By Dato' Dr Amar-Singh HSS

The Movement Control Order (MCO) was relaxed on 4th May 2020 to allow for some sectors of society to return to work and business. We recognize that not all Malaysians practice safe prevention measures. Mask usage is a useful adjunct protective measure to safe physical distancing and hand washing.

I searched for images and videos of the public posted only on the 4th of May 2020 on mainstream and social media. These images and videos were analyzed as to the use of masks, type of masks, adequacy of face covering (position of mask), whether masks were being touched and the use of other face devices. Individuals who could not be visualized well were excluded. Care was taken to avoid any duplicate images or videos.

I was able to identify 448 individuals seen clearly from 36 images and videos. They were imaged at food outlets, in or at entry to malls, in or at mass transport locations, at roadside queues, etc. Of these only 355 could be analyzed as the rest had their backs facing the camera. Most were taken in the Klang Valley. The table shows a summary of the data.

Although this data is a small 'snap-shot' of the public, it offers some idea of the behavior on the first day post MCO relaxation. The data however offers no idea of the behavior inside offices and throughout the day.

While it is encouraging that vast majority (95%) had masks, however 3% did not use them correctly and another 3% were touching the outer surface of the mask. The majority (68%) used 3-ply surgical mask which may be of concern. While 3-ply surgical masks are more protective than cloth masks they do not last as long (1-2 hours) and once damp need to be changed. Excessive use by the general public of surgical mask will deplete an important resource for healthcare professionals (HCPs). It is possible that some were wearing surgical masks for travel and might then change to cloth masks or no masks in the office. A small percentage (1.8%) were using N-95 masks and this should be discouraged as there is a shortage for HCPs.

3% were seen hanging the mask around neck or leaving the nose exposed, which defeats the purpose of wearing mask. Some would do this when eating but fail to recognize the risk of pulling down the mask and putting it up again with resultant hand contamination. Hand disinfection before wearing and when taking off masks is crucial. Of even more concern is the 3% that were spotted touching the mask with hands or hand phones—a good way to get infected with the coronavirus. Hand phones should be used with the speaker function and not brought to the face when wearing a mask. 2% percent of public/staff were identified wearing gloves. The public and staff should be discouraged from wearing gloves routinely, as this gives a false sense of security. With gloves on they may touch many surfaces, becoming a risk to others. Gloves should only be used short term, for cleaning activities.

Two security persons were noticed using a face shield. Face shields are useful but not always easy to wear in a busy work environment. Cashiers, security guards and front-line staff should consider wearing safety glasses (with side & top shields) that can be easily cleaned or washed.

In three images, the public were seen entering their details into a book. Although the authorities have asked premises to note down the person visiting the location this practice of using a physical book is dangerous as it aids COVID-19 transmission.

There has been much debate about the value of masks in this pandemic. A recent evidence-based analysis of the studies available 'Review Face Masks Against COVID-19: An Evidence Review' (preprint available here) concluded that "The preponderance of evidence indicates that mask wearing reduces the transmissibility per contact by reducing transmission of infected droplets in both laboratory and clinical contexts. Public mask wearing is most effective at stopping spread of the virus when compliance is high... Thus we recommend the adoption of public cloth mask wearing, as an effective form of source control, in conjunction with existing hygiene, distancing, and contact tracing strategies. We recommend that public officials and governments strongly encourage the use of widespread face masks in public, including the use of appropriate regulation."

In the face of this pandemic, I would encourage the public to use cloth masks routinely when outside the home. The public must remember that wearing masks must not lull us into a false sense of security. Safe physical distancing is the single most important measure and must never be neglected.

(Dato' Dr Amar-Singh HSS is a Senior Consultant Pediatrician.)