Title : Impact of community masking on COVID-19: A cluster-randomized trial in Bangladesh

Authors : Jason Abaluck*†, Laura H. Kwong†, Ashley Styczynski†, Ashraful Haque, Md. Alamgir Kabir,Ellen Bates-Jefferys, Emily Crawford, Jade Benjamin-Chung, Shabib Raihan, Shadman Rahman,Salim Benhachmi, Neeti Zaman Bintee, Peter J. Winch, Maqsud Hossain, Hasan Mahmud Reza,Abdullah All Jaber, Shawkee Gulshan Momen, Aura Rahman, Faika Laz Banti, Tahrima Saiha Huq,Stephen P. Luby‡, Ahmed Mushfiq Mobarak

Abstract : INTRODUCTION Mask usage remains low across many parts of the world during the COVID-19 pandemic, and strategies to increase mask-wearing remain untested. Our objectives were to identify strategies that can persistently increase mask-wearing and assess the impact of increasing mask-wearing on symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. RATIONALE We conducted a cluster-randomized trial of community-level mask promotion in rural Bangladesh from November 2020 to April 2021 (N = 600 villages, N = 342,183 adults). We cross-randomized mask promotion strategies at the village and household level, including cloth versus surgical masks. All intervention arms received free masks, information on the importance of masking, role modeling by community leaders, and in-person reminders for 8 weeks. The control group did not receive any interventions. Participants and surveillance staff were not informed of treatment assignments, but project materials were clearly visible. Outcomes included symptomatic SARS-CoV-2 seroprevalence (primary) and prevalence of proper mask-wearing, physical distancing, social distancing, and symptoms consistent with COVID-19 illness (secondary). Mask-wearing and distancing were assessed through direct observation at least weekly at mosques, markets, the main entrance roads to villages, and tea stalls. Individuals were coded as physically distanced if they were at least one arm’s length from the nearest adult; social distancing was measured using the total number of adults observed in public areas. At 5- and 9-week follow-ups, we surveyed all reachable participants about COVID-19–related symptoms. Blood samples collected at 10- to 12-week follow-ups for symptomatic individuals were analyzed for SARS-CoV-2 immunoglobulin G (IgG) antibodies. RESULTS There were 178,322 individuals in the intervention group and 163,861 individuals in the control group. The intervention increased proper mask-wearing from 13.3% in control villages (N = 806,547 observations) to 42.3% in treatment villages (N = 797,715 observations) (adjusted percentage point difference = 0.29; 95% confidence interval = [0.26, 0.31]). This tripling of mask usage was sustained during the intervention period and for 2 weeks after. Physical distancing increased from 24.1% in control villages to 29.2% in treatment villages (adjusted percentage point difference = 0.05 [0.04, 0.06]). We saw no change in social distancing. After 5 months, the impact of the intervention on mask-wearing waned, but mask-wearing remained 10 percentage points higher in the intervention group. Beyond the core intervention of free distribution and promotion at households, mosques, and markets; leader endorsements; and periodic monitoring and reminders, several elements had no additional effect on mask-wearing, including text reminders, public signage commitments, monetary or nonmonetary incentives, and altruistic messaging or verbal commitments. The proportion of individuals with COVID-19–like symptoms was 7.63% (N = 12,784) in the intervention arm and 8.60% (N = 13,287) in the control arm, an estimated 11.6% reduction after controlling for baseline covariates. Blood samples were collected from consenting, symptomatic adults (N = 10,790). Adjusting for baseline covariates, the intervention reduced symptomatic seroprevalence by 9.5% (adjusted prevalence ratio = 0.91 [0.82, 1.00]; control prevalence = 0.76%; treatment prevalence = 0.68%). We find that surgical masks are particularly effective in reducing symptomatic seroprevalence of SARS-CoV-2. In villages randomized to surgical masks (N = 200), the relative reduction was 11.1% overall (adjusted prevalence ratio = 0.89 [0.78, 1.00]). The effect of the intervention is most concentrated among the elderly population; in surgical mask villages, we observe a 35.3% reduction in symptomatic seroprevalence among individuals ?60 years old (adjusted prevalence ratio = 0.65 [0.45, 0.85]). We see larger reductions in symptoms and symptomatic seropositivity in villages that experienced larger increases in mask use. No adverse events were reported. CONCLUSION A randomized-trial of community-level mask promotion in rural Bangladesh during the COVID-19 pandemic shows that the intervention increased mask usage and reduced symptomatic SARS-CoV-2 infections, demonstrating that promoting community mask-wearing can improve public health.

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