As a new disease, the scientific knowledge around Covid-19 – and therefore guidelines for the public built on this knowledge – has been fast-changing as experts learn more about how the coronavirus spreads.
One of the areas where guidance has differed between countries and developed over time is whether symptom-free people should wear face masks. Wearing a face mask is obligatory in Germany and France on public transport, for example, while in Sweden it is not recommended even while people continue to visit restaurants, bars and shops.
Sweden isn't alone in advising against general mask-wearing; neighbouring Denmark has the same recommendation, but the spread of infection is far lower than in Sweden.
On Friday, the World Health Organisation changed its advice on face masks and urged governments to advise their use anywhere where social distancing is hard. That includes on public transport, in supermarkets, at schools, at work, and at social gatherings, and those over 60 should wear medical-grade masks in these situations. Previously, the organisation's advice was that only people sick with coronavirus or caring for those who were needed to wear masks.
But the official advice from the Swedish Public Health Agency remains: “Face masks aren't needed in normal situations in society, where it's better to keep distance from other people and be careful to wash hands.” The agency has issued instructions for owners of restaurants, bars and shops on how they should ensure social distancing takes place, and some restaurants have been forced to close temporarily for violating these laws.
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Photo: Janerik Henriksson/TT
The WHO acknowledged that widespread mask-wearing was “not yet supported by high quality or direct scientific evidence”, but said that it was changing its stance based on the available studies, including those related to asymptomatic transmission (people spreading the virus before they themselves show symptoms).
The organisation stated that “governments should encourage the general public to wear masks in specific situations and settings as part of a comprehensive approach”. It advised governments to weigh up factors including availability of masks, risk of exposure to the virus, and the setting. Some of the benefits listed were to reduce asymptomatic transmission, reduce stigmatisation of those wearing masks, and helping people to feel they were playing a role in stopping the infection.
While some countries have required the wearing of masks, Sweden's Public Health Agency states that “a face mask which is itchy and falls below the nose contributes to your hands often touching the mouth, eyes and nose which can increase the risk of infection”.
This was one of the potential risks also raised by the WHO, along with potential discomfort, breathing difficulties depending on the type of mask, and “a false sense of security, leading to potentially lower
adherence to other critical preventive measures such as physical distancing and hand hygiene”.
State epidemiologist Anders Tegnell told the TT newswire: “[The WHO] doesn't say that you should wear face masks, rather that you can do it if you don't manage to keep social distance. Other methods are better, according to WHO, like social distancing. The scientific basis for face masks is weak, but the basis for social distancing is strong.”
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Anders Tegnell, right. Photo: Anders Wiklund/TT
Sweden was slower to recommend social distancing than many neighbouring countries, recommending keeping a distance from others only on April 1st, but Tegnell argued that changing guidance around face masks could also undermine these parts of the overall strategy.
“It could send out signals that it's OK to go out if you're sick [if you wear a mask]. That would break a successful communication. The foundation of the Swedish strategy is to stay home if you are sick and keep social distance. Recommending face masks could go against that,” he told TT.
He also added that in Sweden, there is less risk of crowding than in some other cities, due partly to the continued recommendation to work from home unless absolutely necessary. “In London for example it's a completely different situation, there's not a shadow of a chance to reduce [the number of people using] public transport. They have chosen to open up completely, we haven't done that here. That creates crowded environments,” Tegnell said.
He also said that other countries had chosen not to recommend face masks, and suggested that one reason it has become such a talking point in Sweden could be that people are looking for “easy solutions, which don't exist”.
In its updated advice, the WHO stresses the importance of governments or other decision-makers clearly communicating the purpose of mask-wearing, and how to use a face mask safely, in order to mitigate this risk.
Asked if it would be helpful if everyone wore a mask correctly, Tegnell said that it's very hard to avoid touching one's face when wearing a mask, saying that even healthcare staff require training in how to wear them, and noting that at the daily coronavirus press conferences, the journalists wearing masks typically touch their faces more than others.
It's possible that Sweden will change its tactic, however, with Tegnell saying that the Public Health Agency may change their advice if there was stronger scientific evidence to support widespread mask-wearing.