The coronavirus has led to many changes to our daily lives, but the most conspicuous is arguably the wearing of face masks in enclosed spaces.
For anyone over the age of 11, the wearing of a face mask is now compulsory in shops, on public transport and in several other places (all listed here). And now in England and Scotland, pupils over the age of 12 will have to wear a mask in certain situations in schools (in England, it is only mandatory where a local lockdown is in place, heads have the right to decide on masks otherwise).
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The World Health Organisation (WHO) states that those who are 12 years old and above should wear masks in the same conditions as adults, while those between the ages of 6 and 11 should wear a mask in certain circumstances (read the full guidance here).
On the issue of schools in particular, however, the WHO gives a rather non-commital judgement: "The policy on wearing a mask or face covering should be in line with national or local guidelines."
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In France, which has had a similar pandemic experience to the UK, face masks will be compulsory in schools for both teachers and pupils over the age of 11, even when social distancing is possible.
In Italy, staff have to wear masks but no decision has been made as yet around the wearing of masks by pupils. In Germany, decisions on face masks are made by each region but the country's National Academy of Sciences Leopoldina has recommended the use of face masks for anyone who is 15 and above.
In Asia, face masks are a more accepted part of life and both children and teaching staff are used to wearing them when required.
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So why has England stopped short of full face mask where in schools? And what is the scientific advice on masks that may help school leaders come to a decision?
We caught up with Trish Greenhalgh, professor of primary care health sciences at the University of Oxford, who has been a leading voice during this pandemic in translating the science around face masks.
Tes: Face masks have been a contentious topic right from the start of the pandemic. Is there something about face masks culturally in Western countries that prevented their acceptance from the off?
Greenhalgh: It does appear that way, though if you look at the Czech Republic, you will see how dramatically a "Western" country can shift its cultural norms in a short time. Masks were promoted from an early stage and strongly presented as socially responsible.
Tes: You have argued strongly for the use of face masks as a protection from the individual wearing it, rather than for the individual wearing it. You explain, in your latest paper, that much of the research around protective face covering looks at the latter, not the former. Why is that?
Greenhalgh: Covid-19 is spread mainly by droplets. Droplets are what come out of the mouth and nose (like a wet cough or a sneeze). After a few inches, the droplets evaporate and become tiny airborne particles. So the most efficient way of stopping Covid-19 is to stop the droplets on their way out rather than try to stop the airborne particles on their way in.
Tes: What about visors? Do we not need protection for our eyes as well?
Greenhalgh: There’s surprisingly little research on SARS-CoV-2 [the virus known as Covid-19] and the eye. People who have symptomatic Covid-19 including conjunctivitis (which only occurs in about 2 per cent of people) could have infectious eye secretions.
Theoretically, there’s a small risk of transmission through splashes into the eye – for example, if someone sneezed and it unfortunately landed in another person’s eye (find the paper here). But both these scenarios are rare.
So while visors might offer more protection, the question is, is the additional hassle worth it?
Tes: The evidence for face masks as "protection from" is positive and relies on a reduction in transmission, rather than an eradication of transmission, is that correct?
Greenhalgh: Yes, it is. And even with social distancing, it suggests that a face mask can still be effective indoors. Outdoors, it’s much less crucial, so long as social distancing is maintained.
Tes: If we go into a school context, to the best of your knowledge, would masks be appropriate for teachers to wear to protect each other from staff-to-staff transmission?
Greenhalgh: This is a mathematical game. If you are (unknowingly) harbouring the SARS-CoV-2 virus, and you meet three people in your daily work, you have a low chance of passing it on. If you meet 50 people, you have a much higher chance.
So there are no absolutes. If, as a teacher, you’re in a room all day with a class of 30 children and you meet one other teacher in your coffee break, I’m more worried about the kids, to be honest.
Tes: To the best of your knowledge, would masks be appropriate for children to wear, to protect each other and also staff from child-to-child and child-staff-child transmission?
Greenhalgh: I’m not a teacher or a child psychologist, but I am a parent. Masks work the same way on a child as they do on an adult – they mainly protect other people, but they do offer some protection for the individual.
On the other hand, kids’ mental health and social wellbeing is really important right now. If compulsory masking is going to tip some kids into a bad space after weeks of stressful lockdown, we need to balance that risk with the potential benefits.
Ethically, it’s difficult since the people who benefit are different in these two scenarios. As a recent paper in the European Journal of Pediatrics argued, “the child’s will must not be forced”, but much can be achieved through education and engagement of both children and parents.
Tes: If you were a headteacher, would you balance the safety benefits of face masks with the potential detrimental impact of social/relationship barriers of wearing a mask, particularly around small children?
Of course. It’s not just age that will influence the decision, it’s also socioeconomic and cultural factors. Your readers will be well aware of the data which says that many kids (stereotypically the "middle-class" ones) are doing very well with home-schooling, but that others may be falling behind and even at risk of physical or emotional abuse.
There are complex trade-offs to be made between the package of measures that is optimal for getting one cohort of children safely and happily back in the classroom and the package that is preferred by the parents of another cohort. Masking is only one of the factors involved, of course. These things need to be deliberated carefully, taking account of all relevant local issues.
Tes: A final question – we are told constantly that we are "following the science", but is there enough science on this virus to be able to have any confidence in that statement?
Greenhalgh: Yes, there’s lots of science. But science doesn’t take the politics out of policymaking or make ethically tricky decisions for you.
We know that masking is going to reduce transmission overall, but that science is never going to tell you whether these kids in this school should wear this kind of mask in these local circumstances. That’s why I think decisions should be delegated to localities and individual schools (and even individual year groups).