11/13/2020 5 Questions: Stanford scientists on COVID-19 mask guidelines | News Center | Stanford Medicine

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5 Questions: Stanford scientists on COVID-19 mask guidelines

Scientists say we should wear masks to control the spread of COVID-19. Stanford experts share the
evidence that informed the World Health Organization’s recommendations.

JUN 19 On June 5, the World Health Organization revised its guidelines about when people should wear cloth masks.

2020 Previously, the organization had recommended that only those with symptoms of COVID-19, the respiratory disease
caused by the novel coronavirus, or those caring for them, wear cloth masks over the nose and mouth. 

On June 18, California Gov. Gavin Newsom issued a statewide order requiring people to wear masks in most public
spaces.

A video produced for the World Health Organization explains source control in the context of the COVID-19 pandemic.
Larry Chu and Amy Price

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The new guidelines recommend that everyone who comes in close contact with others in crowded or close quarters, such
as on a bus or in a store, wear a cloth mask composed of at least three di erent layers of material. People 60 or older, or those with
underlying health conditions, should wear medical masks, such as surgical masks, in public, and physicians and health care
providers should wear medical masks in all areas of a hospital, even if the area in which they are working has no COVID-19
patients, according to the organization.

The new guidelines were devised a er WHO o icials reviewed information from researchers at Stanford and elsewhere about the
ability of cloth masks to slow the spread of the disease, which has now infected more than 8 million people worldwide and
caused more than 400,000 deaths.

The revised recommendations more closely echo those of the U.S. Centers for Disease Control and Prevention, which since early
April has recommended cloth masks in public settings where social distancing is di icult to maintain.

Science writer Krista Conger spoke with two Stanford researchers involved in the change to the WHO guidelines: Amy Price,
PhD, a senior research scientist at Stanford’s Anesthesia Informatics and Media Laboratory, and Larry Chu, MD, a professor of
anesthesia and director of the AIM Laboratory. They recently co-authored an article in Nanotechnology Letters assessing the
filtering and breathability of various household fabrics o en used to make masks.

 1. How do cloth face coverings prevent the spread of COVID-19? 

Chu: In order to answer this, it’s first important to understand the concept of source control. We’ve learned that as many as 40% of
people infected with the virus that causes COVID-19 may have no symptoms. But when they talk, cough or sneeze, they can still
spread the virus to others in the form of respiratory droplets expelled into the air. Those droplets evaporate into fine particles
that may linger. The mask traps these larger droplets before they can evaporate. So, wearing a mask regularly can prevent
spreading at the source even when we don’t know we are sick. But masks are just one important way to prevent this disease from
spreading. Washing your hands regularly and thoroughly and keeping at least 6 feet apart from one another are still vitally
important.  

Price: Many people argue that cloth masks can’t be e ective because they can’t filter out viral particles, which are extremely tiny.
But, as Larry explained, most of these particles leave the mouth and nose in much larger droplets that become smaller through
evaporation as they move away from the body. Trapping droplets with the mask means not nearly as many viral particles escape.
So, when all parties in a gathering are wearing well-constructed, well-fitting masks, it provides an extra layer of safety for
everyone. If two people are wearing masks, the viral particles can travel about 5 feet away from each individual. When an infected
person is not wearing a mask, those particles can floatthrough the air 30 feet or more and stay alive for up to 30 hours.

2. How do you respond to people who feel that wearing a mask can be harmful?
Price: I’ve heard so many misconceptions about cloth masks. Some people think that if you wear a mask for long periods of time
you will trap and breathe in excess amounts of carbon dioxide, which could lead to brain damage. That’s just not true. A properly
constructed mask provides more than enough ventilation. In fact, one way to test if your mask is well made is to try to blow out a
candle through the mask from about 1 foot away. If you can’t do so, your mask might be too tightly woven. Other people feel that
wearing a mask encourages people to touch their face and to loosen their adherence to other safety precautions like social
distancing and hand washing. We’ve found the opposite. Wearing a mask reminds people to continue to be cautious. With a mask
on, you actually touch your face less. People who experience skin irritation should ensure their mask has a layer of wicking fabric,
like cotton, against the face, and everyone should change the mask if it becomes wet or dirty. Finally, it’s been suggested that
mask-wearing may increase the concentration of viral particles around an infected person’s mouth and could increase the severity

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 11/13/2020 5 Questions: Stanford scientists on COVID-19 mask guidelines | News Center | Stanford Medicine

of the illness. While it’s true that some studies of health care workers have suggested that the viral dose is an important
determinant of infection, it’s di erent for someone who is already infected. If you are sick, you already have the virus in your
lungs; it’s not going to get any worse. 

3. What’s the best way to make and use a mask? 

Chu: Our studies show that, if constructed properly with high-quality materials, a homemade cloth mask can function as well as
or better than a surgical mask. Based on our studies, the WHO now recommends a cloth mask of at least three layers of di erent
materials. The outermost layer should be made of a fabric that is at least somewhat water resistant. That can be a fabric that is a
combination of cotton and polyester, nylon or rayon. The middle layer should either be a polypropylene —
a spunbond material used in some reusable grocery bags, mattress covers and cra projects — or three-ply disposable facial
tissues like Kleenex. Finally, the innermost layer should be a wicking material to draw moisture away from the face. One
hundred percent so  cotton works well here. 

Larry Chu narrates a video on the best nonmedical mask materials.

Larry Chu and Amy Price

Fit is also important. It shouldn’t fit too tightly, but it should sit against the skin all the way around from the middle of your nose to
under your chin and almost to your ears, and it shouldn’t gape or bulge away when you move your head or speak. 

 Finally, treat your mask like your toothbrush. Don’t share it with anyone, and keep it in a plastic Ziploc bag when not in use. When
you remove it, do so in a way that doesn’t spread germs from the front of the mask to your face, and wash your hands a er
touching the mask.  

 4. What does it mean to charge a mask? Does it work for all materials? How is it accomplished? 

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Price: When we began researching cloth masks, we realized there was not a lot of evidence about their e ectiveness when used as
source control in a community setting. We collaborated with some phenomenal materials scientists here at Stanford, including
Nobel laureate Steven Chu, PhD, and Yi Cui, PhD, to conduct a study of the e ectiveness of various readily available household
fabrics, including cotton, polyester, polypropylene, nylon and silk. We found we could make some materials as e ective as a
surgical mask by charging them with static electricity by rubbing them with latex gloves for 30 seconds prior to use. A similar
approach is used in the construction of medical protective equipment, including surgical masks and N95
respirators. Overall, charging masks can increase their e iciency by as much as 30%, and the e ect can last for many hours.

 5. If everyone wore a face mask in public, what would it accomplish?

Chu: The timing of these new recommendations is critically important. Across the country, communities are beginning to end
shelter-in-place and to return to work and community settings. Nonmedical face masks will become an increasingly important
way, in conjunction with frequent hand washing and social distancing, to prevent the resurgence of disease.  

Price: We know that during the first wave of the pandemic, those countries that implemented masking early were more successful
than others at reducing the spread of the virus. Wearing a mask doesn’t mean that you are weak or afraid or a coward. It’s a way to
protect the vulnerable around you. It’s our duty to keep each other healthy.

By
KRISTA CONGER
Krista Conger is a science writer in the O ice of Communications. Email her at kristac@stanford.edu.

Stanford Medicine integrates research, medical education and health care at its three institutions - Stanford University School of
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