The Face Shield Strategy: Moving to the Community
With the assistance of a great supply management team, we have been able to outfit all of our clinical staff with face shields. See here for our rationale and implementation. Acceptance by healthcare workers has been good and compliance is easy to visually monitor. Our message is that the shields are to be worn at all times except when eating or when in a room alone. Shields alone are worn for non-COVID care. For the care of COVID patients, masks are added beneath the shield, except in the instance of aerosol-generating procedures, when N95 respirators are worn beneath the shield.
This week CDC recommended the use of cloth masks for all persons in public settings. Although cloth masks are better than nothing, depending on the material, the filtration efficiency varies, and they can become contaminated. Moreover, adjusting the mask increases the frequency of touching the face, which can lead to autoinoculation if the hands are contaminated. We're not very excited about this strategy. However, we believe that face shields offer a better solution for the public. Dan and I laid out the case for this in an OpEd in the Des Moines Register this week.
The advantages of face shields are their durability allowing them to be worn an indefinite number of times, the ability to easily clean them after use, their comfort, and they prevent the wearer from touching their face. Importantly, they cover all the portals of entry for this virus--the eyes, the nose, and the mouth. Moreover, the supply chain is significantly more diversified than that of face masks, so availability is much greater. Large companies, such as Apple, Nike and John Deere, have converted production lines to make face shields. Smaller companies, such as Upstaging, have as well. Upstaging is selling shields to consumers as well as hospitals. (I ordered some from them and received them in less than 24 hours.) Because the design of face shields is simple, massive production should not be difficult. Individuals and groups are making them via 3-D printing, and they can even be made from materials that are readily available from stores that sell office or craft supplies. Our goal should be to have a face shield for every person in the country. It should be worn anytime a person leaves their home, while in any public place, and even at work. From news reports, it appears that face shields are already being more commonly worn in other nations, particularly in some Asian countries.
Some argue that face shields may not prevent infectious aerosols that could be propelled around the edge of the shield. However, it appears that with this virus, transmission occurs mostly via droplets that do not have the ability to move in air currents and waft around the shield edges. But importantly, if everyone is shielded, these aerosols would need to move around the shield of the infected person and then waft around the shield of the uninfected person for infectious droplet nuceli to land on their face. The probability of this happening seems low, particularly since persons who are symptomatic and coughing should not be leaving their homes anyway. And hand hygiene still needs to be stressed to prevent autoinoculation.
Some are critical of any strategy that isn't perfect. But let's think about the influenza vaccine. Although the effectiveness varies from year to year, on average it's 40%. We push this vaccine hard in the hospital and in the community. Could we expect that face shields are at least 40% effective in reducing the transmission of COVID-19? I think so. Universal shielding would bend the curve more quickly and accelerate the ability to reduce social distancing and restrictions on movement.
Face shields are a simple solution that if implemented universally would have a major impact on public health. Until we have a vaccine, this may be our best intervention for preventing transmission in the community.
Addendum: See our viewpoint on this topic in JAMA here.