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      The impact and effectiveness of the general public wearing masks to reduce the spread of pandemics in the UK: a multidisciplinary comparison of single-use masks versus reusable face masks

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          Abstract

          During the coronavirus (COVID-19) pandemic, the UK government mandated the use of face masks in various public settings and recommended the use of reusable masks to combat shortages of medically graded single-use masks in healthcare. To assist decision-making on the choice of masks for future pandemics, where shortages may not be a contributing factor, the University College London (UCL) Plastic Waste Innovation Hub has carried out a multidisciplinary comparison between single-use and reusable masks based on their anatomy, standalone effectiveness, behavioural considerations, environmental impact and costs. Although current single-use masks have a higher standalone effectiveness against bacteria and viruses, studies show that reusable masks have adequate performance in slowing infection rates of respiratory viruses. Material flow analysis (MFA), life cycle assessment (LCA) and cost comparison show that reusable masks have a lower environmental and economic impact than single-use masks. If every person in the UK uses one single-use mask each day for a year, it will create a total of 124,000 tonnes of waste, 66,000 tonnes of which would be unrecyclable contaminated plastic waste (the masks), with the rest being the recyclable packaging typically used for transportation and distribution of masks. Using reusable masks creates >85% less waste, generates 3.5 times lower impact on climate change and incurs 3.7 times lower costs. Further behavioural research is necessary to understand the extent and current practices of mask use; and how these practices affect mask effectiveness in reducing infection rates. Wearing single-use masks may be preferred over reusable masks due to perceptions of increased hygiene and convenience. Understanding behaviour towards the regular machine-washing of reusable masks for their effective reuse is key to maximise their public health benefits and minimise environmental and economic costs.

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          The behaviour change wheel: A new method for characterising and designing behaviour change interventions

          Background Improving the design and implementation of evidence-based practice depends on successful behaviour change interventions. This requires an appropriate method for characterising interventions and linking them to an analysis of the targeted behaviour. There exists a plethora of frameworks of behaviour change interventions, but it is not clear how well they serve this purpose. This paper evaluates these frameworks, and develops and evaluates a new framework aimed at overcoming their limitations. Methods A systematic search of electronic databases and consultation with behaviour change experts were used to identify frameworks of behaviour change interventions. These were evaluated according to three criteria: comprehensiveness, coherence, and a clear link to an overarching model of behaviour. A new framework was developed to meet these criteria. The reliability with which it could be applied was examined in two domains of behaviour change: tobacco control and obesity. Results Nineteen frameworks were identified covering nine intervention functions and seven policy categories that could enable those interventions. None of the frameworks reviewed covered the full range of intervention functions or policies, and only a minority met the criteria of coherence or linkage to a model of behaviour. At the centre of a proposed new framework is a 'behaviour system' involving three essential conditions: capability, opportunity, and motivation (what we term the 'COM-B system'). This forms the hub of a 'behaviour change wheel' (BCW) around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these conditions; around this are placed seven categories of policy that could enable those interventions to occur. The BCW was used reliably to characterise interventions within the English Department of Health's 2010 tobacco control strategy and the National Institute of Health and Clinical Excellence's guidance on reducing obesity. Conclusions Interventions and policies to change behaviour can be usefully characterised by means of a BCW comprising: a 'behaviour system' at the hub, encircled by intervention functions and then by policy categories. Research is needed to establish how far the BCW can lead to more efficient design of effective interventions.
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            Rational use of face masks in the COVID-19 pandemic

            Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that caused coronavirus disease 2019 (COVID-19), the use of face masks has become ubiquitous in China and other Asian countries such as South Korea and Japan. Some provinces and municipalities in China have enforced compulsory face mask policies in public areas; however, China's national guideline has adopted a risk-based approach in offering recommendations for using face masks among health-care workers and the general public. We compared face mask use recommendations by different health authorities (panel ). Despite the consistency in the recommendation that symptomatic individuals and those in health-care settings should use face masks, discrepancies were observed in the general public and community settings.1, 2, 3, 4, 5, 6, 7, 8 For example, the US Surgeon General advised against buying masks for use by healthy people. One important reason to discourage widespread use of face masks is to preserve limited supplies for professional use in health-care settings. Universal face mask use in the community has also been discouraged with the argument that face masks provide no effective protection against coronavirus infection. Panel Recommendations on face mask use in community settings WHO 1 • If you are healthy, you only need to wear a mask if you are taking care of a person with suspected SARS-CoV-2 infection. China 2 • People at moderate risk* of infection: surgical or disposable mask for medical use. • People at low risk† of infection: disposable mask for medical use. • People at very low risk‡ of infection: do not have to wear a mask or can wear non-medical mask (such as cloth mask). Hong Kong 3 • Surgical masks can prevent transmission of respiratory viruses from people who are ill. It is essential for people who are symptomatic (even if they have mild symptoms) to wear a surgical mask. • Wear a surgical mask when taking public transport or staying in crowded places. It is important to wear a mask properly and practice good hand hygiene before wearing and after removing a mask. Singapore 4 • Wear a mask if you have respiratory symptoms, such as a cough or runny nose. Japan 5 • The effectiveness of wearing a face mask to protect yourself from contracting viruses is thought to be limited. If you wear a face mask in confined, badly ventilated spaces, it might help avoid catching droplets emitted from others but if you are in an open-air environment, the use of face mask is not very efficient. USA 6 • Centers for Disease Control and Prevention does not recommend that people who are well wear a face mask (including respirators) to protect themselves from respiratory diseases, including COVID-19. • US Surgeon General urged people on Twitter to stop buying face masks. UK 7 • Face masks play a very important role in places such as hospitals, but there is very little evidence of widespread benefit for members of the public. Germany 8 • There is not enough evidence to prove that wearing a surgical mask significantly reduces a healthy person's risk of becoming infected while wearing it. According to WHO, wearing a mask in situations where it is not recommended to do so can create a false sense of security because it might lead to neglecting fundamental hygiene measures, such as proper hand hygiene. However, there is an essential distinction between absence of evidence and evidence of absence. Evidence that face masks can provide effective protection against respiratory infections in the community is scarce, as acknowledged in recommendations from the UK and Germany.7, 8 However, face masks are widely used by medical workers as part of droplet precautions when caring for patients with respiratory infections. It would be reasonable to suggest vulnerable individuals avoid crowded areas and use surgical face masks rationally when exposed to high-risk areas. As evidence suggests COVID-19 could be transmitted before symptom onset, community transmission might be reduced if everyone, including people who have been infected but are asymptomatic and contagious, wear face masks. Recommendations on face masks vary across countries and we have seen that the use of masks increases substantially once local epidemics begin, including the use of N95 respirators (without any other protective equipment) in community settings. This increase in use of face masks by the general public exacerbates the global supply shortage of face masks, with prices soaring, 9 and risks supply constraints to frontline health-care professionals. As a response, a few countries (eg, Germany and South Korea) banned exportation of face masks to prioritise local demand. 10 WHO called for a 40% increase in the production of protective equipment, including face masks. 9 Meanwhile, health authorities should optimise face mask distribution to prioritise the needs of frontline health-care workers and the most vulnerable populations in communities who are more susceptible to infection and mortality if infected, including older adults (particularly those older than 65 years) and people with underlying health conditions. People in some regions (eg, Thailand, China, and Japan) opted for makeshift alternatives or repeated usage of disposable surgical masks. Notably, improper use of face masks, such as not changing disposable masks, could jeopardise the protective effect and even increase the risk of infection. Consideration should also be given to variations in societal and cultural paradigms of mask usage. The contrast between face mask use as hygienic practice (ie, in many Asian countries) or as something only people who are unwell do (ie, in European and North American countries) has induced stigmatisation and racial aggravations, for which further public education is needed. One advantage of universal use of face masks is that it prevents discrimination of individuals who wear masks when unwell because everybody is wearing a mask. It is time for governments and public health agencies to make rational recommendations on appropriate face mask use to complement their recommendations on other preventive measures, such as hand hygiene. WHO currently recommends that people should wear face masks if they have respiratory symptoms or if they are caring for somebody with symptoms. Perhaps it would also be rational to recommend that people in quarantine wear face masks if they need to leave home for any reason, to prevent potential asymptomatic or presymptomatic transmission. In addition, vulnerable populations, such as older adults and those with underlying medical conditions, should wear face masks if available. Universal use of face masks could be considered if supplies permit. In parallel, urgent research on the duration of protection of face masks, the measures to prolong life of disposable masks, and the invention on reusable masks should be encouraged. Taiwan had the foresight to create a large stockpile of face masks; other countries or regions might now consider this as part of future pandemic plans. © 2020 Sputnik/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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              Aerosol Filtration Efficiency of Common Fabrics Used in Respiratory Cloth Masks

              The emergence of a pandemic affecting the respiratory system can result in a significant demand for face masks. This includes the use of cloth masks by large sections of the public, as can be seen during the current global spread of COVID-19. However, there is limited knowledge available on the performance of various commonly available fabrics used in cloth masks. Importantly, there is a need to evaluate filtration efficiencies as a function of aerosol particulate sizes in the 10 nm to 10 μm range, which is particularly relevant for respiratory virus transmission. We have carried out these studies for several common fabrics including cotton, silk, chiffon, flannel, various synthetics, and their combinations. Although the filtration efficiencies for various fabrics when a single layer was used ranged from 5 to 80% and 5 to 95% for particle sizes of 300 nm, respectively, the efficiencies improved when multiple layers were used and when using a specific combination of different fabrics. Filtration efficiencies of the hybrids (such as cotton–silk, cotton–chiffon, cotton–flannel) was >80% (for particles 90% (for particles >300 nm). We speculate that the enhanced performance of the hybrids is likely due to the combined effect of mechanical and electrostatic-based filtration. Cotton, the most widely used material for cloth masks performs better at higher weave densities (i.e., thread count) and can make a significant difference in filtration efficiencies. Our studies also imply that gaps (as caused by an improper fit of the mask) can result in over a 60% decrease in the filtration efficiency, implying the need for future cloth mask design studies to take into account issues of “fit” and leakage, while allowing the exhaled air to vent efficiently. Overall, we find that combinations of various commonly available fabrics used in cloth masks can potentially provide significant protection against the transmission of aerosol particles.
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                Author and article information

                Journal
                UCL Open Environ
                UCLOE
                UCL Open Environment
                UCL Open Environ
                UCL Press (UK )
                2632-0886
                25 August 2021
                2021
                : 3
                Affiliations
                [1 ]UCL Plastic Waste Innovation Hub, University College London, 90 Tottenham Court Road, London W1T 4TJ, UK
                Author notes
                *Corresponding author: E-mail: m.miodownik@ 123456ucl.ac.uk

                aAuthors in alphabetical order, the contributions of each author are included in the Acknowledgements.

                Article
                10.14324/111.444/ucloe.000022
                © 2021 The Authors.

                This is an open access article distributed under the terms of the Creative Commons Attribution Licence (CC BY) 4.0, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 8, Tables: 27, References: 111, Pages: 43
                Funding
                UKRI/EPSRC EP/S024883/1.
                Categories
                Research Article

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