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Face masks: benefits and risks during the COVID-19 crisis

The German government has made it mandatory to wear medical masks covering mouth and nose (MNC) as an effective strategy to fight SARS-CoV-2 infections. In many countries, this directive has been extended on shopping malls or public transportation. The aim of this paper is to critically analyze the statutory regulation to wear protective masks during the COVID-19 crisis from a medical standpoint.

Methods

We performed an extensive query of the most recent publications addressing the prevention of viral infections including the use of face masks in the community as a method to prevent the spread of the infection. We addressed the issues of practicability, professional use, and acceptability based on the community and the environment where the user resided.

Results

Upon our critical review of the available literature, we found only weak evidence for wearing a face surgical mask with ties as an efficient hygienic tool to prevent the spread of a viral infection. However, the use of MNC seems to be linked to relevant protection during close contact scenarios by limiting pathogen-containing aerosol and liquid droplet dissemination. Importantly, we found evidence for significant respiratory compromise in patients with severe obstructive pulmonary disease, secondary to the development of hypercapnia. This could also happen in patients with lung infections, with or without SARS-CoV-2.

Conclusion

Epidemiologists currently emphasize that wearing MNC will effectively interrupt airborne infections in the community. The government and the politicians have followed these recommendations and used them to both advise and, in some cases, mandate the general population to wear MNC in public locations. Overall, the results seem to suggest that there are some clinically relevant scenarios where the use of MNC necessitates more defined recommendations. Our critical evaluation of the literature both highlights the protective effects of certain types of face masks in defined risk groups, and emphasizes their potential risks.

The knowledge that the use of face masks delays the SARS-CoV-2 transmission is rapidly gaining popularity in the general population. Politicians need guidance on how masks should be used by the public to fight the COVID-19 pandemic crisis. In this review, we summarize the relevant literature on this topic.

“The surgical face mask has become a symbol of our times.”

On March 17th, 2020, this was the headline of an article in the New York Times on the role of face masks during the COVID-19 outbreak. Face masks have become a clothing accessory that is worn every day and everywhere. A variety of shapes, forms, and materials are being used and advertised to the point that in 2020 the business of producing and selling non-medical mask was born.

In Germany, the government has ruled that wearing a face mask is obligatory to protect the population from any risks of airborne illness, according to the constitutional law [1] stating that “Protection must be easily provided to every citizen in the country.”

The aim of this paper is to analyze and critically discuss the regulations of some Federal States in Germany, which require protective masks in public to conform to similar regulations already in place in other countries.

Most masks covering the mouth are named mouth nose covering (MNC) according to the Robert Koch Institute (RKI; the German federal government agency and research institute responsible for disease control and prevention) and do not protect against respiratory and airborne infections. In the following review, the term “protective masks” will be used to describe any type of face mask.

The science around the use of masks by the public to impede COVID-19 transmission is advancing rapidly. In this narrative review, we develop an analytical framework to examine mask usage, synthesizing the relevant literature to inform multiple areas: population impact, transmission characteristics, source control, wearer protection, sociological considerations, and implementation considerations. A primary route of transmission of COVID-19 is via respiratory particles, and it is known to be transmissible from presymptomatic, paucisymptomatic, and asymptomatic individuals. Reducing disease spread requires two things: limiting contacts of infected individuals via physical distancing and other measures and reducing the transmission probability per contact. The preponderance of evidence indicates that mask wearing reduces transmissibility per contact by reducing transmission of infected respiratory particles in both laboratory and clinical contexts. Public mask wearing is most effective at reducing spread of the virus when compliance is high. Given the current shortages of medical masks, we recommend the adoption of public cloth kids mask wearing, as an effective form of source control, in conjunction with existing hygiene, distancing, and contact tracing strategies. Because many respiratory particles become smaller due to evaporation, we recommend increasing focus on a previously overlooked aspect of mask usage: mask wearing by infectious people (“source control”) with benefits at the population level, rather than only mask wearing by susceptible people, such as health care workers, with focus on individual outcomes. We recommend that public officials and governments strongly encourage the use of widespread face masks in public, including the use of appropriate regulation.

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