Review of facemasks

Wu lien The designed the first cloth face mask during the Manchurian Plague in 1910.(Goh 1987)

He understood virus particles are transmissable from presymptomatic paucisymptomatic and

asymptomatic carriers

Direct evidence

There are no randomized controlled trails comparing the use of face masks and non use of facemask
in preventing covid infection,( for ethical and logistic reasons).Thus we have no gold standard of
evidence for the efficacy of use of facemask in covid 19 infections

There has been one observational study carried out in Beijing (Wang 2020) showing that face masks
are 79% effective in reducing transmission. Chu(2020) has carried out a systematic review of face
mask use and found a transmission risk reduction 70%.However the review included results from
three studies of non covid, coronavirus infections.

There is one published randomized controlled trial of face masks preventing influenza in the
community ,and masks were found to have a protective efficacy of 80%(Mackintyre 2008)

In such studies there is a need to clarify the setting,the type of mask used , the mask study
information as relating to source control or protecting the wearer from infection, the type of
respiratory illness studied and the prescence or absence of a control group

The Cochrane collaboration studied 67 randomised controlled trials and observational studies, and
in conclusion, stated ..”masks are the best intervention across population settings and threats. But
there is as yet insufficient evidence to provide facial barriers without other meäsures”(Higgins 2019)

Chungtai ‘s 2019 study states facemasks are especially beneficial if used in the presymptomatic
stage of infection by mitigating aerosol dispersal

In summary, the direct evidence for efficacy of mask wearing ,is informative but not compelling

Modelling

The SIRS model (Stutt 2020,Kai 2020) is supportive of wearing masks ,but the modelling is abstract,
non generalisable and not conclusive

Modelling uses the index R0 “(average number of people infected by one person) as an important
element in mulitivariate regression analysis.But to be a comprehensive model it is necessary to
include the population studied, different local health policies,and varying behaviours of those
already infected , as well as “k”the dispersion factor ,and these may be missing

Tian(2020) points out that in some theoretical models asymptomatic carriers are not considered,
and if adherence to mask wearing is socioeconomically, demographically or geographically
clustered ,the model will statistically overstate the impact of mask wearing
Review of facemasks

The lack of causal indentifiabilty, and the many confounders associated with face mask wearing and
covid infection, suggest that a synthesis of different interdisciplinary lines of evidence is needed in
the analysis of utility on face mask use.

Information derived from population impacts, transmission dynamics, source control, social factors
and the effects of mandating face mask use, is also of value in interpreting the value of face mask
use

Population impact

Mask wearing is a population level outcome which reflects individual level interventions, and the
aggregate effect of this on a community as system. Mask wearing slows down caseloads ,protects
health care capacity, and suppress exponential growth of the covid pandemic

However in reality mask wearing is limited by access to masks.

Leffler (2020) found that the transmission rate for respiratory infections were 7.5 times higher if not
wearing a face mask.

Goldman Sachs estimates 1 trillion$ revenue has been lost in USA , because the entire population of
the USA does not wear face masks

Transmission characteristics

Mask wearing reduces transmission and this is supported by epidemiological and ecological
modelling However there are no studies to help the question Who should wear what type of mask”,
in what situation, and when?””

The presymptomatic incubation period has a median duration of 5 days,and people are infectious
without showing symptoms(this differentiates covid 19 from SARS).Virus shedding peaks at 0.7 days
before symptoms.

The SARS viral load has been found to be the same in children as adults (and this can be
extrapolated to Covid 19)

The transmission vectors are contact with surfaces, contact with humans ,speaking, coughing and
breathing .
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Transmission dynamics are “not universal .They are pathogen specific( because of peak shedding
and inactivation rates)

This information tells us who is to wear facemasks, when, and in what situations

The type of facemask best worn has been the subject of investigation.

Milton(2020) found an exhaled 5microgram droplet stayed motionless in air, but moved with
current of air and ventilation.(A 100mcgram diameter droplet defines the boundary between
droplet and aerosol)

A droplet evaporates to an aerosol and this can float for minutes to hours in air(Vuoronin
2020)).These aerosols silently spread(Prather 2020) with breathing,speech and talking. The vibration
of vocal cords provides the particle size and particle propulsion.Some are speech superemitters””

Successful mask filtration varies with particle size and trajectory . Small floating aerosols are
challenging to arrest. It is easier to control particle egress with a mask , than ingress with PPE.

SOURCE control

Unmasked , with a cough,5000 droplet contaminants per 5 cubic feet are released.Wearing a cloth
mask reduces this number to 19 droplet contaminants per 5 cubic feet only

Four ply cotton masks are effective ,preventing 97% transmission

Masks to prevent coronavirus transmission ( types nl63/oc43/229e HKU1) and flu virus are more
effective than preventing transmission of rhino virus

Milton(2020) demonstrated mask wearing reduces viral transmission 3.4 fold ,Wood ‘s study (2018)
of N95 masks,demonstrated 94 % reduction of transmission . Stockwell s (2018) study of surgical
mask gave similar results .A stitched cloth face mask reduced cough jet distance from 8 feet to 2.5
inches

The filtration effects of facemasks (Wilkes 2000) are measured and effectiveness compared using a
challenge jet of 30litre j /min(three times the ventilation rate of humans at rest or light exertion or
work).

Household material was found to be 94% protective, a surgical mask 96% protective, and a teacloth
60% protective. Silk and cotton masks avoided lateral flow and brow jet contamination
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Afinrud(2020)using a laser light scattering method ,demonstrated a forward ejection of jet

particles ,but no jet laterally .The schlieren imaging technique ,developed from Toplers aeronautical
studies, a confirmed the characteristics of the emission cloud

Face masks with valves do not capture respiratory particles as efficiently

Facemasks help in prevention, by also reducing surface transmission ,and in reducing contact of
hands with face

PPE

PPE is an important part of covid prevention .The masks must fit and have adequate filtering
capacity.

The criteria defining N95 masks are that they block 95% pathogens ,of 0.3 micron diameter ,at a
flow rate 85litre/m(National Institute of Occupational Health and safety (2020)

It should be noted the WHO (2020) advice concerning characteristics of covid preventing masks was
based on a study using 78nm diameter and allowing 98 % penetration of the mask .(SARS cov 2 has a
diameter of 100microns.one micron=1000nm))

Zhao(2020) found , that without triboelectric charge ,with 600 threads per square inch of cotton,
polyester or polypropolene, multilayered structured masks exceeded the efficiency of N95 mask.

An unfitted surgical mask ,with 3 clips and two rubber attachments has been found to be equally as
effective as N95 mask in prevention of droplet transmission

The conclusion from the study of Van der Sande(2008) was that all types of masks have limitations

Mackintyre’s(2008) study compared surgical masks to cloth masks, but the results are not robust as
the study had no mask control group. It showed poor prevention of filtration for rhinovirus
compared to coronovirus

Wilkes(2000), and also separately, Radonovitch(2009) ,did not establish N95 mask superiority over
surgical mask .The study results of Johnson( 2009) and Yan (2019) were similar.

Risk compensation behaviour

A social concern about facemask(Pless 2016)is that increasing public use of facemasks may divert
attention away from other protective behaviours and increase risk.

However this did not occur in other comparable epidemic circumstances (HIV , motorcycle helmet
use ,seat belt use,ski helmet use) and may not occur with facemask use
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Other Remarks

Face shields provide additive protection to face masks and are useful for those needing to lip read

Mandating face mask use enhances risk awareness and higher adherence levels, although it polarizes
beliefs, increases reactance and resistance to wearing the facemask

Masks may have outer surface contamination , become wet and should be changed after
>6hrFisman (2020).Chunghtai (2019)

More studies of mask efficiency are needed in different groups (eg children ,elderly) studies of mask
protection at different and relevant flow rates of rest and exertion, and studies carried out of
protective efficacy in different contexts (eg to reduce the Stigma of facemasks in blacks in USA)

Research into novel materials and design (eg two layers paper towel at right angles ,paper towel and
face shield of polyvinylidene nanofibers) may provide future improved facemasks