New Normal: Will face shields replace masks?
TORONTO -- Plenty of people trying to do their best to follow public health advice are finding it difficult and uncomfortable to wear masks when out in public.
But how effective are masks when they aren’t worn correctly and could face shields be a more practical long-term solution as we gradually learn to live with this virus lurking around us?
Ride public transit or visit any store, garden centre, or barber shop and you are bound to find plenty of people without masks and more who are wearing them incorrectly: pulled down so they don’t cover their nose or riding under their chin. Wearers are touching the outside of the mask to readjust them or to pull them off so they can be heard.
All of that negates the benefits of wearing the mask, increases the risk of having potentially contaminated hands near the face, and may give wearers a false sense of security when out among others, experts say.
The idea behind asking people to mask up is to minimize the risk of those carrying the virus without any symptoms (studies have found that to anywhere from 18 per cent to 81 per cent of COVID-19 cases are asymptomatic) from unknowingly and silently spreading it to others.
While the science isn’t exactly definitive, face coverings are believed to offer at least something of a barrier to prevent respiratory droplets emitted through coughing, sneezing, laughing or talking from travelling from an infected person to others.
But many Canadians are learning that face masks are irritating, if not even downright excruciating. If they don’t fit right, they drift up into your eyes or down under your nose. They are hot and itchy, and will only feel more so the heat and humidity of summer takes hold.
Some people feel claustrophobic, anxious or dizzy in them.
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They are also a barrier to human connection. It’s hard to have a conversation with someone behind a mask, and never mind trying to smile. For those with hearing issues, masks are very troubling, and there is no doubt kids, and plenty of adults, find them unsettling, if not downright scary.
And for some with breathing issues or some cognitive issues, masks are a no-go entirely.
Face shields – clear sheets of plastic that cover from the forehead down past the chin – overcome virtually all the cons posed by masks, while having the added benefit of covering the eyes. So could they be the next go-to accessory in a COVID-19 world as stay-at-home restrictions are eased?
Experts who spoke to CTVNews.ca say more research is needed, but that face shields could be a potential alternative to medical and non-medical masks for the public now that health authorities, including Health Canada, the World Health Organization, and the U.S. Centers for Disease Control are recommending the use of face masks in situations where physical distancing can’t be maintained.
Health-care workers routinely wear shields in addition to medical masks to protect from splashing or projectile droplets when doing certain surgeries and procedures, including inserting and removing breathing tubes and COVID-19 swab tests.
But guidelines issued by the federal government for the public use of non-medical masks or face coverings make no mention of face shields.
According to Public Services and Procurement Canada, as of May 19, the federal government had ordered more than 55.5 million face shields and as of May 25, Health Canada had fast-tracked approval on about 90 face shield products.
Canada has mostly avoided the controversy around face masks fuelled by U.S. President Donald Trump’s refusal to wear one and open mocking of political foes who do. There have even been a growing number of conflicts, some violent, when people have been asked to wear masks in stores and restaurants south of the border.
But face coverings will become an ever-more significant public face of Canada’s COVID-19 battle as the country – to varying degrees across the provinces – opens up its economy and loosens pandemic restrictions while still trying to contain a virus that is responsible for more than 88,467 cases and 6,873 deaths in Canada and 5.6 million cases and 353,373 deaths worldwide as of this writing.
COMFORTABLE, EASY TO USE
Infectious diseases specialist Dr. Daniel Diekema generally wears a face shield when out in public, although he has a face mask on hand, too, when establishments specifically mandate masks.
He was a co-author on an article published at the end of April in JAMA, the Journal of the American Medical Association, which advocated for a place for face shields among a host of mitigation measures, including hand-washing, physical distancing, testing, tracing and quarantine measures, and controlling outbreaks in high-risk environments, such as long-term care.
“Masks and face shields mostly protect those around the wearer when physical distancing is not possible,” said Diekema during a phone interview with CTVNews.ca from Iowa City, Iowa.
“No one can or should say that masks or shields are the solution or are perfect barriers. They aren’t.”
But shields are a good alternative to masks for the public for plenty of reasons, ranging from comfort, and superior ability to communicate verbally and non-verbally, says Diekema, who is the director of the division of infectious diseases at University of Iowa Health Care.
They are also hard to use incorrectly, are generally less obtrusive and intimidating.
“I think masks can be scary to some people and I’ve also noticed there is a level of discomfort when people are in masks because I’ve realized just how much I depend on seeing an entire face just to recognize people.”
While shields may not entirely block the respiratory droplets ejected during a cough or sneeze, they direct them downwards and prevent them from flying out in front of you, which is dangerous in face-to-face situations, he says.
While we all know we shouldn’t touch our face, even an infectious disease doctor is prone to unconsciously try to scratch his nose, says Diekema. A face shield prevents that.
His is so comfortable he sometimes forget he has it on when he’s walking home from work.
“If you get a lightweight, clear face shield that fits you well, I can attest it’s much more comfortable and easier to wear than a mask.”
Shields are reusable and relatively quick and easy to clean with disinfectant wipes or soap and water, an advantage over cloth masks that must be run through a washing machine or disposable ones that pile up in garbage cans.
Dr. Avinash Sinha, an anesthesiologist at McGill University Health Centre, says face shields are an adequate solution when masks aren’t suitable and are certainly preferable to a mask worn incorrectly.
“If you can’t wear a mask, face shields are better than nothing. But a mask offers close protection so that it’s much harder for the virus to sneak around the mask.”
For instance, a shield might not be effective if someone standing beside the wearer coughs or sneezes in their direction.
Sinha, who works on an acute care team for COVID-19 patients, is part of a team of McGill physicians and scientists that has developed a reusable cloth mask for the public, along with a website to share facts about masks.
“I think it’s important to give people the tools to make better choices,” he said in a call with CTVNews.ca. “Choose something you can comply with wearing. That is key, whether it’s a mask or a shield, figure out what it is you will use in public.”
He does warn that masks aren’t meant to be worn for long periods of time. As the material gets wet from breathing, it loses its filtration function, says Sinha. It also can become contaminated with bacteria and mold.
A shield can be just as dirty.
“Just because you can’t see it, doesn’t mean it’s clean. You must be careful taking it off and remember that your hands must always be away from your face.”
And always remember you aren’t impervious to this virus, no matter what protection you choose, unless you wash your hands frequently, avoid touching your face, and stay more than two metres away from others wherever possible, Sinha says.
There are “obvious benefits” to face shields, says Dr. Zain Chagla, medical director of infection control at St. Joseph’s Healthcare in Hamilton, Ont.
They don’t move around as much, they don’t compress the face, they’re easy to clean, they block the wearer from touching their face, and they allow for others to see expressions and to read lips. They are also affordable, widely available, and can be easily produced in 3D printers.
He says they are a “pretty good” but not perfect barrier to keep droplets out but “there is still no evidence for shields preventing you from shedding droplets if you’re sick/asymptomatic,” Chagla wrote in an email to CTVNews.ca.
He said that there is some data that suggests cloth masks are protective in both directions – preventing the wearer from both acquiring and shedding the virus.
“Masks I think are useful for the average person, and face shields could be considered if there is an issue with masks,” he wrote. “Keep a few washable masks and make sure they get cleaned regularly.”
LESS TROUBLESOME FOR MANY
Dr. Susan Waserman, a specialist in allergies and immunology at Hamilton Health Sciences, expects face shields may become commonplace in schools and within pediatric hospitals, because kids, along with those with a range of sensory and cognitive conditions, aren’t as frightened or upset by them.
They can even be worn by little ones. A hospital in Thailand puts tiny face shields on newborns born during the pandemic to protect them.
They are also a better solution for those with asthma and other respiratory diseases.
A person with asthma may be OK to wear a mask for a half-hour trip to the grocery store, but they won’t be able to wear one for a shift at work, says Waserman.
“Masks can cause hyperventilation and breathing in hot, humid air may cause irritation and trigger asthma symptoms.”
The Asthma Society of Canada is suggesting that those who can tolerate a mask to wear one in public.
“Right now, there is a stigma and a lot of judgement around not wearing a mask, so we need to remind people to be supportive of each other and mindful that not everyone can wear a mask,” said CEO Vanessa Foran.
She sees why many find face shields more comfortable, but she says until there is enough evidence that they are effective against the coronavirus, her organization won’t recommend them.
“My concern about face shields is not that they are a good idea or a bad idea. I fear that people will get closer to each other than they should because they have a false sense of security. Nothing replaces physical distancing and hand washing.”
Masks leave those living with hearing loss struggling in a world where they can’t lip read. A Kentucky woman’s Facebook post last month documenting her difficulties in a grocery store was shared close to 70,000 times.
“I’ve faced a lot of frustration with communication while being Deaf, but never like this. In this time we’re living in, it’s hard. It is so hard,” Kimberly Fugate wrote.
WHAT THE SCIENCE SAYS
To be effective, say the doctors in the JAMA article, shields need to extend lower than the chin, beyond the ears and there should be no gap between the forehead and the shield’s head piece.
Diekema and his colleagues aren’t alone in advocating the use of shields for the public. The Infectious Diseases Society of America has included them among other personal protective equipment in its recommendations for easing pandemic restrictions.
The JAMA paper points out that experience and evidence shows that even during the COVID-19 crisis, health-care workers “rarely acquire infections during patient care when proper PPE is used and that most of their infections are acquired in the community where PPE is typically not worn.”
Just how effective shields and masks are is still a relative unknown, but is now the subject of research going on around the world, he says.
A 2014 simulation study found that a face shield reduced the wearer’s exposure to the flu virus by 96 per cent at a distance of 18 inches from someone who was coughing.
But Diekema and his colleagues point out that no studies have evaluated the ability of face shields to contain a sneeze or cough when worn by infected people, what public health experts call source control.
But the science around masks is spotty, too, though plenty of research is underway.
One group of researchers found significant suppression of COVID-19 when at least 80 per cent of the population is wearing masks, even homemade varieties, versus only minimal impact when 50 per cent of less is wearing them.
They concluded that when combined with other measures, including social distancing and mass contact tracing, a “‘mouth-and-nose lockdown’ is far more sustainable than a ‘full body lockdown’, from economic, social, and mental health standpoints.”
Another study found cloth masks can help reduce transmission of COVID-19.
But another study concluded sweeping mask policies will not reduce the transmission of the novel coronavirus.
“Overall, the body of research on mask efficacy in real-world settings is small and scattershot,” two infectious disease experts wrote in early April.
Waserman doesn’t deny that wearing masks can be tricky and uncomfortable and that shields protect more of the face and are easier to deal with.
But she says there is a lack of definitive data comparing the effectiveness of masks and shields.
“As we ease restrictions, we need alternatives in order to go about life in a safer manner, but the science is not there yet,” she told CTVNews.ca in a phone interview.
“Can shields do everything? We don’t know.”
No intervention – even a vaccine – will ever be 100 per cent effective, says Waserman. That’s never possible in disease prevention. So adding shields to a suite of measures makes sense, she says.
SHIELDING A RETURN TO WORK
Joshua Bradshaw expects face shields will become standard attire in a range of workplaces – everything from fast food restaurants, to pool-cleaning companies, to large manufacturers.
Bradshaw is the president of Vital Manufacturing in Surrey, B.C., which shifted from producing custom automation equipment to making face shields that attach to the brim of a baseball hat.
“The demand has been incredible. I thought it would do well, but it blew past any expectations. This is a solution to help companies get back to work,” he told CTVNews.ca in a phone interview.
“Medical masks are uncomfortable. No one could wear them for an eight-hour shift long-term.”
He says Cap Shield customers – ranging from individual consumers buying a few at $12 each to go to the grocery store to giant corporations buying them in bulk for employees – appreciate that shields are unobtrusive and easy to clean and reuse.
While many medical supply companies don’t sell to the public or require large orders, individuals and small businesses have some options starting at $4 each, including some sporting, home improvement and workplace supply retailers, Amazon, Walmart.ca, and Etsy. The Canadian Shield in Kitchener-Waterloo, Ont. sells its face shield in packs of two for $19.95.
Vital has ramped up production of its Cap Shield from 20,000 a week to hundreds of thousands and has licensing deals around the world that will take production into the millions.
The threat of coronavirus isn’t going away any time soon, but even after it recedes, Bradshaw says face shields are here to stay in food service.
“I just can’t imagine a day down the road where the head of a fast food chain says, ‘Now it’s OK if we sneeze in people’s food again.’”
Edited by Senior Producer Mary Nersessian