The use of face masks/face shields to prevent transmission of COVID-19 and other infectious diseases–are they effective?

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How effective is wearing face masks and/or face shields in preventing the transmission of COVID-19 and other infectious diseases? Recommendations in the United States, at least, have varied often depending upon who issued them–politicians or medical professionals.

Quick bibliography: What does the research say about the effectiveness of wearing face masks and/or face shields to prevent the transmission of infectious diseases?

*Bhaskar ME, Arun S. (2020). SARS-CoV-2 Infection Among Community Health Workers in India Before and After Use of Face Shields. JAMA. Published online August 17, 2020. [PDF] [Cited by]

“Before face shields, 62 workers (40 women) visited 5880 homes with 31 164 persons. From the 5880 homes visited, 222 persons tested positive for SARS-CoV-2, between May 4 to May 13. Twelve workers (19%) were infected during this period. Eight developed symptoms (fever, cough, sore throat, myalgia, and anosmia) and 4 were asymptomatic.

After face shields, 50 workers (previously uninfected) continued to provide counseling, visiting 18 228 homes. Among the counseled, 118 428 persons, 2682 subsequently tested positive for SARS-CoV-2. No worker developed asymptomatic or symptomatic infection.

This study found no SARS-CoV-2 [COVID-19] infections among community health workers after the addition of face shields to their personal protective equipment. The face shields may have reduced ocular exposure or contamination of masks or hands or may have diverted movement of air around the face. Further investigation of face shields in community settings is warranted.”

*Eikenberry, S. E., Mancuso, M., Iboi, E., Phan, T., Eikenberry, K., Kuang, Y., . . . Gumel, A. B. (2020). To mask or not to mask: Modeling the potential for face mask use by the general public to curtail the COVID-19 pandemic.Infectious Disease Modelling, 5, 293-308. [PDF] [Cited by]

“Face mask use by the general public for limiting the spread of the COVID-19 pandemic is controversial, though increasingly recommended, and the potential of this intervention is not well understood. We develop a compartmental model for assessing the community-wide impact of mask use by the general, asymptomatic public, a portion of which may be asymptomatically infectious. Model simulations, using data relevant to COVID-19 dynamics in the US states of New York and Washington, suggest that broad adoption of even relatively ineffective face masks may meaningfully reduce community transmission of COVID-19 and decrease peak hospitalizations and deaths. Moreover, mask use decreases the effective transmission rate in nearly linear proportion to the product of mask effectiveness (as a fraction of potentially infectious contacts blocked) and coverage rate (as a fraction of the general population), while the impact on epidemiologic outcomes (death, hospitalizations) is highly nonlinear, indicating masks could synergize with other non-pharmaceutical measures. Notably, masks are found to be useful with respect to both preventing illness in healthy persons and preventing asymptomatic transmission. Hypothetical mask adoption scenarios, for Washington and New York state, suggest that immediate near universal (80%) adoption of moderately (50%) effective masks could prevent on the order of 17–45% of projected deaths over two months in New York, while decreasing the peak daily death rate by 34–58%, absent other changes in epidemic dynamics. Even very weak masks (20% effective) can still be useful if the underlying transmission rate is relatively low or decreasing: In Washington, where baseline transmission is much less intense, 80% adoption of such masks could reduce mortality by 24–65% (and peak deaths 15–69%), compared to 2–9% mortality reduction in New York (peak death reduction 9–18%). Our results suggest use of face masks by the general public is potentially of high value in curtailing community transmission and the burden of the pandemic. The community-wide benefits are likely to be greatest when face masks are used in conjunction with other non-pharmaceutical practices (such as social-distancing), and when adoption is nearly universal (nation-wide) and compliance is high.”

*Hartley, D. M., & Perencevich, E. N. (2020). Public health interventions for COVID-19: Emerging evidence and implications for an evolving public health crisis.JAMA, 323(19), 1908-1909. [PDF] [Cited by]

“For decades, leading scientists and influential professional societies have warned of the dangers of emerging infections and the specter of a global pandemic. The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its subsequent spread has lived up to and surpassed many of the warnings and has caused an evolving global public health and economic crisis. Significantly, no pharmaceutical agents are known to be safe and effective at preventing or treating coronavirus disease 2019 (COVID-19), the resulting illness. This leaves the medical and public health community with only nonpharmaceutical interventions (NPIs) to rely on for reducing the burden of COVID-19. These measures aim to reduce disease transmission both locally and globally and include bans on public gatherings, compulsory stay-at-home policies, mandating closures of schools and nonessential businesses, face mask ordinances, quarantine and cordon sanitaire (ie, a defined quarantine area from which those inside are not allowed to leave), among others. The effectiveness of NPIs has been studied theoretically, especially within the context of pandemic influenza, and also through analysis of historical observational data. A common finding of these studies is that implementing NPIs, especially when done rapidly after initial detection of a new contagious pathogen, can reduce transmission.

*Jefferson, T., Foxlee, R., Del Mar, C., Dooley, L., Ferroni, E., Hewak, B., . . . Rivetti, A. (2008). Physical interventions to interrupt or reduce the spread of respiratory viruses: Systematic review.BMJ (Clinical Research Ed.), 336(7635), 77-80. [PDF] [Cited by]

“To systematically review evidence for the effectiveness of physical interventions to interrupt or reduce the spread of respiratory viruses.

Search strategy of the Cochrane Library, Medline, OldMedline, Embase, and CINAHL, without language restriction, for any intervention to prevent transmission of respiratory viruses (isolation, quarantine, social distancing, barriers, personal protection, and hygiene). Study designs were randomised trials, cohort studies, case-control studies, and controlled before and after studies.

Of 2300 titles scanned, 138 full papers were retrieved, including 49 papers of 51 studies. Study quality was poor for the three randomised controlled trials and most of the cluster randomised controlled trials; the observational studies were of mixed quality. Heterogeneity precluded meta-analysis of most data except that from six case-control studies. The highest quality cluster randomised trials suggest that the spread of respiratory viruses into the community can be prevented by intervening with hygienic measures aimed at younger children. Meta-analysis of six case-control studies suggests that physical measures are highly effective in preventing the spread of SARS: handwashing more than 10 times daily (odds ratio 0.45, 95% confidence interval 0.36 to 0.57; number needed to treat=4, 95% confidence interval 3.65 to 5.52); wearing masks (0.32, 0.25 to 0.40; NNT=6, 4.54 to 8.03); wearing N95 masks (0.09, 0.03 to 0.30; NNT=3, 2.37 to 4.06); wearing gloves (0.43, 0.29 to 0.65; NNT=5, 4.15 to 15.41); wearing gowns (0.23, 0.14 to 0.37; NNT=5, 3.37 to 7.12); and handwashing, masks, gloves, and gowns combined (0.09, 0.02 to 0.35; NNT=3, 2.66 to 4.97). The incremental effect of adding virucidals or antiseptics to normal handwashing to decrease the spread of respiratory disease remains uncertain. The lack of proper evaluation of global measures such as screening at entry ports and social distancing prevent firm conclusions being drawn.

Routine long term implementation of some physical measures to interrupt or reduce the spread of respiratory viruses might be difficult but many simple and low cost interventions could be useful in reducing the spread.”

*Ngonghala, C. N., Iboi, E., Eikenberry, S., Scotch, M., MacIntyre, C. R., Bonds, M. H., & Gumel, A. B. (2020). Mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel coronavirus.Mathematical Biosciences, 325, 108364. [PDF] [Cited by]

“A pandemic of a novel Coronavirus emerged in December of 2019 (COVID-19), causing devastating public health impact across the world. In the absence of a safe and effective vaccine or antivirals, strategies for controlling and mitigating the burden of the pandemic are focused on non-pharmaceutical interventions, such as social-distancing, contact-tracing, quarantine, isolation, and the use of face-masks in public. We develop a new mathematical model for assessing the population-level impact of the aforementioned control and mitigation strategies. Rigorous analysis of the model shows that the disease-free equilibrium is locally-asymptotically stable if a certain epidemiological threshold, known as the reproduction number (denoted by ), is less than unity. Simulations of the model, using data relevant to COVID-19 transmission dynamics in the US state of New York and the entire US, show that the pandemic burden will peak in mid and late April, respectively. The worst-case scenario projections for cumulative mortality (based on the baseline levels of anti-COVID non-pharmaceutical interventions considered in the study) decrease dramatically by 80% and 64%, respectively, if the strict social-distancing measures implemented are maintained until the end of May or June, 2020. The duration and timing of the relaxation or termination of the strict social-distancing measures are crucially-important in determining the future trajectory of the COVID-19 pandemic. This study shows that early termination of the strict social-distancing measures could trigger a devastating second wave with burden similar to those projected before the onset of the strict social-distancing measures were implemented. The use of efficacious face-masks (such as surgical masks, with estimated efficacy 70%) in public could lead to the elimination of the pandemic if at least 70% of the residents of New York state use such masks in public consistently (nationwide, a compliance of at least 80% will be required using such masks). The use of low efficacy masks, such as cloth masks (of estimated efficacy less than 30%), could also lead to significant reduction of COVID-19 burden (albeit, they are not able to lead to elimination). Combining low efficacy masks with improved levels of the other anti-COVID-19 intervention strategies can lead to the elimination of the pandemic. This study emphasizes the important role social-distancing plays in curtailing the burden of COVID-19. Increases in the adherence level of social-distancing protocols result in dramatic reduction of the burden of the pandemic, and the timely implementation of social-distancing measures in numerous states of the US may have averted a catastrophic outcome with respect to the burden of COVID-19. Using face-masks in public (including the low efficacy cloth masks) is very useful in minimizing community transmission and burden of COVID-19, provided their coverage level is high. The masks coverage needed to eliminate COVID-19 decreases if the masks-based intervention is combined with the strict social-distancing strategy.”

*Perencevich, E. N., Diekema, D. J., & Edmond, M. B. (2020). Moving personal protective equipment into the community: Face shields and containment of COVID-19.JAMA, published online April 29, 2020. [PDF] [Cited by]

“On March 19, 2020, California became the first state to issue a stay-at-home order in response to the evolving coronavirus disease 2019 (COVID-19) pandemic. It was quickly recognized that widespread diagnostic testing with contact tracing, used successfully in countries such as South Korea and Singapore, would not be available in time to significantly contain the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Over the following month, additional nonpharmaceutical mitigation strategies, including school closures, bans on large in-person gatherings, and partial closures of restaurants and retail stores, were applied to “flatten the epidemic curve” and limit the peak effects of a surge of patients on health care systems. Yet, even as the benefits of mitigation bundles have not fully been realized, there are widespread calls to reopen businesses, given the immense economic and social consequences of extreme physical distancing strategies. The COVID-19 pandemic arrived swiftly and found many countries unprepared. Even highly prepared countries are now facing second-wave outbreaks that have forced implementation of extreme social distancing measures. To minimize the medical and economic consequences, it is important to rapidly assess and adopt a containment intervention bundle that drives transmissibility to manageable levels. Face shields, which can be quickly and affordably produced and distributed, should be included as part of strategies to safely and significantly reduce transmission in the community setting. Now is the time for adoption of this practical intervention.”

*Saunders-Hastings, P., Crispo, J. A. G., Sikora, L., & Krewski, D. (2017). Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis.Epidemics, 20, 1-20. [Cited by]

“The goal of this review was to examine the effectiveness of personal protective measures in preventing pandemic influenza transmission in human populations.

We collected primary studies from Medline, Embase, PubMed, Cochrane Library, CINAHL and grey literature. Where appropriate, random effects meta-analyses were conducted using inverse variance statistical calculations.

Meta-analyses suggest that regular hand hygiene provided a significant protective effect (OR = 0.62; 95% CI 0.52–0.73; I2 = 0%), and facemask use provided a non-significant protective effect (OR = 0.53; 95% CI 0.16–1.71; I2 = 48%) against 2009 pandemic influenza infection. These interventions may therefore be effective at limiting transmission during future pandemics.“

For additional research about the effectiveness of wearing face masks and/or face shields to prevent the transmission of infectious diseases, please see the Science Primary Literature Database.

Questions? Please let me know (engelk@grinnell.edu).

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