check four weeks into the crisis found that a few had not done so. This is crucial for staff protection. Staff must wear the correct size N95 facemask.
Audit is very important. It should be recorded if staff have undergone mask fitting, training in putting on gown and removing them, and in infection control measures such as changing gloves and wiping down their stethoscopes between patients. We assigned senior staff to be our main auditor. This role was very important in enabling us to maintain strict compliance of infection control measures.
We were fortunate to have enough outdoor space to separate the different categories of patients. This we believe was one of the reasons why we did not have any transmission of the disease within the department.
Communication
This was one of the most critical components in our management of the SARS crisis.
At the hospital level, the ED head was kept updated of the latest developments at the daily meetings chaired by the chief executive officer. The ED’s input was taken into consideration during decision making and there was direct access to senior management and this was of importance in obtaining logistical support and in resource management.
The relationship between ED and ID physicians has always been close and the two groups had worked together previously during the Nipah virus outbreak.9
This was why ID physicians were comfortable visiting the ED and sharing any new information that they had available as well as exchanging ideas with the ED staff.
The ED also obtained up to date information especially of at risk areas from the epidemiology team. It also helped that one of them had worked as a medical officer in the ED previously and was familiar with our work processes.
These open channels between the ID, epidemiology, and ED teams allowed for the early identification of new cases and clusters like the family of eight and those from other hospitals. Early identification allowed for contact tracing and isolation to be achieved much faster.
This open channel of communication was also present between the staff who ran the ED hotline and the home surveillance team. There were a few SARS patients who had been discharged initially but were subsequently recalled and admitted because of this close working relationship between the two teams.
At the department level, the open letter issued by the HOD was one form of communication. It is not easy to disseminate ever changing information in an ED as most staff work shifts. Briefings and debriefings by senior staff both medical and nursing became one of the most important lines of communication for the department.
Command and control
In a crisis, the chain of command must be clear to all concern. Fortunately, in ED TTSH the medical, nursing, and support staff have the same head of department. This made it easier for decisions to be made and carried out as the final responsibility belonged to only one person, the head of department. This made it easier for the staff to respond to changes.
Staff were frequently reminded in the first few weeks to follow only instructions from the head of department. The more senior the staff, the harder it was for them to comply and there was a tendency for this group to issue instructions without clearing with the head of department. This can cause confusion to the ground. It is important for the head of department to maintain discipline in such situations.
Staff morale
The fear felt by the staff must be acknowledged. We admitted our ignorance and were open about any information we received. We explained the rationale behind decisions and changes that were made.
The staff were prepared from the start that the SARS crisis would be a marathon and not a sprint. They were warned to expect many changes within a day and that decisions may be reversed frequently depending on whatever information we receive. It was very important to the staff for the head of department and senior staff to be visible in the ED during this period.
The hospital management was very supportive in providing funds for us to provide meals and recreational activities for the staff. Public support was also a great morale booster.
However, the staff did face prejudices. “They were fighting the unknown virus as well as fighting discrimination.”10
Patient behaviour
Contact with a known case is important but this may not be evident at the initial assessment.11 In the case of the family of eight, they did not know but in at least one case, the patient was not forthcoming with the truth. This behaviour is not peculiar to Singapore. It also occurred in Taiwan (L M Wang, personal communication).
We postulate that these patients were in denial.
Fortunately, we learnt this lesson very early during the crisis. We decided to actively search the computerised database of SARS patients and contact for every patient we screened even though this added to the turnaround time at screening.
Community spread
We were expecting the worse from the start of the crisis. We suspected that it would be a matter of time before SARS spread to the community. Even though contact history was an important discriminator11 for us, we did not rely on it too strongly. We admitted all patients who fitted the clinical picture of SARS12 even if they did not have a contact history. To date, we have yet to trace the contact history of the last patient in Singapore diagnosed to have probable SARS.
Clinical expertise
We had 24 hour senior doctor cover. This ensured that the quality of care did not suffer during the crisis. It also allowed us to gain clinical experience of this new disease very quickly. We discovered like Hong Kong that although fever is a cardinal symptom,11 it could be absent in a minority of patients.
The presence of this leadership was very important in giving the staff confidence as they handled multiple changes and new problems.
Conclusion
We have survived the SARS crisis by expecting the worse and hoping for the best. We are now moving from crisis to a transition period.
Acknowledgments
I would like to thank the staff of ED, TTSH for their support during this SARS crisis. They are a great team to work with.
Lessons learnt
REFERENCES

  1. Goh LG. Reflections on the Singapore SARS outbreak, commentary. SMA News2003;35:5.
    Google Scholar

  2. The Straits Times. http://straitstimes.asia1.com.sg/columnist/0,1886,56-178860,00.html.
    Google Scholar

  3. Leo YS, Chen M, Heng BH, et al. Severe acute respiratory syndrome—Singapore 2003. MMWR2003;52:405–11.
    PubMedGoogle Scholar

  4. Ministry of Health, Singapore. Enhanced precautionary measures to break SARS transmission, 22 March 2003; http://www.asia1.com/straitstimes/.
    Google Scholar
  5. Reference withdrawn.
    Google Scholar

  6. Chee YC. SARS (and me) (Part 1). SMA NewsMarch 2003;35:6.
    Google Scholar

  7. WHO. http://www.who.int/csr/don/2003_05_30a/en/.
    Google Scholar

  8. Bloom BR. Lessons from SARS. Science2003;300:701.
    AbstractGoogle Scholar

  9. Tambyah PA. The Nipah virus outbreak—a reminder. Singapore Med J1999;40:329–30.
    PubMedGoogle Scholar

  10. Chee YC. Heroes and heroines of the war on SARS. Singapore Med J44:221–8.
    Google Scholar

  11. Tomlinson B, Cockram C. SARS: experience at Prince of Wales Hospital, HongKong. Lancet2003;361:1486–7.
    CrossRefPubMedWeb of ScienceGoogle Scholar

  12. Hsu LY, Lee CC, Green JA, et al. Severe acute respiratory syndrome (SARS) in Singapore: clinical features of index patient and initial contacts. CDC2003;9:1–7.
    Google Scholar
View Abstract




Request Permissions
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


Request permissions

Copyright information:
Copyright 2003 by the Emergency Medicine Journal

Other content recommended for you
  1. Improving the wait time to admission by reducing bed rejections
    Yuzeng Shen et al., BMJ Open Quality, 2019
  2. Improving the wait time to triage at the emergency department
    Shen Yuzeng et al., BMJ Open Quality, 2020
  3. Improving Emergency Department flow through optimized bed utilization
    Lucas Brien Chartier et al., BMJ Open Quality, 2016
  4. Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department
    Jenny Liu et al., BMJ Open, 2018
  5. Multicentre, prospective observational study of the correlation between the Glasgow Admission Prediction Score and adverse outcomes
    Dominic Jones et al., BMJ Open, 2019

  1. More opportunities found for respiratory infections to spread among staff in emergency departments
    MedicalXpress, 2013
  2. No method in traffic madness
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  5. And Science Ground to a Halt While Reviews Were Underway
    GenomeWeb, 2009
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PDFHelp

If you had bothered to read your own article you'd see that the devil is in the details. Protection requires the use of properly fitted N95 or better masks PLUS protection for the eyes as well.
 

knowwhatyouwantinlife

Alfrescian
Loyal
There are various levels of ppe and all levels of ppe requires a mask may it be surgical or n95 or even n99 in certain industries...
The numbers onboard the diamond princess as a sandbox and controlled environment is the current best proxy...
https://www.channelnewsasia.com/new...ned-cruise-ship-in-japan-as-covid-19-12440282
355 test positive out of 1300 tested (27%) with everyone on some form of mask...let's leave the balance 1800 plus passengers not tested out of the equation for now...so in this case masks are proven somewhat effective
 

nirvarq

Alfrescian (InfP)
Generous Asset
So simply put no point wearing mask w/o eyes protection and since everything is karma or cause/effects the chance of infection by 70 virus carriers out of 6 million is 0.00116666667 percent chance that you'll meet one of them.

So the best strategy is quick isolation once upon contracted is all we need do ? No one dies so far in SG and the death rate for 2019-nCoV has been about 2%.

So PAP is correct ! No need scared, plus because scare also no use more stress than helps even economy wise. PAP BANZAI ! lol........

*Plus when you wear mask you breathe harder creating a stronger stream of air flow coming in near the top sides of your nose nearer to the eyes which is much easier to be infected instead of the nose with hairs. It is only good for protection of direct and near encounter like for medical staffs or when you're sick you wear. When droplets is present so does airborne because droplets are created by accumulated micro airborne particles/molecules of water this is basic common sense.
 
Last edited:

mojito

Alfrescian
Loyal
Why Face Masks Don’t Work: A Revealing Review
October 18, 2016
by John Hardie, BDS, MSc, PhD, FRCDC


Introduction

The above quotation is ascribed to Justice Archie Campbell author of Canada’s SARS Commission Final Report. 1 It is a stark reminder that scientific knowledge is constantly changing as new discoveries contradict established beliefs. For at least three decades a face mask has been deemed an essential component of the personal protective equipment worn by dental personnel. A current article, “Face Mask Performance: Are You Protected” gives the impression that masks are capable of providing an acceptable level of protection from airborne pathogens. 2 Studies of recent diseases such as Severe Acute Respiratory Syndrome (SARS), Middle Eastern Respiratory Syndrome (MERS) and the Ebola Crisis combined with those of seasonal influenza and drug resistant tuberculosis have promoted a better understanding of how respiratory diseases are transmitted. Concurrently, with this appreciation, there have been a number of clinical investigations into the efficacy of protective devices such as face masks. This article will describe how the findings of such studies lead to a rethinking of the benefits of wearing a mask during the practice of dentistry. It will begin by describing new concepts relating to infection control especially personal protective equipment (PPE).




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Trends in Infection Control
For the past three decades there has been minimal opposition to what have become seemingly established and accepted infection control recommendations. In 2009, infection control specialist Dr. D. Diekema questioned the validity of these by asking what actual, front-line hospital-based infection control experiences were available to such authoritative organization as the Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Association (OSHA) and the National Institute for Occupational Safety and Health (NIOSH). 3 In the same year, while commenting on guidelines for face masks, Dr. M. Rupp of the Society for Healthcare Epidemiology of America noted that some of the practices relating to infection control that have been in place for decades, ”haven’t been subjected to the same strenuous investigation that, for instance, a new medicine might be subjected.” 4 He opined that perhaps it is the relative cheapness and apparent safety of face masks that has prevented them from undergoing the extensive studies that should be required for any quality improvement device. 4 More recently, Dr. R. MacIntyre, a prolific investigator of face masks, has forcefully stated that the historical reliance on theoretical assumptions for recommending PPEs should be replaced by rigorously acquired clinical data. 5 She noted that most studies on face masks have been based on laboratory simulated tests which quite simply have limited clinical applicability as they cannot account for such human factors as compliance, coughing and talking. 5
Covering the nose and mouth for infection control started in the early 1900s when the German physician Carl Flugge discovered that exhaled droplets could transmit tuberculosis. 4 The science regarding the aerosol transmission of infectious diseases has, for years, been based on what is now appreciated to be “very outmoded research and an overly simplistic interpretation of the data.” 6 Modern studies are employing sensitive instruments and interpretative techniques to better understand the size and distribution of potentially infectious aerosol particles. 6 Such knowledge is paramount to appreciating the limitations of face masks. Nevertheless, it is the historical understanding of droplet and airborne transmission that has driven the longstanding and continuing tradition of mask wearing among health professionals. In 2014, the nursing profession was implored to “stop using practice interventions that are based on tradition” but instead adopt protocols that are based on critical evaluations of the available evidence. 7
A December 2015 article in the National Post seems to ascribe to Dr. Gardam, Director of Infection Prevention and Control, Toronto University Health Network the quote, “I need to choose which stupid, arbitrary infection control rules I’m going to push.” 8 In a communication with the author, Dr. Gardam explained that this was not a personal belief but that it did reflect the views of some infection control practitioners. In her 2014 article, “Germs and the Pseudoscience of Quality Improvement”, Dr. K Sibert, an anaesthetist with an interest in infection control, is of the opinion that many infection control rules are indeed arbitrary, not justified by the available evidence or subjected to controlled follow-up studies, but are devised, often under pressure, to give the appearance of doing something. 9
The above illustrate the developing concerns that many infection control measures have been adopted with minimal supporting evidence. To address this fault, the authors of a 2007 New England Journal of Medicine (NEJM) article eloquently argue that all safety and quality improvement recommendations must be subjected to the same rigorous testing as would any new clinical intervention. 10 Dr. R. MacIntyre, a proponent of this trend in infection control, has used her research findings to boldly state that, “it would not seem justifiable to ask healthcare workers to wear surgical masks.” 4 To understand this conclusion it is necessary to appreciate the current concepts relating to airborne transmissions.
Airborne Transmissions
Early studies of airborne transmissions were hampered by the fact that the investigators were not able to detect small particles (less than 5 microns) near an infectious person. 6 Thus, they assumed that it was the exposure of the face, eyes and nose to large particles (greater than 5 microns) or “droplets” that transmitted the respiratory condition to a person in close proximity to the host. 6 This became known as “droplet infection”, and 5 microns or greater became established as the size of large particles and the traditional belief that such particles could, in theory, be trapped by a face mask. 5 The early researchers concluded that since only large particles were detected near an infectious person any small particles would be transmitted via air currents, dispersed over long distances, remain infective over time and might be inhaled by persons who never had any close contact with the host. 11 This became known as “airborne transmission” against which a face mask would be of little use. 5
Through the use of highly sensitive instruments it is now appreciated that the aerosols transmitted from the respiratory tract due to coughing, sneezing, talking, exhalation and certain medical and dental procedures produce respiratory particles that range from the very small (less than 5 microns) to the very large (greater than a 100 microns) and that all of these particles are capable of being inhaled by persons close to the source. 6, 11 This means that respiratory aerosols potentially contain bacteria averaging in size from 1-10 microns and viruses ranging in size from 0.004 to 0.1 microns. 12 It is also acknowledged that upon their emission large “droplets” will undergo evaporation producing a concentration of readily inhalable small particles surrounding the aerosol source. 6
The historical terms “droplet infection” and “airborne transmission” defined the routes of infection based on particle size. Current knowledge suggests that these are redundant descriptions since aerosols contain a wide distribution of particle sizes and that they ought to be replaced by the term, “aerosol transmissible.” 4, 5 Aerosol transmission has been defined as “person –to – person transmission of pathogens through air by means of inhalation of infectious particles.” 26 In addition, it is appreciated that the physics associated with the production of the aerosols imparts energy to microbial suspensions facilitating their inhalation. 11
Traditionally face masks have been recommended to protect the mouth and nose from the “droplet” route of infection, presumably because they will prevent the inhalation of relatively large particles. 11 Their efficacy must be re-examined in light of the fact that aerosols contain particles many times smaller than 5 microns. Prior to this examination, it is pertinent to review the defence mechanism of the respiratory tract.
Respiratory System Defences
Comprehensive details on the defence mechanisms of the respiratory tract will not be discussed. Instead readers are reminded that; coughing, sneezing, nasal hairs, respiratory tract cilia, mucous producing lining cells and the phagocytic activity of alveolar macrophages provide protection against inhaled foreign bodies including fungi, bacteria and viruses. 13 Indeed, the pathogen laden aerosols produced by everyday talking and eating would have the potential to cause significant disease if it were not for these effective respiratory tract defences.
These defences contradict the recently published belief that dentally produced aerosols, “enter unprotected bronchioles and alveoli.” 2 A pertinent demonstration of the respiratory tract’s ability to resist disease is the finding that- compared to controls- dentists had significantly elevated levels of antibodies to influenza A and B and the respiratory syncytial virus. 14 Thus, while dentists had greater than normal exposure to these aerosol transmissible pathogens, their potential to cause disease was resisted by respiratory immunologic responses. Interestingly, the wearing of masks and eye glasses did not lessen the production of antibodies, thus reducing their significance as personal protective barriers. 14 Another example of the effectiveness of respiratory defences is that although exposed to more aerosol transmissible pathogens than the general population, Tokyo dentists have a significantly lower risk of dying from pneumonia and bronchitis. 15 The ability of a face mask to prevent the infectious risk potentially inherent in sprays of blood and saliva reaching the wearers mouth and nose is questionable since, before the advent of mask use, dentists were no more likely to die of infectious diseases than the general population. 16
The respiratory tract has efficient defence mechanisms. Unless face masks have the ability to either enhance or lessen the need for such natural defences, their use as protection against airborne pathogens must be questioned.
Face Masks
History: Cloth or cotton gauze masks have been used since the late 19th century to protect sterile fields from spit and mucous generated by the wearer. 5,17,18 A secondary function was to protect the mouth and nose of the wearer from the sprays and splashes of blood and body fluids created during surgery. 17 As noted above, in the early 20th century masks were used to trap infectious “droplets” expelled by the wearer thus possibly reducing disease transmission to others. 18 Since the mid-20th century until to-day, face masks have been increasingly used for entirely the opposite function: that is to prevent the wearer from inhaling respiratory pathogens. 5,20,21 Indeed, most current dental infection control recommendations insist that a face mask be worn, “as a key component of personal protection against airborne pathogens”. 2
Literature reviews have confirmed that wearing a mask during surgery has no impact whatsoever on wound infection rates during clean surgery. 22,23,24,25,26 A recent 2014 report states categorically that no clinical trials have ever shown that wearing a mask prevents contamination of surgical sites. 26 With their original purpose being highly questionable it should be no surprise that the ability of face masks to act as respiratory protective devices is now the subject of intense scrutiny. 27 Appreciating the reasons for this, requires an understanding of the structure, fit and filtering capacity of face masks.
Structure and Fit: Disposable face masks usually consist of three to four layers of flat non-woven mats of fine fibres separated by one or two polypropylene barrier layers which act as filters capable of trapping material greater than 1 micron in diameter. 18,24,28 Masks are placed over the nose and mouth and secured by straps usually placed behind the head and neck. 21 No matter how well a mask conforms to the shape of a person’s face, it is not designed to create an air tight seal around the face. Masks will always fit fairly loosely with considerable gaps along the cheeks, around the bridge of the nose and along the bottom edge of the mask below the chin. 21 These gaps do not provide adequate protection as they permit the passage of air and aerosols when the wearer inhales. 11,17 It is important to appreciate that if masks contained filters capable of trapping viruses, the peripheral gaps around the masks would continue to permit the inhalation of unfiltered air and aerosols. 11
Filtering Capacity:
The filters in masks do not act as sieves by trapping particles greater than a specific size while allowing smaller particles to pass through. 18 Instead the dynamics of aerosolized particles and their molecular attraction to filter fibres are such that at a certain range of sizes both large and small particles will penetrate through a face mask. 18 Accordingly, it should be no surprise that a study of eight brands of face masks found that they did not filter out 20-100% of particles varying in size from 0.1 to 4.0 microns. 21 Another investigation showed penetration ranges from 5-100% when masks were challenged with relatively large 1.0 micron particles. 29 A further study found that masks were incapable of filtering out 80-85% of particles varying in size from 0.3 to 2.0 microns. 30 A 2008 investigation identified the poor filtering performance of dental masks. 27 It should be concluded from these and similar studies that the filter material of face masks does not retain or filter out viruses or other submicron particles. 11,31 When this understanding is combined with the poor fit of masks, it is readily appreciated that neither the filter performance nor the facial fit characteristics of face masks qualify them as being devices which protect against respiratory infections. 27 Despite this determination the performance of masks against certain criteria has been used to justify their effectiveness.2 Accordingly, it is appropriate to review the limitations of these performance standards.
Performance Standards: Face masks are not subject to any regulations. 11 The USA Federal Food and Drug Administration (FDA) classifies face masks as Class II devices. To obtain the necessary approval to sell masks all that a manufacturer need do is satisfy the FDA that any new device is substantially the same as any mask currently available for sale. 21 As ironically noted by the Occupational Health and Safety Agency for Healthcare in BC, “There is no specific requirement to prove that the existing masks are effective and there is no standard test or set of data required supporting the assertion of equivalence. Nor does the FDA conduct or sponsor testing of surgical masks.” 21 Although the FDA recommends two filter efficiency tests; particulate filtration efficiency (PFE) and bacterial filtration efficiency (BFE) it does not stipulate a minimum level of filter performance for these tests. 27 The PFE test is a basis for comparing the efficiency of face masks when exposed to aerosol particle sizes between 0.1 and 5.0 microns. The test does not assess the effectiveness of a mask in preventing the ingress of potentially harmful particles nor can it be used to characterize the protective nature of a mask. 32 The BFE test is a measure of a mask’s ability to provide protection from large particles expelled by the wearer. It does not provide an assessment of a mask’s ability to protect the wearer. 17 Although these tests are conducted under the auspices of the American Society of Testing and Materials (ASTM) and often produce filtration efficiencies in the range of 95-98 %, they are not a measure of a masks ability to protect against respiratory pathogens. Failure to appreciate the limitations of these tests combined with a reliance on the high filtration efficiencies reported by the manufacturers has, according to Healthcare in BC, “created an environment in which health care workers think they are more protected than they actually are.” 21 For dental personnel the protection sought is mainly from treatment induced aerosols.
Dental Aerosols
For approximately 40 years it has been known that dental restorative and especially ultrasonic scaling procedures produce aerosols containing not only blood and saliva but potentially pathogenic organisms. 33 The source of these organisms could be the oral cavities of patients and/or dental unit water lines. 34 Assessing the source and pathogenicity of these organisms has proven elusive as it is extremely difficult to culture bacteria especially anaerobes and viruses from dental aerosols. 34 Although there is no substantiated proof that dental aerosols are an infection control risk, it is a reasonable assumption that if pathogenic microbes are present at the treatment site they will become aerosolized and prone to inhalation by the clinician which a face mask will not prevent. As shown by the study of UK dentists, the inhalation resulted in the formation of appropriate antibodies to respiratory pathogens without overt signs and symptoms of respiratory distress. 14 This occurred whether masks were or were not worn. In a 2008 article, Dr. S. Harrel, of the Baylor College of Dentistry, is of the opinion that because there is a lack of epidemiologically detectable disease from the use of ultrasonic scalers, dental aerosols appear to have a low potential for transmitting disease but should not be ignored as a risk for disease transmission. 34 The most effective measures for reducing disease transmission from dental aerosols are pre-procedural rinses with mouthwashes such as chlorhexidine, large diameter high volume evacuators, and rubber dam whenever possible. 33 Face masks are not useful for this purpose, and Dr. Harrel believes that dental personnel have placed too great a reliance on their efficacy. 34 Perhaps this has occurred because dental regulatory agencies have failed to appreciate the increasing evidence on face mask inadequacies.
The Inadequacies
Between 2004 and 2016 at least a dozen research or review articles have been published on the inadequacies of face masks. 5,6,11,17,19,20,21,25,26,27,28,31 All agree that the poor facial fit and limited filtration characteristics of face masks make them unable to prevent the wearer inhaling airborne particles. In their well-referenced 2011 article on respiratory protection for healthcare workers, Drs. Harriman and Brosseau conclude that, “facemasks will not protect against the inhalation of aerosols.” 11 Following their 2015 literature review, Dr. Zhou and colleagues stated, “There is a lack of substantiated evidence to support claims that facemasks protect either patient or surgeon from infectious contamination.” 25 In the same year Dr. R. MacIntyre noted that randomized controlled trials of facemasks failed to prove their efficacy. 5 In August 2016 responding to a question on the protection from facemasks the Canadian Centre for Occupational Health and Safety replied:
  • The filter material of surgical masks does not retain or filter out submicron particles;
  • Surgical masks are not designed to eliminate air leakage around the edges;
  • Surgical masks do not protect the wearer from inhaling small particles that can remain airborne for long periods of time. 31
In 2015, Dr. Leonie Walker, Principal Researcher of the New Zealand Nurses Organization succinctly described- within a historical context – the inadequacies of facemasks, “Health care workers have long relied heavily on surgical masks to provide protection against influenza and other infections. Yet there are no convincing scientific data that support the effectiveness of masks for respiratory protection. The masks we use are not designed for such purposes, and when tested, they have proved to vary widely in filtration capability, allowing penetration of aerosol particles ranging from four to 90%.” 35
Face masks do not satisfy the criteria for effectiveness as described by Drs. Landefeld and Shojania in their NEJM article, “The Tension between Needing to Improve Care and Knowing How to Do It. 10 The authors declare that, “…recommending or mandating the widespread adoption of interventions to improve quality or safety requires rigorous testing to determine whether, how, and where the intervention is effective…” They stress the critical nature of this concept because, “…a number of widely promulgated interventions are likely to be wholly ineffective, even if they do not harm patients.” 10 A significant inadequacy of face masks is that they were mandated as an intervention based on an assumption rather than on appropriate testing.
Conclusions
The primary reason for mandating the wearing of face masks is to protect dental personnel from airborne pathogens. This review has established that face masks are incapable of providing such a level of protection. Unless the Centers for Disease Control and Prevention, national and provincial dental associations and regulatory agencies publically admit this fact, they will be guilty of perpetuating a myth which will be a disservice to the dental profession and its patients. It would be beneficial if, as a consequence of the review, all present infection control recommendations were subjected to the same rigorous testing as any new clinical intervention. Professional associations and governing bodies must ensure the clinical efficacy of quality improvement procedures prior to them being mandated. It is heartening to know that such a trend is gaining a momentum which might reveal the inadequacies of other long held dental infection control assumptions. Surely, the hallmark of a mature profession is one which permits new evidence to trump established beliefs. In 1910, Dr. C. Chapin, a public health pioneer, summarized this idea by stating, “We should not be ashamed to change our methods; rather, we should be ashamed not to do so.” 36 Until this occurs, as this review has revealed, dentists have nothing to fear by unmasking. OH
Don't be silly. If it don't work, why drs nurses insist on wearing? Think u can just reason away a virus? :cautious:
 

Leongsam

High Order Twit / Low SES subject
Admin
Asset
Don't be silly. If it don't work, why drs nurses insist on wearing? Think u can just reason away a virus? :cautious:

You still don't get it do you. If masks worked why would the medical workers dress up like this? The answer is that if you're going to kit up take measures that actually work ie eye protection plus proper filtration of the air being inhaled.

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The gauze masks that are being distributed do absolutely nothing because first of all they don't cover the eyes which is the obvious route of droplet infection.

Neither do they filter the air being inhaled because they leak all over the place. All they do is provide a false sense of security for dumb fucks that don't know any better.

It's like using this as a helmet when on a motorcycle.

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mojito

Alfrescian
Loyal
You still don't get it do you. If masks worked why would the medical workers dress up like this? The answer is that if you're going to kit up take measures that actually work ie eye protection plus proper filtration of the air being inhaled.

View attachment 71895

The gauze masks that are being distributed do absolutely nothing because first of all they don't cover the eyes which is the obvious route of droplet infection.

Neither do they filter the air being inhaled because they leak all over the place. All they do is provide a false sense of security for dumb fucks that don't know any better.

It's like using this as a helmet when on a motorcycle.

View attachment 71896
Silly you. Not hear Loong say? Mask supply is for healthcare worker! If every healthcare worker wear hazmat suits like that, then where the mask supplies go to? Where the N95s? :thumbsdown:
 

Hypocrite-The

Alfrescian
Loyal
We don't need face masks for coronavirus. But there are other ways to protect ourselves - ABC News
A woman wearing a mask crosses a road in the Shibuya district on February 02, 2020 in Tokyo, Japan.
The WHO declared the coronavirus a global health emergency in January.(Getty Images: Tomohiro Ohsumi / Stringer)
It's been a big year for face masks — and it's only February.
First, it was bushfire smoke.
Now, Australians have been panic-buying face masks to protect themselves from coronavirus.
Described by the World Health Organisation as 'public enemy number one', the coronavirus outbreak — dubbed COVID-19 — has more than 69,000 confirmed cases, and more than 1,600 people have died.
It's not clear how widespread or deadly the flu-like infection will be, but Australian health officials say there is no need for the general public to wear face masks.
There are, however, a number of ways you can reduce your risk of being infected — and in doing so, improve your odds of staving off other infections, including the flu and common cold.
Wait, why don't I need a face mask?
At this stage, the risk of catching coronavirus in Australia is low.
So far, there has been no human-to-human transmission of the virus (in Australia), with all of the people infected in Australia having recently been in China.
"At the moment, all of the cases we've seen have come from Hubei province or been in contact with people who had confirmed cases from there," Australia's Chief Medical Officer Brendan Murphy told RN Breakfast on Wednesday.
This means there is little reason for the general public to wear face masks, given the risk is so low.
"The only time when you would want to take broader community measures was [if] there is evidence of sustained community transmission in Australia," Dr Murphy said.
Surgical masks 'no use' for healthy people
Experts believe those with coronaviruses most often spread the infection via "respiratory droplets" — the little secretions we generate when we sneeze or cough.
Because of this, the virus tends to spread between people who are in close contact.
Surgical masks — the ones you typically see in public — provide some barrier against larger droplets and splashes of fluid being shared by infected people.
People in Sydney's CBD are seen wearing masks on January 31, 2020 in Sydney, Australia.
Face masks are not designed to keep healthy people from getting sick.(Getty Images: Jenny Evans / Stringer)
This is why people who are sick are encouraged to wear them, and why they are a sensible precaution in a place like Wuhan, the disease epicentre.
Surgical face masks, however, are not designed to provide respiratory protection, said Abrar Chughtai, an infectious disease epidemiologist from the University of New South Wales.
"When face masks were designed in the early 19th century, surgeons started using them to prevent the spread of their pathogens into operating fields," Dr Chughtai said.
"The main objective ... was to prevent the spread of infection."
Surgical masks do not provide a seal around the face, and therefore do not filter viral airborne particles.
It's a different story for health care workers, and the Australian Government has urged them to wear face masks.
"They are in direct and close contact with patients ... so they should use face masks or respirators," Dr Chughtai said.
Respirators, such as the P2 masks recommended for bushfire smoke, are thicker than surgical masks and able to filter 95 per cent of airborne particles.
However, these masks are uncomfortable and difficult to wear for long periods of time, so they are not recommended for general use in countries where transmission is not widespread.
Wash your hands properly
Given there is no vaccine to prevent the latest strain of coronavirus, the best way to prevent infection is to avoid being exposed to the virus.
Instead of worrying about face masks, healthy people should take every precaution they normally would to avoid catching the flu.
As with colds and other seasonal viruses, one of the most important things you can do is wash your hands — and wash them often.
Research shows hand washing significantly helps to prevent illness and the spread of infection.
Hand washing shouldn't just follow toilet use. You should also wash your hands:
  • after you cough or sneeze,
  • before you eat and when you prepare food,
  • after you handle animals,
  • when you care for someone unwell.
Your handwashing technique is also important — a quick splash under the tap won't cut it.
Person washing their hands under water tap with soap.
Handwashing is the cheapest and most effective form of infection control we have.(Pexels)
To get properly germ-free hands, you need to wash them for at least 20 seconds with soap under clean, running water.
When there's no water, a hand sanitiser or gel that contains at least 60 per cent alcohol is your best bet.
Be mindful of what you touch
The most common way seasonal illnesses spread is when our hands pick up bugs from contaminated surfaces. Once the virus is on our hands, it's all too easy for it to be transferred to our mouth, nose or eyes, where it can more readily enter cells and make us sick.
So, avoid touching your eyes, nose or mouth, especially if you haven't washed your hands for a while.
If you cough or sneeze, try to cover your mouth and nose with your elbow or a tissue, before throwing the tissue into a closed bin.
It's a good idea to clean and disinfect frequently touched objects and surfaces.
As is the case for colds and flus, avoid close contact with people who are sick. And if you're sick, keep your distance from others to protect them from getting sick too.
When going to the GP
If you have been to China and you are experiencing flu-like symptoms, you should immediately phone your GP and explain your symptoms and your travel history.
Do not make an appointment or attend a GP practice or hospital without informing them first, as they will need to make arrangements to protect others before you arrive.
If you have come into contact with someone who might have coronavirus, you can find more detailed advice here.
 

LaoTze

Alfrescian
Loyal
Yes! The surgical masks MIGHT filter out droplets that got the virus.
Those droplets will likely be breathed in from side of the masks and bottom of masks.
Even if not that case, those droplets stay on the mask.
And dry up in maybe 5 to 10 minutes.

Remember the virus will still be alive after many hours and days even when on door knobs and railings and buttons.
You think they die immediately on your mask fibres? Or remain alive.

And the live virus now on your mask fibres.
And when you inhale, the air rushing past the fibres will pick up the virus into your nose and lungs.

Besterest way to stay safe is to paste a yellow fu on your forehead that cover you down to your lips.

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If you kiasu, stick two of them.
 

Leongsam

High Order Twit / Low SES subject
Admin
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Alternative Coronavirus masks by Max Siedentopf
Max Siedentopf suggests alternative masks to protect against coronavirus

Amy Frearson | 13 hours ago 20 comments

Underwear, vegetables and carrier bags could all be used in the fight against coronavirus, suggests designer Max Siedentopf.

Siedentopf, a German-Namibian designer based in London, has created a series of provocative images showing everyday items being used as protective face masks.
Global demand for surgical face masks is growing, as people try to protect themselves against the virus. However doctors don't advise using them for protection as research shows they have limited use in preventing the spread of viruses.

Alternative Coronavirus masks by Max Siedentopf with lettuce leaf

Siedentopf's project, titled How-To Survive A Deadly Global Virus, suggests a variety of objects that could be used as alternatives to face masks.

"Since the virus is currently spreading globally, the series offers handy solutions how you can use simple everyday objects to protect yourself," he said.

Alternative Coronavirus masks by Max Siedentopf with sanitary pad

The series consists of 12 photographic portraits, each featuring a different mask.

Pants and a bra both feature, along with a sneaker that is tied around the face with shoelaces. There's also an image showing a man with a sanitary towel stuck to his face.

Alternative Coronavirus masks by Max Siedentopf with water bottle
Plastic objects used as masks include a large plastic water bottle worn around the head and a milk bottle that covers just the mouth and nose, while more biodegradable options include a lettuce leaf.

There's even an image showing a women wearing a tent over her head.

Alternative Coronavirus masks by Max Siedentopf with sneaker

Siedentopf was inspired to create the series after seeing images of alternative masks going viral on social media.

"People shared photos of alternative solutions to the conventional air mask, using objects such as orange peels, bras or water bottles," he said.



In 2018, Siedentopf installed binoculars on viewing balcony of the Tate Modern in London in protest against residents of the Roger Stirk Harbour + Partner's Neo Bankside development next door taking the art gallery to court over privacy issues.

Alternative Coronavirus masks by Max Siedentopf with orange peel

The outbreak of coronavirus originated in Wuhan, China, on 31 December. Efforts to contain the virus failed and is has now spread worldwide, with cases reported in Europe, North America and the Middle East.

Approximately 1,700 people have died after contracting the deadly virus and it is being treated as a global emergency by the World Health Organization.

Design shows in China were postponed due to the outbreak and a new hospital has been built in Wuhan to treat patients.

Alternative Coronavirus masks by Max Siedentopf with Tesco carrier bag

Although Siedentopf's project shows alternatives to surgical face masks, doctors don't advise using them as protection against the virus.

It is believed that wearing a mask for too long could even put a wearer at further risk, as it only traps virus particles, rather than deactivating them. They are considered more useful to people who are already sick, as they prevent germs from spreading.

The World Health Organization recommends washing hands regularly, discarding tissues after each use and maintaining distance from other people, in order to reduce risk of contracting a virus.
 

knowwhatyouwantinlife

Alfrescian
Loyal
Conveniently skirting around the fact that the diamond princess has only about 30% infected and almost all passengers are wearing some form of mask...bummer :rolleyes:
 

sweetiepie

Alfrescian
Loyal
Dezeen Magazine
Next story


Follow:
Alternative Coronavirus masks by Max Siedentopf
Max Siedentopf suggests alternative masks to protect against coronavirus

Amy Frearson | 13 hours ago 20 comments

Underwear, vegetables and carrier bags could all be used in the fight against coronavirus, suggests designer Max Siedentopf.

Siedentopf, a German-Namibian designer based in London, has created a series of provocative images showing everyday items being used as protective face masks.
Global demand for surgical face masks is growing, as people try to protect themselves against the virus. However doctors don't advise using them for protection as research shows they have limited use in preventing the spread of viruses.

Alternative Coronavirus masks by Max Siedentopf with lettuce leaf

Siedentopf's project, titled How-To Survive A Deadly Global Virus, suggests a variety of objects that could be used as alternatives to face masks.

"Since the virus is currently spreading globally, the series offers handy solutions how you can use simple everyday objects to protect yourself," he said.

Alternative Coronavirus masks by Max Siedentopf with sanitary pad

The series consists of 12 photographic portraits, each featuring a different mask.

Pants and a bra both feature, along with a sneaker that is tied around the face with shoelaces. There's also an image showing a man with a sanitary towel stuck to his face.

Alternative Coronavirus masks by Max Siedentopf with water bottle
Plastic objects used as masks include a large plastic water bottle worn around the head and a milk bottle that covers just the mouth and nose, while more biodegradable options include a lettuce leaf.

There's even an image showing a women wearing a tent over her head.

Alternative Coronavirus masks by Max Siedentopf with sneaker

Siedentopf was inspired to create the series after seeing images of alternative masks going viral on social media.

"People shared photos of alternative solutions to the conventional air mask, using objects such as orange peels, bras or water bottles," he said.



In 2018, Siedentopf installed binoculars on viewing balcony of the Tate Modern in London in protest against residents of the Roger Stirk Harbour + Partner's Neo Bankside development next door taking the art gallery to court over privacy issues.

Alternative Coronavirus masks by Max Siedentopf with orange peel

The outbreak of coronavirus originated in Wuhan, China, on 31 December. Efforts to contain the virus failed and is has now spread worldwide, with cases reported in Europe, North America and the Middle East.

Approximately 1,700 people have died after contracting the deadly virus and it is being treated as a global emergency by the World Health Organization.

Design shows in China were postponed due to the outbreak and a new hospital has been built in Wuhan to treat patients.

Alternative Coronavirus masks by Max Siedentopf with Tesco carrier bag

Although Siedentopf's project shows alternatives to surgical face masks, doctors don't advise using them as protection against the virus.

It is believed that wearing a mask for too long could even put a wearer at further risk, as it only traps virus particles, rather than deactivating them. They are considered more useful to people who are already sick, as they prevent germs from spreading.

The World Health Organization recommends washing hands regularly, discarding tissues after each use and maintaining distance from other people, in order to reduce risk of contracting a virus.
KNN what about using @ginfreely toa jibye kang KNN
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