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Science Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2

Science Brief: Community Use of Cloth Masks to Control the Spread of SARS-CoV-2

Summary of Recent Changes

  • Data were added from studies published since the last update that further demonstrate that mask wearing reduces new infections.
  • Data were added that demonstrate the importance of mask fit to improve performance and reduce community exposure to SARS-CoV-2.
  • A section was added on the health effects of mask wearing.

Background

SARS-CoV-2 infection is transmitted predominately by inhalation of respiratory droplets generated when people cough, sneeze, sing, talk, or breathe. CDC recommends community use of masks, specifically non-valved multi-layer cloth masks, to prevent transmission of SARS-CoV-2. Masks are primarily intended to reduce the emission of virus-laden droplets (“source control”), which is especially relevant for asymptomatic or presymptomatic infected wearers who feel well and may be unaware of their infectiousness to others, and who are estimated to account for more than 50% of transmissions.1,2  Masks also help reduce inhalation of these droplets by the wearer (“filtration for wearer protection”). The community benefit of masking for SARS-CoV-2 control is due to the combination of these effects; individual prevention benefit increases with increasing numbers of people using masks consistently and correctly.

Source Control to Block Exhaled Virus

Multi-layer cloth masks block release of exhaled respiratory particles into the environment,3-6 along with the microorganisms these particles carry.7,8  Cloth masks not only effectively block most large droplets (i.e., 20-30 microns and larger)9 but they can also block the exhalation of fine droplets and particles (also often referred to as aerosols) smaller than 10 microns ;3,5 which increase in number with the volume of speech10-12 and specific types of phonation.13 Multi-layer cloth masks can both block up to 50-70% of these fine droplets and particles3,14  and limit the forward spread of those that are not captured.5,6,15,16 Upwards of 80% blockage has been achieved in human experiments that have measured blocking of all respiratory droplets,4 with cloth masks in some studies performing on par with surgical masks as barriers for source control.3,9,14

Filtration for Wearer Protection

Studies demonstrate that cloth mask materials can also reduce wearers’ exposure to infectious droplets through filtration, including filtration of fine droplets and particles less than 10 microns. The relative filtration effectiveness of various masks has varied widely across studies, in large part due to variation in experimental design and particle sizes analyzed. Multiple layers of cloth with higher thread counts have demonstrated superior performance compared to single layers of cloth with lower thread counts, in some cases filtering nearly 50% of fine particles less than 1 micron .14,17-29 Some materials (e.g., polypropylene) may enhance filtering effectiveness by generating triboelectric charge (a form of static electricity) that enhances capture of charged particles18,30 while others (e.g., silk) may help repel moist droplets31 and reduce fabric wetting and thus maintain breathability and comfort. In addition to the number of layers and choice of materials, other techniques can improve wearer protection by improving fit and thereby filtration capacity. Examples include but are not limited to mask fitters, knotting-and-tucking the ear loops of medical procedures masks, using a cloth mask placed over a medical procedure mask, and nylon hosiery sleeves.31-35

Human Studies of Masking and SARS-CoV-2 Transmission

Data regarding the “real-world” effectiveness of community masking are limited to observational and epidemiological studies.

  • An investigation of a high-exposure event, in which 2 symptomatically ill hair stylists interacted for an average of 15 minutes with each of 139 clients during an 8-day period, found that none of the 67 clients who subsequently consented to an interview and testing developed infection. The stylists and all clients universally wore masks in the salon as required by local ordinance and company policy at the time.36
  • In a study of 124 Beijing households with > 1 laboratory-confirmed case of SARS-CoV-2 infection, mask use by the index patient and family contacts before the index patient developed symptoms reduced secondary transmission within the households by 79%.37
  • A retrospective case-control study from Thailand documented that, among more than 1,000 persons interviewed as part of contact tracing investigations, those who reported having always worn a mask during high-risk exposures experienced a greater than 70% reduced risk of acquiring infection compared with persons who did not wear masks under these circumstances.38
  • A study of an outbreak aboard the USS Theodore Roosevelt, an environment notable for congregate living quarters and close working environments, found that use of face coverings on-board was associated with a 70% reduced risk.39
  • Investigations involving infected passengers aboard flights longer than 10 hours strongly suggest that masking prevented in-flight transmissions, as demonstrated by the absence of infection developing in other passengers and crew in the 14 days following exposure.40,41

At least ten studies have confirmed the benefit of universal masking in community level analyses: in a unified hospital system,42 a  German city,43 two U.S. states,44, 45 a panel of 15 U.S. states and Washington, D.C.,46, 47 as well as both Canada48 and the U.S. 49-51 nationally. Each analysis demonstrated that, following directives from organizational and political leadership for universal masking, new infections fell significantly. Two of these studies46, 47 and an additional analysis of data from 200 countries that included the U.S.51 also demonstrated reductions in mortality. Another 10-site study showed reductions in hospitalization growth rates following mask mandate implementation 49. A separate series of cross-sectional surveys in the U.S. suggested that a 10% increase in self-reported mask wearing tripled the likelihood of stopping community transmission.53 An economic analysis using U.S. data found that, given these effects, increasing universal masking by 15% could prevent the need for lockdowns and reduce associated losses of up to $1 trillion or about 5% of gross domestic product.47

Two studies have been improperly characterized by some sources as showing that surgical or cloth masks offer no benefit. A community-based randomized control trial in Denmark during 2020 assessed whether the use of surgical masks reduced the SARS-CoV-2 infection rate among wearers (personal protection) by more than 50%. Findings were inconclusive,54 most likely because the actual reduction in infections was lower. The study was too small (i.e., enrolled about 0.1% of the population) to assess whether masks could decrease transmission from wearers to others (source control). A second study of 14 hospitals in Vietnam during 2015 found that cloth masks were inferior to surgical masks for protection against clinical upper respiratory illness or laboratory-confirmed viral infection.55 The study had a number of limitations including the lack of a true control (no mask) group for comparison, limited source control as hospitalized patients and staff were not masked, unblinded study arm assignments potentially biasing self-reporting of illness, and the washing and re-use of cloth masks by users introducing the risk of infection from self-washing. A follow up study in 2020 found that healthcare workers whose cloth masks were laundered by the hospital were protected equally as well as those that wore medical masks.56

Adverse Health Effects of Mask Wearing

Research supports that mask wearing has no significant adverse health effects for wearers.  Studies of healthy hospital workers, older adults, and adults with COPD reported no change in oxygen or carbon dioxide levels while wearing a cloth or surgical mask either during rest or physical activity.57-59 Among 12 healthy non-smoking adults, there was minimal impact on respiration when wearing a mask compared with not wearing a mask; however, the authors noted that while some respiratory discomfort may have been present, mask use was safe even during exercise.60 The safety of mask use during exercise has been confirmed in other studies of healthy adults.61-63 Additionally, no oxygen desaturation or respiratory distress was observed among children less than 2 years of age when masked during normal play.64 While some studies have found an increase in reports of dyspnea65 (difficulty breathing) when wearing face masks, no physiologic differences were identified between periods of rest or exercise while masked or non-masked.63

Conclusions

Experimental and epidemiological data support community masking to reduce the spread of SARS-CoV-2. The prevention benefit of masking is derived from the combination of source control and wearer protection for the mask wearer. The relationship between source control and wearer protection is likely complementary and possibly synergistic14, so that individual benefit increases with increasing community mask use. Further research is needed to expand the evidence base for the protective effect of cloth masks and in particular to identify the combinations of materials that maximize both their blocking and filtering effectiveness, as well as fit, comfort, durability, and consumer appeal. Mask use has been found to be safe and is not associated with clinically significant impacts on respiration or gas exchange. Adopting universal masking policies can help avert future lockdowns, especially if combined with other non-pharmaceutical interventions such as social distancing, hand hygiene, and adequate ventilation.

Table: Summary of studies that have assessed the effect of mask mandates on COVID-19 infection risks 
Type of investigation Location Study months (all 2020) Population studied Intervention Outcome
Hendrix36 Cohort study Hair salon in Springfield, MO  (USA) May 2 symptomatically infected stylists and 139 patrons Universal masking in salon (by local ordinance and company policy) No COVID-19 infections among 67 patrons who were available for follow-up
Payne39 Cohort study USS Theodore Roosevelt, Guam (USA) March 382 U.S. Navy service members Mask wearing (self-report) Masking reduced risk of infection by 70% (unadjusted OR 0.30, 95% CI = 0.17-0.52)
Wang Y37 Cohort study Households in Beijing (China) February-March 124 households of diagnosed cases comprising 335 people Mask wearing by index cases or >1 household member prior to index case’s diagnosis (self-report) Masking reduced risk of secondary infection by 79% (adjusted OR 0.21, 95% CI = 0.06-0.79)
Doung-Ngern38 Case-control study Bangkok (Thailand) April- May 839 close contacts of 211 index cases Mask wearing by contact at time of high-risk exposure to case (self-report) Always having used a mask reduced infection by 77% (adjusted OR 0.23, 95% CI = 0.096-0.60).
Gallaway44 Population-based intervention Arizona, USA January-August State population Mandatory mask wearing in public Temporal association between institution of masking policy and subsequent decline in new diagnoses.
Rader52 Serial cross-sectional surveys United States June- July 374,021 persons who completed web-based surveys Self-reported mask wearing in grocery stores and in the homes of family or friends A 10% increase in mask wearing tripled the likelihood of stopping community transmission (adjusted OR 3.53, 95% CI = 2.03-6.43).
Wang X42 Population-based intervention with trend analysis Boston, MA (USA) March- April 9,850 healthcare workers (HCW) Universal masking of HCW and patients, Mass General Brigham health care system Estimated daily decline in new diagnoses among HCW of 0.49%
Mitze43 Population-based intervention with trend analysis Jena (Thuringia), Germany April City population aged >15 years Mandatory mask wearing in public spaces (e.g., public transport, shops) Estimated daily decline in new diagnoses of 1.32%
Van Dyke45 Population-based intervention with trend analysis Kansas, USA June- August State population Mandatory mask wearing in public spaces Estimated case rate per 100,000 decreased by 0.08 in counties with mask mandates but increased by 0.11 in those without.
Lyu and Wehby46 Population-based intervention with trend analysis 15 US states and Washington DC March- May State population Mandatory mask wearing in public Estimated overall initial daily decline in new diagnoses of 0.9%, grew to 2.0% at 21 days following mandates.
Joo49 Population-based intervention with trend analysis United States March-October State populations Mandatory mask wearing in public Estimated decline in weekly hospitalization rates by up 5.6 percentage points for adults aged 18–64 years after mandate implementation, compared with growth rates during the 4 weeks preceding implementation of the mandate.
Guy51 Population-based intervention with trend analysis 2,313 counties, US March-December County population Mandatory mask wearing in public Estimated overall initial daily decline in new diagnoses of 0.5%, grew to 1.8% at 81-100 days following mandates. Estimated overall initial daily decline in deaths of 0.7%, grew to 1.9% at 81-100 days following mask mandate implementation.
Karaivanov48 Counterfactual modeling using national data Canada March-August County population Mandatory mask wearing indoors Estimated weekly 24%-46% decline in new diagnoses following mask mandates.
Chernozhukov50 Counterfactual modeling using national data United States March-May State population Mandatory mask wearing for employees in public businesses Nationally mandating face masks for employees early in the pandemic could have reduced the weekly growth rate of cases and deaths by more than 10 percentage points in late April and 19%- 47% fewer deaths nationally by the end of May.
Leffler52 169 countries Jan–May County population Mask wearing by tradition, mandate, or recommendation Duration of mask wearing by the public was negatively associated with per-capita mortality from COVID-19.
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