The spread of respiratory viruses, such as the novel coronavirus (SARS-CoV-2), can occur via droplets that are dispersed by infected individuals through coughing and sneezing. There is also evidence to suggest that these droplets can be dispersed by talking or even normal breathing.1-2
Personal protective equipment, such as a protective face mask, is therefore necessary for healthcare workers who require adequate protection when treating infected patients. In addition to healthcare workers, there is evidence to suggest that masks may be a useful tool that can be used in the fight against the spread of respiratory diseases, such as COVID-19.
Who should wear face masks?
The current recommendation on who should wear face masks, and which types of facemasks should be worn, take into account multiple factors including the risk of exposure, risk of severe COVID-19 disease, and the preservation of specific medical supplies during this current crisis.
There is no question that healthcare professionals are currently at greatest risk of contracting COVID-19 and are therefore required to wear personal protective equipment, including face masks.1,3
N95 respirator masks should be worn by healthcare professionals who are on the front lines, taking care of patients with COVID-19. Under these circumstances, respirator masks should be worn to protect the healthcare professionals from respiratory droplets or fine airborne particles that may contain the SARS-CoV-2 virus.2While the SARS-CoV-2 virus is believed to spread most commonly via respiratory droplets, there are some medical procedures that can cause the aerosolization of the virus and therefore result in airborne transmission.4Some of these medical procedures include intubation, endotracheal aspiration, induction of sputum, face mask ventilation, and mechanical ventilation. This means that healthcare workers taking care of patients with COVID-19 should take airborne transmission precautions, which includes the use of N95 respirator masks.5
However, N95 respirator masks may only be necessary for those medical personnel who are in close contact with infected patients or performing medical procedures.6 Medical masks may be sufficient for the remainder of healthcare providers who are not at such a high risk of coming into contact with aerosolized particles.
Patients who have tested positive for COVID-19 and those caring for them
Patients who have tested positive for COVID-19 should wear medical masks to prevent virus particles from spreading due to coughing, sneezing, or talking. This can protect those who might come into close contact with these patients, including those who are caring for them. In addition, this prevents the unintended spread of virus particles that can fall from the droplets and settle onto surfaces that others my inadvertently come into contact with.
A recent study found that in households where one person was infected with a respiratory virus, implementing the use of face masks reduced the transmission of the virus by up to 80%.7 The results of this study did not differ between the use of medical masks or N95 respirators.
Those who are at greater risk of severe COVID-19 disease should protect themselves by wearing masks. According to the World Health Organization, those who are at significantly greater risk for COVID-19 complications have been identified as people who are over the age of 60, although the risk begins to increase at approximately 40 years of age. People who have underlying medical conditions, including cardiovascular disease, diabetes, chronic respiratory disease, and cancer are also at greater risk of serious COVID-19 infection.8
The general public
In the case of the current pandemic, while it is widely accepted that healthcare workers, those caring for the sick, and those with COVID-19 infection should be wearing masks, significant controversy exists surrounding the use of masks as protection for the general population. These recommendations may be due a prioritization of personal protective equipment for healthcare workers coupled with the current worldwide shortages of masks, rather than the actual evidence to support or refute its use.9
Some studies have, in fact, demonstrated that wearing masks in the community can provide effective protection, particularly in crowded areas.10Respiratory droplets have been found to spread in some instances further than the estimated two meters, and sometimes more than eight.1The SARS-CoV-2 virus spreads primarily via respiratory droplets from infected patients. However, critically, there is now significant evidence to suggest that patients begin to spread the virus asymptomatically, either prior to symptoms appearing, or in the absence of symptoms altogether.11-12 The spread of the virus may therefore be reduced if masks were worn as a public health intervention, particularly in crowded places, or areas where it is difficult to maintain an appropriate amount of physical distancing.13-15Taken together, evidence from these studies suggests that combining mask wearing with current hand hygiene and physical distancing recommendations may provide added benefit in reducing transmission.
The CDC and Health Canada recommend that the general public wear non-medical or cloth masks but not wear medical or N95 masks, in an effort to conserve those for medical professionals who require them.16-17
Types of masks
There are different types of masks that differ in their ability to prevent the transmission of microorganisms, and are therefore typically used for different purposes.
Medical masks (surgical masks)
Medical masks, also known as surgical masks, are typically worn in healthcare settings to prevent infection via droplets that occur due to coughing or sneezing. These loose-fitting masks can prevent, for example, the spread of pathogens during surgical procedures, protecting both the patient and healthcare provider.
In terms of protection against SARS-CoV-2, medical masks can protect the wearer from larger respiratory droplets (> 5μm), however, smaller particles such as airborne particles (generally < 5 μm), or single virus particles (60-140nm) would still be able to pass through the pores in these masks.3,18-19
N95 respirator masks
N95 respirator masks are tighter fitting than medical masks and provide a higher degree of protection. This type of mask requires specific fit testing, and can be easily mis-used by the general public. Standard N95 respirators that are approved by the National Institute of Occupational Safety and Health (NIOSH) are tested to make sure that these masks filter at least 95% of airborne particles. The NIOSH standards are accepted by Health Canada as a quality standard.20
N95 masks are the US standard respirator mask, however, other international equivalents include KN95 (China), FFP2 (Europe), and P2 (Australia).21 Although there are some differences between the N95 and KN95, they are both rated to be able to capture 95% of tiny particles (0.3 microns), and have been authorized by the FDA.22
Although there is limited research to demonstrate the effectiveness of non-medical or cloth masks,23 the CDC does recommend wearing a cloth mask in while in public – such as while grocery shopping – particularly in areas where there has been a significant amount of community spread.16 Health Canada suggests that although cloth masks can be a useful protective measure, they should not replace physical distancing and hand hygiene practices.17
Can masks be disinfected and re-used?
In an effort to conserve masks, healthcare workers are currently extending the use of masks to more than one patient encounter even though these are ‘single-use’ items.24 This practice may significantly increase risk of infection due to the continuous touching of the mask, which may become contaminated after extended use.23 Repeated use increases the chances that the surfaces of the mask could be contaminated with virus particles, which can cause infection if the wearer touches these surfaces and then touches their face.
The possibility of decontaminating and reusing masks as a method of prolonging their use has recently been explored. Systematic scientific research will be necessary to clearly define the best possible methods that have sufficiently decontaminate, while maintaining the integrity of the masks to ensure they remain effective.
Research studies have found that washing masks in water, disinfecting with alcohol, UV light, or cleaning chemicals can significantly damage the masks and impair their effectiveness.25-31
A recent study reported that wrapping N95 masks in protective peel pouches and then steam sterilizing them may be a successful method of decontamination.25 Another study tested a relatively simple method of sterilizing masks, where medical masks and N95 respirator masks were placed in plastic bags and steamed on a pot of boiling water for five minutes. In this way, the masks remained dry, ensuring they remained effective, while the researchers found a complete inactivation of avian coronaviruses that were used to simulate contamination.32 Similarly, researchers investigated whether a rice cooker could be used to steam-sterilize masks, comparing this with dry-heat decontamination.33 The steam treatment took a maximum of 15 minutes, which included 5 minutes of active steaming. Dry heat contamination was performed in an oven, which consisted of exposing the masks to 100-degree heat for 15 minutes. The researchers found the steam treatment to be a superior method of decontaminating the masks compared to the dry heat; they also reported that the steaming method was more effective than UV light decontamination. This study did not, however, assess the effectiveness of the masks following decontamination.
- Bahl P, Doolan C, de Silva C, Chughtai AA, Bourouiba L, MacIntyre CR. Airborne or droplet precautions for health workers treating COVID-19? [published online ahead of print, 2020 Apr 16]. J Infect Dis. 2020;jiaa189. doi:10.1093/infdis/jiaa189
- Gralton J, Tovey E, McLaws ML, Rawlinson WD. The role of particle size in aerosolised pathogen transmission: a review. Journal of Infection 2011; 62: 1–13.
- Cook, T.M. (2020), Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic – a narrative review. Anaesthesia. doi:10.1111/anae.15071
- Doremalen, N., Bushmaker, T., Morris, DH., Holbrook, MG., Gamble, A., Williamson, BN., Tamin, A., Harcourt, JL., THronburg, NJ., Gerber, SI., Lloyd-Smith, JO., de Wit, E., Munster, VJ.(2020), Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med; 382:1564-1567DOI: 10.1056/NEJMc2004973
- Azap, A., Erdinc, FS. (2020). Medical mask or N95 respirator: When and how to use? Turk J Med Sci. doi: 10.3906/sag-2004-199.
- Long Y, Hu T, Liu L. (2020). Effectiveness of N95 respirators versus surgical masks against influenza: a systematic review and meta-analysis. J Evid Based Med.
- MacIntyre CR, Cauchemez S, Dwyer DE, et al. Face mask use and control of respiratory virus transmission in households. Emerg Infect Dis. 2009;15(2):233‐241. doi:10.3201/eid1502.081167
- World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10
- MacIntyre, CR. (2020). Community Universal Face Mask Use during the COVID 19 pandemic—from households to travelers and public spaces, Journal of Travel Medicine, , taaa056, https://doi.org/10.1093/jtm/taaa056
- MacIntyre CR, Chughtai AA. Facemasks for the prevention of infection in healthcare and community settings. BMJ (Clinical research ed). 2015;350:h694-h.
- United Nations Office for the Coordination of Humanitarian Affairs. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). New York, NY, USA: OCHA, 2020. https://reliefweb.int/report/china/report-who-china-joint-missioncoronavirus-disease-2019-covid-19
- Bai Y, Yao L, Wei T, et al. (2020). Presumed asymptomatic carrier transmission of COVID-19 JAMA
- Feng, S., Shen, C., Xia, N., Song, W., Fan, M., Cowling, BJ. (2020) Rational use of face masks in the COVID-19 pandemic.Lancet Respir Med. pii: S2213-2600(20)30134-X. doi: 10.1016/S2213-2600(20)30134-X.
- Cheng VCC, Wong SC, Chuang VWM, So SYC, Chen JHK, Sridhar S, To KKW, Chan JFW, Hung IFN, Ho PL, Yuen KY. (2020). The role of community-wide wearing of face mask for control of coronavirus disease 2019 (COVID-19) epidemic due to SARS-CoV-2. J Infect. pii: S0163-4453(20)30235-8. doi: 10.1016/j.jinf.2020.04.024.
- Zhou, Z.‐G., Yue, D.‐S., Mu, C.‐L. and Zhang, L. (2020), Mask is the possible key for self‐isolation in COVID‐19 pandemic. J Med Virol. Accepted Author Manuscript. doi:10.1002/jmv.25846
- Government of Canada. Non-medical masks and face coverings. Available at: https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html
- Centers for Disease Control and Prevention.Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-Based Transmission. Available at: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html
- Derrick JL, Gomersall CD. (2005). Protecting healthcare staff from severe acute respiratory syndrome: filtration capacity of multiple surgical masks. J Hosp Infect. 59:365–368.
- Sandaradura I, Goeman E, Pontivivo G, et al. (2020). A close shave? Performance of P2/N95 respirators in health care workers with facial hair: results of the BEARDS (Adequate Respiratory DefenceS) study. J Hosp Infect.
- Government of Canada. Optimizing the use of masks and respirators during the COVID-19 outbreak. Available at: https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/masks-respirators-covid19.html
- 3M. Comparison of FFP2, KN95, and N95 and Other Filtering Facepiece Respirator Classes. Available at: https://multimedia.3m.com/mws/media/1791500O/comparison-ffp2-kn95-n95-filtering-facepiece-respirator-classes-tb.pdf
- FDA. Authorized respirators. Available at: https://www.fda.gov/media/136663/download
- Abd-Elsayed, A., Karri, J. (2020). Utility of Substandard Face Mask Options for Health Care Workers During the COVID-19 Pandemic.Anesthesia & Analgesia: Volume Publish Ahead of Print – Issue – doi: 10.1213/ANE.0000000000004841
- Strategies for Optimizing the Supply of N95 Respirators: Crisis/Alternate Strategies. Center for Disease Control website https://www.cdc.gov/coronavirus/2019- ncov/hcp/respirators-strategy/crisis-alternate-strategies.html
- Carrillo, I., Floyd, A., Valverde, C., Tingle, T., & Zabaneh, F. (2020). Immediate Use Steam Sterilization (IUSS) Sterilizes N95 Masks Without Mask Damage. Infection Control & Hospital Epidemiology, 1-5. doi:10.1017/ice.2020.145
- Centers for Disease Control and Prevention. Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings. Available at: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
- Centers for Disease Control and Prevention. Cloth masks and mask sterilisation as options in case of shortage of surgical masks and respirators. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/Cloth-face-masks-incase-shortage-surgical-masks-respirators2020-03-26.pdf.
- Heimbuch BK, Wallace WH, Kinney K, et al. (2011). A pandemic influenza preparedness study: use of energetic methods to decontaminate filtering facepiece respirators contaminated with H1N1 aerosols and droplets. Am J Infect Control.39(1)
- Feldmann F, Shupert WL, Haddock E, Twardoski B, Feldmann H. (2019). Gamma irradiation as an effective method for inactivation of emerging viral pathogens. Am J Trop Med Hyg, 100(5):1275-1277.
- Viscusi DJ, Bergman MS, Eimer BC, Shaffer RE. (2009). Evaluation of five decontamination methods for filtering facepiece respirators. Ann Occup Hyg, 53(8):815-827.
- van Straten B, de Man P, van den Dobbelsteen J, Koeleman H, van der Eijk A, Horeman T. (2020). Sterilization of disposable face masks by means of standardized dry and steam sterilization processes; an alternative in the fight against mask shortages due to COVID-19. J Hosp Infect, https://doi.org/10.1016/j.jhin.2020.04.001.
- Ma, Q.‐X., Shan, H., Zhang, C.‐M., Zhang, H.‐L., Li, G.‐M., Yang, R.‐M. and Chen, J.‐M. (2020), Decontamination of face masks with steam for mask reuse in fighting the pandemic COVID‐19: experimental supports. J Med Virol. Accepted Author Manuscript. doi:10.1002/jmv.25921
- Li, DF., Cadnum, JL., Redmond., SN, Jones, LD., Donskey, CJ. (2020). It’s Not the Heat, It’s the Humidity: Effectiveness of a Rice Cooker-Steamer for Decontamination of Cloth and Surgical Face Masks and N95 Respirators, AJIC: American Journal of Infection Control. doi: https://doi.org/10.1016/j.ajic.2020.04.012
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