Even between lockdowns, masks can be a symbol of unity

THERE are many patients who attend their GP practices not wearing masks appropriately. They may be ill-fitting, too loose, covering their mouths but not the nose, or poor quality, made of the wrong material.

A patient has morbid obesity and cardiomyopathy with gross lymphoedema. He walks into the consultation room with his mask over his chin and asks if he can have an exemption letter from wearing a mask outside his home as he finds them suffocating. He is unvaccinated and refusing to have the mRNA COVID-19) vaccine especially since he heard it has the potential for cardiac side effects, based on overseas studies particularly in males below 30 years of age. I explain to him that he has a high risk for complications for COVID-19 infection, including hospitalisation and death due to his comorbidities, and the very least he should consider is to wear a properly fitted mask. I took this opportunity to educate him on the value of wearing a good mask especially in enclosed areas such as shopping centres.

These are great opportunities for GPs and other health care workers to ensure patients are well educated on the value of wearing masks properly, through respectful dialogue. As health professionals we should be positive role models by wearing masks ourselves during consultations, especially in high risk areas and during outbreaks, to help patients feel at ease. The Doherty Institute modelling studies have found that public health measures such as wearing facial masks, physical distancing and short lockdowns when required will continue to play an important role even with widespread population vaccination.

At the time of writing this article, New South Wales is almost completely locked down, Victoria is in its sixth COVID-19-related lockdown, and it is likely it will not be the last. Currently, there are lockdowns in place also in the Australian Capital Territory and parts of the Northern Territory.

Protection of health care workers with masks

Since the introduction of compulsory masks at our workplace during COVID-19 outbreaks, our staff have continued to wear properly fitted masks even between lockdowns. The majority of patients seem to be happy to wear masks at our practice, and for those who are not, we ensure they too feel comfortable and welcome.

Health care workers who demonstrate comfort in wearing masks are good role models for our patients, and studies have found that masks can significantly reduce the risk of COVID-19 transmission in workplaces. In our practice, we have noticed a marked difference compared with previous years; our staff have not taken a single day of sick leave for influenza, colds, and other illnesses.

Recent studies have confirmed our observation that the incidence of influenza virus in Australia has been historically the lowest ever in 2021. In Victoria, health care workers must now wear a N95 or P2 respirator with high and low risk patients with suspected COVID-19 during high risk of community transmission.

Efficacy of masks

While vaccines are being rolled out, studies have found masks are very effective and play an important role in significantly reducing aerosol transmission of COVID-19. When masks were mandated in Melbourne in July 2020 during a severe outbreak, they contributed to a significant reduction in COVID-19 cases in a very short time. Apart from reducing aerosol spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), masks act as a barrier and help reduce viral load and hence the severity of COVID-19 if exposed.

Long term use of masks to reduce recurring lockdowns

In Victoria, masks must be worn outside the home by anyone aged 12 years and over, unless there are lawful exceptions. On Friday, the NSW government made it mandatory for everyone to wear a mask while outside their home across the state from midnight tonight, unless they are exercising. Up until now NSW Health has only “strongly recommended wearing face masks if you are unable to physically distance from people you do not live with”. Wearing face masks is mandatory in the ACT for everyone aged 12 years and over outside the home, since the start of their lockdown on 12 August 2021.

Health authorities may need to consider masks for the long haul in high risk areas, especially after and between lockdowns to help reduce unexpected exposures to COVID-19 and to soften the blows to the community of repeated lockdowns.

Strict quarantines can be improved, but as we have witnessed in Australia, they are not bulletproof. For masks to be effective, the community needs to be well educated with simple language on the benefits of appropriate mask wearing until we have control of the pandemic or COVID-19 is no longer a threat to us.

Public education should focus on how to wear masks correctly to be effective and the benefits of wearing them in high risk and crowded areas, such as public transport, shopping centres, sporting events, concerts, and any enclosed public events, especially where physical distancing is impossible. Masks may possibly help reduce the frequency of lockdowns, which have proven to be harmful and devastating for the wider community during outbreaks.

Community acceptance of masks

While there are members of the community still resistant to wearing masks, many people seem to have accepted masks and they are now becoming common practice. Studies found that implementing a mandatory policy increased compliance and correlated positively with other protective behaviour. The more people that wear masks in a social group, the more likely people feel comfortable about wearing them. Communities with high reported mask-wearing and physical distancing had the highest predicted probability of transmission control.

Medical exemptions for masks

Health practitioners are not obliged to provide a medical exemption certificate for patients who are not wanting to wear a mask. In Victoria, for example, there are valid medical exemptions such as severe skin conditions, eye conditions such as face mask-associated ocular irritation and dryness due to regular and prolonged use of facial masks, feelings of suffocation, asthma, anxiety, panic, shortness of breath, intellectual disability, autism, or trauma. In Tasmania and NSW, it is now mandatory for people to hold a medical certificate from their health practitioner or hold a statutory declaration that they are exempt from wearing a mask due to valid medical reasons. It is common for patients to request a written supportive letter for mask exemption.

Cloth versus disposable masks

There are two types of masks available to the community: disposable and cloth masks.

Recent studies (here and here) have found cloth masks for community use can be quite effective in reducing respiratory spread of COVID-19. One study found that well fitting, three-layered cloth masks can be as effective at reducing the transmission of COVID-19 as surgical masks. The Burnet Institute found that masks are very effective in preventing COVID-19 transmission, and good masks when worn properly can block 99% of COVID-19-linked droplets.

Cloth masks made according to Federal guidelines and Victorian guidelines should be washed in hot water above 55–65⁰C for more than 5 minutes and detergent to kill the virus. Cloth masks are also recyclable and better for the environment than disposable masks.

Simple methods, such as the use of adhesive tape can help position masks on the face properly to be more effective.

Conclusion

Growing research and health authorities are urging the use of mass masking during the pandemic at times of high COVID-19 risk exposure with lockdowns and other public health measures. Long term mask use in crowded public places where physical distancing is impossible between lockdowns can be used as a weapon to help us combat and prevent further lockdowns. Masks should not be seen as a negative but as a symbol of compassion and union to keep our communities protected and healthy.

Associate Professor Vicki Kotsirilos AM is a GP with over 35 years of clinical experience.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.