Face masks
The use of face masks to reduce the risk of infection is an established medical procedure. It is therefore surprising that it has created such a controversy in the context of COVID-19. The initial recommendation by WHO and other health authorities that masks should only be used by health workers and symptomatic patients resulted in widespread confusion in the public, exacerbated by the images of people in Asia wearing masks in all settings. In addition, different types of masks perform different functions in different settings, greatly complicating communication efforts.
Face masks prevent transmission of respiratory viruses in two ways:
- When worn by healthy individuals they are protecting them from infection by reducing the exposure of the mouth and nose to viral particles present in the air or on contaminated hands;
- When worn by an infected person they perform source control, by reducing the amount of virus dispersed in the environment while coughing, sneezing or talking. Singing is probably out of bounds with no mask.
Different types of masks perform these tasks differently, which also dictates the situations in which they should be used. Type of masks currently used include:
- N95 (or FFP2) masks, designed to block 95% of very small particles. They reduce the wearer’s exposure to particles including aerosols and large droplets. They also reduce the patient or other bystanders’ exposure to particles emitted by the wearer (unless they are equipped with a one-way valve to facilitate breathing).
- Surgical masks only filter large particles and, being loose fitted, will reduce only marginally the exposure of the wearer to droplets and aerosols. They do, however, limit considerably the emission of saliva or droplets by the wearer, reducing the risk of infecting other people.
- Cloth masks will stop droplets that are released when the wearer talks, sneezes, or coughs. Ideally, they should include multi-layers of fabric. When surgical or N95 masks are not available, cloth masks can still reduce the risk of transmission in public places.
If masks are protective, why were they not widely recommended at the beginning of the epidemic? Whether due to poor communication, fear of shortage of essential medical supplies or under-appreciation of the role of asymptomatic carriers in spreading the virus, the resulting controversy was not helpful in combating the pandemic and greatly undermined the credibility of public health authorities.
It was only on 5 June, months into the pandemic, that
WHO released updated guidance on the use of masks, recognizing the role that face masks can play in reducing transmission from asymptomatic carriers in particular settings. This was a few days after the publication of a comprehensive review and meta-analysis of observational studies showing a large reduction in risk of infection with all types of masks (
Chu 2020).
Surgical masks were shown to work even in a hamster model (
Chan JF 2020). Other authors, based on reviews or modelling, recommend wearing suitable masks whenever an infected person may be nearby (
Meselson 2020,
Prather 2020,
Zhang 2020). (See also the discussion on droplets and aerosols, page xxx.)
Meanwhile the controversy continues, including on the potential negative effects of wearing masks on health, for example on cardiopulmonary capacity (
Fikenzer 2020).
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Regardless of the controversy and the mounting “No-Mask” movements, face masks are “here to stay”. The sight of people wearing face masks in public, which in the past surprised and amused Western travelers to Asian countries, will be a common sight worldwide for months and maybe years to come.