Future Health Care Crisis Associated with Prolonged Use of Face Mask:A Novel Challenge in Covid Era

Introduction

The World Health Organization has declared SARS COVID-19 as a global health crisis, resulting in major disruptions, national emergencies, and lockdowns, with only essential services remaining operational. The origin of the pneumonia-like infection of unknown cause is believed to be from bats, and the infection was first detected in the city of Wuhan in Hubei province, China. The virus spreads primarily through respiratory secretions and droplets, as well as direct contact, through which the virus enters the mucous membranes.^1-3

In the absence of effective drugs and medical facilities, many measures were used to reduce the burden of disease and to avoid exhausting limited hospital resources. Wearing masks is considered to be one of the non-pharmaceutical intervention measures that could be implemented, without significantly disrupting social practices.^4,5

With the ongoing COVID-19 pandemic, facemasks have become an integral part of our everyday life. Apart from the inconvenience associated with its use, the prolonged use of mouth masks comes with a plethora of problems like physical as well as psychological deterioration along with various other symptoms because of their consistent and recurrent use, collectively called the “Mask Induced Exhaustion Syndrome.”⁶ As the state of infection still prevails, there have been simultaneous calls for a more nuanced approach within the medical fraternity, as well as users and observers of medical devices.⁷

According to the study by Lim et al., various side effects like headaches and associated conditions were observed as a result of long term use of face masks,⁸ while a study by Foo, et al., showed adverse skin reactions from mask use in the general population.⁹ Continuous pressure created by the use of personal protective equipment and mask could result in the breakdown of the skin as well as cause damage to the bridge of the nose and cheekbones that could be attributed to the usage of masks and eyewear.¹⁰

While there have been continuous debates about the pros and cons of wearing masks in public places around the world, it has become the new social norm in many countries at the same time. Considering various facts, it is important to understand long-term health and psychological hazards that could be created by the overuse of facemasks. Therefore, this review focused to understand various side effects associated with the longterm use of facemasks in the general population.

Standardization and Classification of Facemask

Respiratory masks are safety shields that cover a part of the face and protect the wearer from environmental pollutants and exposure to airborne infections. Medical or surgical masks in Europe are usually graded by three levels of Bacterial Filtration Efficiency (BFE1, BFE2, and Type R), whereas in the US, grading is done about fluid protection recommended by ASTM regulations.¹¹ The American Society for Testing and Standard Specification (ASTM) has evaluated masks based on four main categories.¹²

• Fluid resistance––is the ability to resist the entry of blood particles or any body fluids.

• Filtration efficiency: This is further categorized into BFE where bacterial particles are filtered (0.3 microns).

• Breathability: This is categorized by the ability of the operator to breathe easily; it is normally labeled on the mask as Delta P; it denotes the pressure drop across a face mask and is expressed as pascal or mm H20/cm2 .

• Flame spread: This measures the flame spread of the mask material. Depending on these four categories, masks can be selected based on the procedures performed.

The available facemasks can be classified as full masks (normed following EN 136) and a half and quarter masks (EN 140). Filtering facepieces (FFP) are labeled as half masks. They resist the entry of microbes via the airway and shield both the mask-wearer and the surrounding people. They are regularly noted as “triple layer mask.”¹³

Medical mask filtration tests and FFR tests are carried out on a cross-section of the mask and the entire surface of the mask, respectively. As a result, the layers of filtration material and the FFR shape ensure that the FFR’s outer edges seal around the wearer’s face, resulting in guaranteed filtration. Other performance requirements for FFR include staying within specified parameters.¹⁴

During the ongoing COVID-19 pandemic, WHO in 2020 has recommended the regular use of following masks-¹³

i. Masks for everyday use: Mostly recommended for the general public for everyday usage. This helps in the reduction of viral spread, especially during exhalation (Figure 1). But due to the lack of filtration of minute particles, it cannot be used in health care setup.

ii. MNP (Medical mouth-nose- protection): Also called “triple layer mask”. They have the filtering capability against aerosols (Figure 2). They are affixed to the head with straps that go around the ears or head or both. Their performance is tested according to ASTM F2100, EN 14683, or equivalent that aim to balance filtration, breathability and optionally, fluid penetration resistance.¹² These masks consist of three layers of nonwoven fabric. The outer layer helps to repel salivary droplets. The middle layer helps to prevent particles above a certain size from penetrating. The inner layer absorbs the moisture from exhaled air and also helps to trap droplets from the user. These masks can be recommended for routine medical check-ups and treatments.

iii. FFP2-mask (Face Filtering Piece)/N95-mask/ P2 (Figure 3): These masks offer more than 95% of the filtration capacity of airborne pathogens during inhalation.¹⁵ These are certified according to the National Institute for Occupational Safety and Health (NIOSH) 42 CFR 84 protocol. These masks effectively protect as long as there is no exhaling valve.¹³ Unlike the loose fit surgical mask, it has extra filtration layers that are manufactured to achieve a close facial fit. It also consists of multiple layers and the layer which help in filtration is made of polypropylene with an embedded electrostatic charge. Straps of these masks are composed of thermoplastic elastomer while nose clips are made from aluminium, nose foam from polyurethane, and the shell and cover web are made from polyester material.¹² These types of masks are best suited for the health care profession.

iv. FFP3-mask: Most effective mask with the ability to filter more than 99% of particles while inhaling. These masks also help to protect the environment in the absence of an exhaling valve.¹³ The total inward leakage of these masks is considered to be less than 2%.

Significance of Wearing Facemask

The role of face masks among health care workers and the general public in curtailing the COVID-19 pandemic is huge.¹⁶ The potential benefits of mouth masks can be summarized as follows:

• It is a comprehensive strategy to prevent the transmission of the virus through droplet infection which in turn forms a barrier in preventing the spread of infection

• It also protects people caring for COVID-19 patients in non-clinical settings and also makes others aware of their role in preventing the spread of the virus

• Motivates the public regarding the prevention protocols of hand hygiene and also prevents other respiratory illness which will worsen the current situation.¹⁷

Table 1 briefly summarises various studies in the literature about the efficacy of face mask use during COVID-19 pandemic.

Pathophysiological Implications Associated with the Use of Protective Facemask

Wearing a mask has numerous advantages, including unquestionable anti-infection properties. However, there are some risks and side effects to consider. This is especially true when it comes to general public use. Based on the design, masks have also been shown to increase dead space within the lungs.¹³

Facemasks function by increasing resistance to air movement during inhalation.26 Although intermittent and repetitive increase in respiration resistance may be adaptive that could strengthen various muscles of respiration,27 long term use could create ill effects that may create health crisis.²⁶

In normal conditions, air contains 20.93% O2 and 0.03% CO2 , providing partial pressures of 100 mmHg and 40 mmHg for these gases in the arterial blood. The trapped air which is re-breathed repeatedly could lead to hypoxemia and hypercapnia. This could result in cardiopulmonary and neurological complications.²⁸

A low level of oxygen in the blood can cause myocardial ischemia, serious arrhythmias, right or left ventricular dysfunction, dizziness, hypotension, syncope, and pulmonary hypertension, among other things, whereas chronic low-grade hypoxemia and hypercapnia caused by wearing a facemask can aggravate pre-existing medical conditions.²⁸

A bilateral headache was the most common side effect of prolonged face mask use in a study of 158 health care workers during the COVID-19 pandemic.²⁹ This was reported in nearly 80% of the cases. During the 30 days of mask wear, headaches occurred one to four times.³⁰

Kim et al evaluated the effects of N95 masks on lung function and heart rate while performing low-tomoderate levels of activities. The results of this study showed good tolerance to the mask and recommended the daily use of MNP as a general means of protection.³⁰

Psychological and Behavioural Modifications

Human behaviour is often determined by subjective experiences, that is most directly related to how people comprehend various life situations. The selfdetermination theory³¹ reports three fundamental needs for adequate well-being: autonomy, psychological relatedness, and competence. These needs may determine the attitude and compliance towards mask-wearing. Autonomy, or the ability to possess and exhibit free will and control over one’s actions, is considered one of the most basic psychological needs, and when these are hampered, it may lead to some level of discomfort psychologically.³²

Long-term use of face masks compromises basic humanto-human connectivity through facial expression, and self-identity is somewhat obscured. These dehumanizing movements erase the uniqueness and individuality of both the person wearing the facemask and the connected person.³³ Social connections and relationships are fundamental human needs that are innately inherited by all people, and a lack of human-to-human connections is associated with poor mental and physical health.³⁴ Similarly, another research conducted to assess the attitude towards maskwearing reported that men who firmly believed they should be tough were likely to develop negative feelings towards wearing a mask and lacked the intention to wear a face mask regularly.³⁵

Environmental Challenges due to Improper Mask Disposal

Accumulation of plastic wastes has become a grave threat to the ecosystem and researchers predict a twotimes increase in the plastic burden by 2030. With the ongoing Covid pandemic, the average monthly usage of 129 billion face masks and 65 billion gloves is estimated to ensure the safety of citizens worldwide. Also, surgical masks and gloves mustn’t be worn for extended hours and they should be adequately discarded to avoid crosscontamination.

The universally recommended N95 masks are made of plastics such as polypropylene (PP) and polyethylene terephthalate (PET). These masks will break down into smaller microplastic fragments. The improper disposal of facemasks is contributing to public littering in several locations. Public littering with PPE and plastics can cause blockage in the sewage system in towns and can harm water percolation within the soil. Plastic contaminants may also reach out and accumulate into the other environmental compartments and can reduce the quality of soil and water that can cause adverse effects on the ecosystem. Also, plastic wastes piled up near lakes, ponds, and other water bodies may act as breeding grounds for mosquitoes that are common carriers for zoonotic diseases, which can also be a threat to public health.³⁶

Recommendations to Mitigate the Effects of Prolonged Face Mask Use:

• The public is asked to take appropriate breaks from continuous mask use, with 15 minutes off following every two hours is recommended. Furthermore, avoiding facial make-up and washing the face with a gentle, fragrance-free, non-comedogenic cleanser in the morning and evening is suggested.³⁷

• Ear savers for the ear straps to rest on them instead of resting directly on the ears were suggested for those suffering from rashes behind the ears.³⁸

• Encourage people to use cloth masks daily to avoid skin reactions caused by face masks. When cloth masks are widely used in public places, they may help to reduce the spread of the virus.³⁹

• Long term use of the mask is not recommended for children under the age of two or individuals with breathing difficulties, or otherwise unable to remove the mask without assistance.⁴⁰

• Proper disposal of facemask and other protective material is advised since protective effect severely compromised by their inappropriate.

Conclusion

The rapid spread of infection and fatality of the disease has brought medical facilities to the verge of collapse in many countries. Various measures have been advised to prevent the transmission of infection between communities, out of which face masks are considered the primary step to prevent and contain the disease spread. Along with the use of mouth masks, various medical complications and environmental challenges have been reported lately due to the long-term overuse and improper disposal. It is, therefore, necessary to institute proper guidelines and recommendations for the use of face masks to prevent future complications.

Conflicts of Interest

None.