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COVID-19 wrap: a wealth of communications resources, the evidence on masks, and what about air travel?

As Australia’s two most populous states battle to contain outbreaks of COVID-19, governments and health and community leaders are under pressure to improve their communications and engagement strategies.

In the latest edition of the COVID-19 wrap, public health researcher Alison Barrett shares a wealth of useful examples of effective communications in multiple settings, and also investigates another hot topic in the current climate – the evidence on masks, and how to use them to best advantage.

Also see the graphics to help clinicians have challenging conversations about COVID-19 with patients and others.


Aboriginal Community Controlled Health Organisations are taking a leading role in COVID‐19 health communication

Finlay, S and Wenitong, M, Australian and New Zealand Journal of Public Health, 24 June 2020

Due to higher rates of non-communicable diseases, limited access to health services in remote communities, and other sociocultural factors, Aboriginal and Torres Strait Islander people are at a greater risk from COVID-19.

Effective health communication is essential to minimise the impact from COVID-19. It should be clear, tailored appropriately for different population groups, from a trusted source and focused on cultural values.

“Despite the increased risk to Aboriginal and Torres Strait Islander people from COVID‐19, there has been little specific communication tailored for them from governments since the pandemic commenced,” Finlay and Wenitong wrote.

Before the World Health Organization (WHO) declared COVID-19 as a pandemic, Aboriginal Community Controlled Health Organisations (ACCHOs) had been communicating culturally appropriate health promotion messages about coronavirus for their communities. They have maintained this service throughout the pandemic, “in addition to their usual service delivery and using existing funding,” the authors wrote.

Culturally appropriate resources for Aboriginal and Torres Strait Islanders should include images of Aboriginal and Torres Strait Islander people and art, language and cultural values. For example, COVID-19 health messages should promote values of looking after community and family, central to Aboriginal and Torres Strait Islander people’s cultural identity. 

Finlay and Wenitong highlighted some examples of ACCHOs that have produced and communicated culturally appropriate messages for their local communities.

The Aboriginal Health and Medical Research Council of NSW (AH&MRC) have developed and shared COVID-19 resources on their social media pages, such as the below post on Facebook, with links to resources on their website.

Apunipima Cape York Health Council, an ACCHO in Queensland, created infographics and short videos communicating key evidence-based health promotion messages to protect communities against COVID-19. Their full range of COVID-19 resources can be found here.

ACCHOs are trusted by Aboriginal and Torres Strait Islander people and provide an invaluable, culturally appropriate service to their communities, as highlighted by Finlay and Wenitong in this article.

It is vital that they have sufficient funding and resources to continue delivering the health promotion messages and services throughout the COVID-19 pandemic and beyond.


Face coverings for the public: Laying straw men to rest

Greenhalgh, T, Journal of Evaluation in Clinical Practice, 26 May

On 10 July, Victorian Premier Daniel Andrews announced recommendations for people living in Melbourne and Mitchell Shire to wear a face mask to help slow the rate of community SARS-CoV-2 infections that have increased in Victoria over the last few weeks.

New confirmed cases of COVID-19, daily count, as of 15 July 2020. Source: ABC.net.au (https://ab.co/3j2ZQpx)

The recommendations are for adults 18 years and over who are in situations where they are unable to physically distance from others when outside their homes, if they need to leave home for the four things currently allowed during the current six-week stage three lockdown: work or study, exercise, shopping for supplies, and medical care and caregiving.

The full recommendations by Victorian Department of Health and Human Services can be viewed here.

Advice about the wearing of face masks to prevent COVID-19 has been confusing throughout the pandemic, with widespread debate and conflicting advice. In the early stages of the pandemic, the general recommendation from the WHO and the Centers for Disease Control and Prevention (CDC) was that the general public did not need to wear face masks.

The advice by the CDC may be due to early belief that the prevalence of the virus in the US was low, and mask wearing is not as culturally accepted there as in other countries. WHO’s earlier advice appeared to come from concern that if worn incorrectly, masks may not be of any benefit and that there was a limited supply of masks for healthcare workers and others who needed them most.

Both the WHO and CDC have since changed their general advice, recommending that people wear face masks in public when they are unable to physically distance from others.

Professor Trish Greenhalgh, an academic from the UK and an advocate for the wearing of face masks since the pandemic began, outlined some of the key evidence for wearing them in this response to a critique of an analysis she wrote for the BMJ in April:

  • SARS-CoV-2 virus is an upper respiratory tract disease, which means it is more contagious than a lower respiratory tract disease, such as SARS-CoV-1.
  • It is most likely to be transmitted by contact with droplets expelled by an infected person who coughs, sneezes or talks.
  • Not discussed by Greenhalgh, but additional evidence has recently been updated by the WHO in a scientific brief to advise that the SARS-CoV-2 virus may also be transmitted by aerosols “that remain infectious when suspended in air over long distances and time”.
  • The droplets and aerosols are easier to control (or block) if they are controlled at the source of the infection (for example, by wearing a face mask).
  • Epidemiological and case studies have found evidence of asymptomatic and pre-symptomatic transmission of COVID-19, including aboard the Diamond Princess Cruise ship and population based testing in Iceland and Vo, Italy where approximately half of all confirmed cases were asymptomatic.
  • An infected passenger on a flight from China to Toronto wore a mask the entire flight and nobody else onboard the flight became infected (this case is discussed in more detail below in my summary of research about risk of transmission on aircraft).
  • A mathematical modelling study found that if 60 percent of the population wore a mask that is at least 60 percent efficient at blocking the virus, the rate of transmission will drop below 1.0 and SARS-CoV-2 infections will stop.
  • Absence of evidence from randomised controlled trials (RCT) does not mean face masks should not be recommended, as RCTs for public health interventions are generally impractical.

In conclusion, Greenhalgh wrote:

It is time to put the straw men to rest and embrace the full range of evidence in the context of the perilous threat the world is now facing.”

A systematic review published since Greenhalgh’s review adds further support for the wearing of face masks.

While the certainty of evidence is low as the studies included in the review were all non-randomised and thus, subject to recall and measurement bias, the authors found that those who were exposed to people with SARS-CoV-2 and used a face mask (both N95 respirator or surgical or reusable cotton face masks) reduced their risk of infection substantially.

The risk of infection without wearing a mask or respirator was 17.4% compared to with wearing a mask or respirator, which was 3.1% (see Infographic below for more details).

Infographic source: The Lancet

Download the graphic above here. You can also download it in Arabic, Chinese (simplified and traditional), Estonian, French, German, Indonesian, Italian, Korean, Portuguese, Russian, and Spanish.

See also this article in JAMA that concludes:

At this critical juncture when COVID-19 is resurging, broad adoption of cloth face coverings is a civic duty, a small sacrifice reliant on a highly effective low-tech solution that can help turn the tide favorably in national and global efforts against COVID-19.”

It is important to note that face masks alone won’t slow the spread of COVID-19; they should be used in conjunction with other public health measures – regular handwashing, physical distancing, and isolating if sick.

Some additional guidelines and resources regarding face masks:

WHO’s current advice on the use of masks during the COVID-19 pandemic can be viewed here, and they also have a range of related infographics, including these below.

In a tweet on 10 July, Greenhalgh provided instructions on how to make your own face mask: https://bit.ly/2DCOBUn

Read the article, DIY Face Mask Project at Home, Women In Engineering Workshop.


 COVID-19: transmission risk on aircraft

NSW Government: Agency for Clinical Innovation, 25 June 2020

A ‘rapid evidence check’ published by the NSW Government: Agency for Clinical Innovation found that, as of 16 June, thirteen cases of COVID-19 had been reported due to infection on aircraft; twelve in China and one in France.

The authors searched PubMed database on 16 June for peer-reviewed literature about transmission of SARS-CoV-2 on aircraft. Due to limited evidence, they also expanded their search to include articles about other respiratory illnesses, such as Middle East Respiratory Syndrome (MERS) and influenza, on aircraft.

A literature review about MERS indicated that there had been no reports of MERS transmission on aircraft. In comparison, a systematic review about influenza and infections on aircraft showed that on five flights, up to four confirmed cases of influenza and six potential cases were identified per flight.

Air conditioning and ventilation systems in aircraft cabins, with HEPA air purifying filters and fifty percent of fresh air added to fifty percent of recirculated air, have been found to keep bacteria and fungi counts low despite crowded with passengers.

The authors acknowledge some limitations of their rapid review. Without searching more databases or grey literature, they cannot confirm if the list of publications they found is complete; and it is also unclear what aircraft types were studied in the publications, which is important because different surface types, aircraft air-conditioning systems, seating arrangements and duration in flight, impact the transmission of disease.

Additional evidence has been published about two case studies involving transmission of COVID-19 on aircraft.

The first confirmed case of COVID-19 in Canada was an individual who showed symptoms on a flight from Guangzhou, China to Toronto. Through contact tracing and daily contact with passengers sitting within 2 metres of the passenger, officials found that no other passengers aboard the flight developed COVID-19. The authors suggest this may be because the confirmed case had mild symptoms and wore a mask during the flight.

An investigation into an outbreak of COVID-19 among passengers who had flown from Singapore to Hangzhou, China in January established that of the 16 passengers to have COVID-19, only one was acquired on the aircraft. The other passengers, all members of four different tour groups, were exposed to the virus in Wuhan, China prior to their tour or during a group tour before boarding.

In short, while there are limitations in the rapid review and case studies, they both suggest little evidence to support the transmission of SARS-CoV-2 virus on aircraft and more studies are required.

The Australian Government Department of Health has published recommendations for managing health risks on international flights during the pandemic, which include practicing good hygiene, wearing a mask, avoiding travel if sick, and for airlines to increase space between passengers.


Persistent symptoms in patients after COVID-19

Carfi, A et al, JAMA, 9 July 2020

We are still learning about the long-term effects of COVID-19. Some of the reported long-lasting symptoms include, but not limited to, muscle atrophy, scarred lung tissue, and extreme fatigue.

Between 21 April and 29 May, 143 patients of a follow-up post-acute COVID-19 care service in Rome, Italy, were included in a study investigating COVID-19 symptoms that persist after the acute symptoms have been managed and patients discharged from hospital.

As part of the study, participants were asked questions about their quality of life and to recount the presence or absence of symptoms during the acute phase of COVID-19 and whether any symptoms still persisted.

The study took place on average 60 days since the first symptoms emerged. More than half of the patients (55.2%) reported experiencing three or more persistent symptoms; just over one-third (32.2%) reported experiencing one or more; and 12.6 percent reported no symptoms.

Forty-four percent reported a worsened quality of life.

Fatigue, dyspnoea, joint pain, chest pain, cough and anosmia were the most common persistent symptoms reported.

One-third (37%) of the participants were female and the average age was 56.5 years. The average stay in hospital was 13.5 days, 72.7 percent had interstitial pneumonia during the acute phase of symptoms and 12.6 percent had been admitted to ICU.

Limitations of the study include a small sample size (143 patients), no control group, the nature of retrospective self-report, and lacking information on symptom history prior acute COVID-19 and information on severity of symptoms during the acute phase.

Despite the limitations, the study supports evidence discussed in the Croakey COVID-19 Wrap, 27 May and highlights a need for further research and support for recovering COVID-19 patients.


Timeline of WHO’s response to COVID-19

World Health Organization (WHO), 29 June 2020

The end of June 2020 marked six months since WHO first learned about a new infectious disease that was named COVID-19 on 11 February.

The timeline of WHO’s response and key events for the first six months of the pandemic can be viewed here.


COVID-19 communication aids

Gray, N and Back, A, BMJ, 11 June 2020

BMJ have published a graphic guide for clinicians who are facing challenging conversations with patients about coronavirus. The graphics are based on text from VitalTalk, a not-for-profit organisation in Seattle, US, that provides training for clinicians about serious illness.

Below are some examples of the graphics. More can be found here.


Alison Barrett is a Masters by Research candidate and research assistant at University of South Australia, with interests in public health, rural health and health inequities. Follow on Twitter: @AlisonSBarrett. Croakey thanks her for providing this column as a probono service to our readers.

See previous editions of the COVID wrap.

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