Absence of Apparent Transmission of SARS-CoV-2 from Two Stylists After Exposure at a Hair Salon with a Universal Face Covering Policy — Springfield, Missouri, May 2020
Weekly / July 17, 2020 / 69(28);930-932
On July 14, 2020, this report was posted online as an MMWR Early Release.
Summary
What is already known about this topic?
Consistent and correct use of cloth face coverings is recommended to reduce the spread of SARS-CoV-2.
What is added by this report?
Among 139 clients exposed to two symptomatic hair stylists with confirmed COVID-19 while both the stylists and the clients wore face masks, no symptomatic secondary cases were reported; among 67 clients tested for SARS-CoV-2, all test results were negative. Adherence to the community’s and company’s face-covering policy likely mitigated spread of SARS-CoV-2.
What are the implications for public health practice?
As stay-at-home orders are lifted, professional and social interactions in the community will present more opportunities for spread of SARS-CoV-2. Broader implementation of face covering policies could mitigate the spread of infection in the general population.
Discussion
SARS-CoV-2 is spread mainly between persons in close proximity to one another (i.e., within 6 feet), and the more closely a person interacts with an infected person and the longer the interaction, the higher the risk for transmission (1). At salon A in Springfield, Missouri, two stylists with COVID-19 symptoms worked closely with 139 clients before receiving diagnoses of COVID-19, and none of their clients developed COVID-19 symptoms. Both stylists A and B, and 98% of the interviewed clients followed posted company policy and the Springfield city ordinance requiring face coverings by employees and clients in businesses providing personal care services. The citywide ordinance reduced maximum building waiting area seating to 25% of normal capacity and recommended the use of face coverings at indoor and outdoor public places where physical distancing was not possible. Both company and city policies were likely important factors in preventing the spread of SARS-CoV-2 during these interactions between clients and stylists. These results support the use of face coverings in places open to the public, especially when social distancing is not possible, to reduce spread of SARS-CoV-2.
Although SARS-CoV-2 is spread largely through respiratory droplets when an ill person coughs or sneezes (1), data suggest that viral shedding starts during the 2-to-3-day period before symptom onset, when viral loads are at their highest (2). Although the rate of transmission of SARS-CoV-2 from presymptomatic patients (those who have not yet developed symptoms) and asymptomatic persons (those who do not develop symptoms) is unclear, these persons likely contribute to the spread of SARS-CoV-2 (3). With the potential for presymptomatic and asymptomatic transmission, widespread adoption of policies requiring face coverings in public settings should be considered to reduce the impact and magnitude of additional waves of COVID-19.
Previous studies show that both surgical masks and homemade cloth face coverings can reduce the aerosolization of virus into the air and onto surfaces (4,5). Although no studies have examined SARS-CoV-2 transmission directly, data from previous epidemics (6,7) support the use of universal face coverings as a policy to reduce the spread of SARS-CoV-2, as does observational data for COVID-19 in an analysis of 194 countries that found a negative association between duration of a face mask or respirator policy and per-capita coronavirus-related mortality; in countries that did not recommend face masks and respirators, the per-capita coronavirus-related mortality increased each week by 54.3% after the index case, compared with 8.0% in those countries with masking policies (CT Leffler, Virginia Commonwealth University, unpublished data, 2020).§ Similar outcomes have been observed for other respiratory virus outbreaks, including the 2002–04 outbreak of Severe Acute Respiratory Syndrome (SARS) (6) and the 2007–08 influenza season (7). A systematic review on the efficacy of face coverings against respiratory viruses analyzed 19 randomized trials and concluded that use of face masks and respirators appeared to be protective in both health care and community settings (8).
The findings in this report are subject to at least four limitations. First, whereas the health department monitored all exposed clients for signs and symptoms of COVID-19, and no clients developed symptoms, only a subset was tested; thus, asymptomatic clients could have been missed. Similarly, with a viral incubation period of 2–14 days, any COVID-19 PCR tests obtained from clients too early in their course of infection could return false-negative results. To help mitigate this possibility, all exposed clients were offered testing on day 5 and were contacted daily to monitor for symptoms until day 14. Second, although the health department obtained supplementary data, no information was collected regarding underlying medical conditions or use of other personal protective measures, such as gloves and hand hygiene, which could have influenced risk for infection. Third, viral shedding is at its highest during the 2 to 3 days before symptom onset; any clients who interacted with the stylists before they became symptomatic were not recruited for contact tracing. Finally, the mode of interaction between stylist and client might have limited the potential for exposure to the virus. Services at salon A were limited to haircuts, facial hair trimmings, and perms. Most stylists cut hair while clients are facing away from them, which might have also limited transmission.
The results of this study can be used to inform public health policy during the COVID-19 pandemic. A policy mandating the use of face coverings was likely a contributing factor in preventing transmission of SARS-CoV-2 during the close-contact interactions between stylists and clients in salon A. Consistent and correct use of face coverings, when appropriate, is an important tool for minimizing spread of SARS-CoV-2 from presymptomatic, asymptomatic, and symptomatic persons. CDC recommends workplace policies regarding use of face coverings for employees and clients in addition to daily monitoring of signs and symptoms of employees, procedures for screening employees who arrive with or develop symptoms at work, and posted messages to inform and educate employees and clients (https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/businesses-employers.html).
M. Joshua Hendrix, MD1; Charles Walde, MD2; Kendra Findley, MS3; Robin Trotman, DO4
1Washington University School of Medicine, St. Louis, Missouri; 2University of Kansas Medical Center, Kansas City, Missouri; 3Springfield-Greene County Health Department, Springfield, Missouri; 4CoxHealth Infection Prevention Services, Springfield, Missouri.