Face masks during the COVID-19 pandemic

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Sewn multi-layered cloth mask.

During the COVID-19 pandemic, face masks have been employed as a public and personal health control measure against the spread of SARS-CoV-2. Their use is intended as personal protection to prevent infection and as source control to limit transmission of the virus in a community or healthcare setting.

The use of face masks or coverings by the general public has been recommended by health officials to minimize the risk of transmissions, with authorities either requiring their use in certain settings, such as on public transport and in shops, or universally in public. Health officials have stated that medical-grade face masks, such as N95 respirators, should be reserved for healthcare workers and caregivers due to concerns about shortages. Early in the pandemic, public health messaging about masking was often characterized by inconsistent and conflicting statements, such as previous recommendations that only infected individuals should wear masks while there was evidence suggesting asymptomatic transmission. There has been criticism and confusion surrounding the use of masks by the general public, translating to low compliance or inconsistent or improper use in many areas.[1][2][3] About 95% of the world's population lived in countries that recommended or mandated the use of masks in public during the pandemic.

Debates have emerged regarding when and whether masks should be worn, even when social distancing at 2 meters (6 feet),[4][5][6] and during exercise.[7] Additionally, public health agencies of some countries and territories changed their recommendations regarding face masks over time.[8] Face mask shortages also occurred, leading to uncertified and substandard masks being reported as sold on the market, with significantly reduced performance.[9]

Different types of face masks have been recommended throughout the COVID-19 pandemic including:

Transparent face shields, medical goggles, and other types of personal protective equipment (colloquially referred to as "PPE") are sometimes used in conjunction with face masks.

Types of masks[edit]

Cloth masks[edit]

Cloth face masks

A cloth face mask is worn over the mouth and nose and made of commonly available textiles. They vary widely in effectiveness, depending on material, fit/seal, number of layers, and other factors. Although they are usually less effective than medical-grade masks, many health authorities recommend their use by the general public when medical-grade masks are in short supply, as a low-cost and reusable option.[10][11] Unlike disposable masks, there are no legal standards for cloth masks.[12]

One study gives evidence that an improvised mask was better than nothing, but not as good as soft electret-filter surgical mask, for protecting health care workers while simulating treatment of an artificially infected patient.[12]

Another study had volunteers wear masks they made themselves, from cotton T-shirts and following the pattern of a standard tie behind the head surgical mask,[13] and found the number of microscopic particles that leaked inside the homemade masks were twice that of commercial masks. The homemade mask also let a median average of three times as many microorganisms be expelled by the wearer.

A peer-reviewed summary of published literature on the filtration properties of cloth and cloth masks suggested two to four layers of plain weave cotton or flannel, at least 100 threads per inch.[14] There is a necessary trade off: increasing the number of layers increases the filtration of the material but decreases breathability. This makes it harder to wear the mask and also increases the amount of leak around the edge of the mask. A plain-language summary of this work, along with a hand-sewn design, suggestions on materials and layering, and how to put on, take off and clean a cloth mask is available.

Decontamination and re-use[edit]

There was no research on decontaminating and reusing cloth masks, as of May 2020.[12] The CDC recommends doffing a mask by handling only the ear loops or ties, placing it directly in a washing machine, and immediately washing one's hands in soap and water for at least 20 seconds. They also recommend washing one's hands before donning the mask and again immediately after one touches it.[15]

There is no information on reusing an interlayer filter, and disposing of it after a single use may be desirable.[12] A narrative review of the literature on filtration properties of cloth and other household materials did not find support for the idea of using a filter. A third layer of cloth, if tolerated, was suggested instead.[14]

Surgical masks[edit]

Surgical mask

A surgical mask is a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. If worn properly, a surgical mask is meant to help block large-particle droplets, splashes, sprays, or splatter that may contain viruses and bacteria, keeping it from reaching the wearer's mouth and nose. Surgical masks may also help reduce exposure of the wearer's saliva and respiratory secretions to others.[16]

Certified medical masks are made of non-woven material. They are mostly multi-layer. Filter material may be made of microfibers with an electrostatic charge; that is, the fibers are electrets. An electret filter increases the chances that smaller particles will veer and hit a fiber, rather than going straight through (electrostatic capture).[17][18][19][better source needed][medical citation needed] While there is some development work on making electret filtering materials that can stand being washed and reused,[20] current commercially produced electret filters are ruined by many forms of disinfection, including washing with soap and water or alcohol, which destroys the electric charge.[21] During the COVID-19 pandemic, public health authorities issued guidelines on how to save, disinfect and reuse electret-filter masks without damaging the filtration efficiency.[22][21] Standard disposible surgical masks are not designed to be washed.

A surgical mask, by design, does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures. Surgical masks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and the face.[16] However, in practice, with respect to some infections like influenza, surgical masks appear as effective as respirators (such as N95 or FFP masks).[23] Surgical masks may be labeled as surgical, isolation, dental, or medical procedure masks.[16] Surgical masks are made of a nonwoven fabric created using a melt blowing process.[24][25]

Surgical masks made to different standards in different parts of the world have different ranges of particles which they filter. For example, the People's Republic of China regulates two types of such masks: single-use medical masks (Chinese standard YY/T 0969) and surgical masks (YY 0469). The latter ones are required to filter bacteria-sized particles (BFE ≥ 95%) and some virus-sized particles (PFE ≥ 30%), while the former ones are required to only filter bacteria-sized particles.[26][27][28]

Filtering facepiece respirators[edit]

N95 mask

An N95 mask is a particulate-filtering facepiece respirator that meets the N95 air filtration rating of the US National Institute for Occupational Safety and Health, meaning that it filters at least 95 percent of airborne particles, while not resistant to oil like the P95. It is the most common particulate-filtering facepiece respirator.[29] It is an example of a mechanical filter respirator, which provides protection against particulates, but not gases or vapors.[30] Like the middle layer of[31] surgical masks, the N95 mask is made of four layers[12] of melt-blown nonwoven polypropylene fabric.[32][33][unreliable medical source?] The corresponding face mask used in the European Union is the FFP2 respirator.[34][35]

Hard electret-filter masks like N95 and FFP masks must fit the face to provide full protection. Untrained users often get a reasonable fit, but fewer than one in four gets a perfect fit. Fit testing is thus standard. A line of vaseline on the edge of the mask[36] has been shown to reduce edge leakage[12] in lab tests using manikins that simulate breathing.[36]

Some N95 series respirators, especially those intended for industrial use, have an exhaust valve to improve comfort, making exhalation easier and reducing leakage on exhalation and steaming-up of glasses. Such respirators are not suitable for source control of respiratory disease, such as COVID-19, when worn by an asymptomatic but possibly infected user.[37]

In the COVID-19 pandemic, there were shortages of filtering facepiece respirators, so that they had to be used for extended periods, and/or disinfected and reused. During the COVID-19 pandemic, public health authorities issued guidelines on how to save, disinfect and reuse masks, as some disinfection methods damaged the filtration efficiency.[22][21] Some hospitals stockpiled used masks as a precaution,[38] and some had to reuse masks.

Elastomeric respirators[edit]

Elastomeric full facepiece respirator.

Elastomeric respirators are reusable devices comprising a tight-fitting half facepiece or full facepiece respirators with exchangeable cartridge filters.[39] They provide an alternative respiratory protection option to filtering facepiece respirators such as N95 masks for healthcare workers during times of short supply caused by the pandemic, as they can be reused over an extended period in healthcare settings.[39][40] However, elastomeric respirators have a separate exhalation vent that allows unfiltered exhaled air to be released, so the healthcare worker must be attentive that he or she is not infected with SARS-CoV-2 to prevent possible spread of the virus to others.[40]

The filters must be replaced when soiled, contaminated, or clogged. These components may be hard to find amidst shortages; the filters may thus be sterilized, in a way that does not harm the filter, and re-used. In medical use, they must be cleaned and disinfected, as some germs can survive on them for weeks.[39]

Full-face versions of elastomeric respirators seal better and protect the eyes. Fitting and inspection is essential to effectiveness.[39]

Powered air-purifying respirators[edit]

Powered air-purifying respirators, including a waist pack and hose to blow air into the headpiece.

A powered air-purifying respirator (PAPR) is a personal protective equipment in which a device with a filter and fan creates a highly filtered airflow towards the headpiece and a positive outflow of air from the headpiece.[41]

There is an increased risk for healthcare workers to become exposed to SARS-CoV-2 when they conduct aerosol-generating procedures on COVID-19 patients, which is why it is argued that such situations may require enhanced personal protective equipment (i.e., higher than N95) such as PAPRs for healthcare workers.[41][42]

In a systematic review, Licina, Silvers, and Stuart (8 August 2020) stated that field studies indicate that there was equivalent rates of infection between healthcare workers, who performed airway procedures on critical COVID-19 patients, utilizing PAPRs or other appropriate respiratory equipment (such as N95 or FFP2), but remarked that there is a need to further collect field data about optimal respiratory protection during highly virulent pandemics.[43]

Face shields and eye protection[edit]

A medical worker wearing a face shield adjunct to other personal protective equipment at a COVID-19 testing site.

Godoy et al. (5 May 2020) stated that face shields are used for barrier protection against splash and splatter contamination, but should not be used as primary protection against respiratory disease transmission due to the lack of a peripheral seal rather than as an adjunct to other facial protection.[12] They remarked that face shields have been used like this alongside medical-grade masks during the COVID-19 pandemic.[12] They cited a cough simulation study by Lindsley et al. (2014) in which face shields were shown to reduce the risk of inhalation exposure up to 95% immediately following aerosol production, but that the protection was decreased with smaller aerosol particles and persistent airborne particles around the sides.[44]

In a systematic review by Chu et al. (27 June 2020) of observational studies on the transmission of coronaviruses, funded by the World Health Organization, researchers found that eye protection including face shields was associated with less infection (adjusted odds ratio 0.22; 95% confidence interval 0·12 to 0·39), but the evidence was rated as low certainty.[45]

The US Centers for Disease Control and Prevention (CDC) does not recommend the use of face shields as a substitute for masks to help slow the spread of COVID-19.[46] In a study by Lindsley et al. (2020, preprint) funded by the National Institute for Occupational Safety and Health, part of the CDC, face shields were found to block very little cough aerosols in contrast to face coverings—such as cloth masks, procedure masks, and N95 respirators—indicating that face shields are not effective as source control devices for small respiratory aerosols and that face coverings are more effective than face shields as source control devices to reduce the community transmission of SARS-CoV-2.[47] The authors remarked that currently not much is known about the amount and sizes of aerosol particles containing SARS-CoV-2 expelled by people who are infected, but that the presence of small aerosol particles containing infectious SARS-CoV-2 have been detected in other studies and these small aerosols may play a role in SARS-CoV-2 transmission.[47]

Face masks with exhalation valves[edit]

In September 2020, after visualizing droplet dispersal for face shields and masks with exhalation valves, scientists reported that these two types of face coverings can be ineffective against COVID-19 spread – e.g. after a cough – and recommended alternatives to minimize viral spread.[48][49]

Recommendations[edit]

About 95% of the world population lives in countries where both the government and leading disease experts recommends or mandates the use of masks in public places to limit the spread of COVID-19.[50]

World Health Organization[edit]

The World Health Organization (WHO), in its updated advice dated 5 June 2020, recommends that the general public should wear non-medical fabric masks where there is known or suspected widespread transmission and where physical distancing is not possible, and that vulnerable people (aged over 60 or with underlying health risks) and people with any symptoms suggestive of COVID-19 as well as caregivers and healthcare workers should wear medical masks (defined as surgical or procedure masks).[51] The stated purpose of mask usage is to prevent the wearer transmitting the virus to others (source control) or to offer protection to healthy wearers against infection (prevention).[51]

The WHO advises that non-medical fabric masks should comprise a minimum of three layers,[51] suggesting an inner layer made of absorbent material (such as cotton), a middle layer made of non-woven material (such as polypropylene) which may enhance filtration or retain droplets, and an outer layer made of non-absorbent material (such as polyester or its blends) which may limit external contamination from penetration.[52]

The World Health Organization and UNICEF gave guidance for the use of face masks by children based on the specific age group.[53]

On 21 August 2020, the WHO along UNICEF released an annex guidance for children.[53] For children aged 5 or younger, they advise that masks should not be required in consideration to a child's developmental milestones, compliance challenges, and autonomy required to use a mask properly, but recognized that the evidence supporting their cut-off age is limited and that countries may hold a different and lower age of cut-off.[53] For children between 6 and 11 years of age, they advise that mask usage should be decided in consideration of several factors including the intensity of local viral transmission, (the latest evidence about) the risk of infection for the age group, the social and cultural environment (which influences social interactions in communities and populations), the capacity to comply with appropriate mask usage, the availability of appropriate adult supervision, and the potential impact on learning and psychosocial development, as well as additional factors involving specific settings or circumstances (such as disabilities, underlying diseases, elderly people, sport activities, and schools).[53] For children aged 12 or older, they advise that masks should be worn under the same conditions for adults in accordance to WHO guidance or national guidelines.[53]

Previously, early in the outbreak, the WHO had only recommended medical masks for people with suspected infection and respiratory symptoms, their caregivers and those sharing living space, and healthcare workers.[54][55] In a 6 April advice, the WHO recognized that wearing a medical mask can limit the spread of certain respiratory viral diseases including COVID-19, but believed that the use of a mask alone is not sufficient to provide an adequate level of protection and that other measures (such as hand hygiene) should be adopted.[56] In the scope of the community setting, the WHO stated that medical masks should be reserved for healthcare workers, except for people with symptoms, claiming that medical masks would create a false sense of security and neglect of other measures.[56] The WHO advice for people to wear masks only if they had symptoms was scrutinized, as experts and researchers have pointed out the asymptomatic transmission of the virus.[57][58][59][60][61] The WHO revised its mask guidance in June, with its officials acknowledging that studies have indicated asymptomatic or pre-symptomatic spread but that not much is known.[62]

The WHO had early suggested that mask usage possibly leads to neglect of other essential health measures such as hand hygiene practices, but, according to Marteau et al. (27 July 2020), available evidence does not support that masking adversely affects hand hygiene.[63] Dame Theresa Marteau, one of the researchers, remarked that "The concept of risk compensation, rather than risk compensation itself, seems the greater threat to public health through delaying potentially effective interventions that can help prevent the spread of disease."[64]

Regarding the use of non-medical fabric masks in the general population, the WHO has stated that high-quality evidence for its widespread use is limited, but advises governments to encourage its use as physical distancing may not be possible in some settings, there is some evidence for asymptomatic transmission, and masks could be helpful to provide a barrier to limit the spread of potentially infectious droplets.[65]

US Centers for Disease Control and Prevention[edit]

Guidance from the US Centers for Disease Control and Prevention on using and making cloth masks during the COVID-19 pandemic.[66]
The CDC does not recommend masks with exhalation valves or vents for source control.[46] In the healthcare workers guidance, if only respirators with valves are available and source control is needed, the CDC recommends that the valve should be covered with a surgical mask, procedure mask, or cloth face covering.[67]

The United States Centers for Disease Control and Prevention (CDC), since 3 April 2020, recommends persons wear a cloth face covering in public.[68] In its guidance, since 28 June, the "CDC recommends that people wear cloth face coverings in public settings and when around people who don't live in your household, especially when other social distancing measures are difficult to maintain. Cloth face coverings may help prevent people who have COVID-19 from spreading the virus to others. Cloth face coverings are most likely to reduce the spread of COVID-19 when they are widely used by people in public settings."[69]

In the guidance, since 28 June, the CDC provides the caveat that cloth face coverings should not be worn by children under the age of two, persons who have trouble breathing, or persons who are unconscious, incapacitated, or otherwise unable to remove the mask without assistance.[69] On 7 August, the CDC added that exhalation valves or vents in masks do not help prevent the person wearing the mask from spreading COVID-19 to others (source control), as the one-way hole in the material may allow expelled respiratory droplets from the exhaled air to reach others.[46][70]

The CDC states that healthcare personnel should wear a NIOSH-approved N95 (or equivalent or higher-level) respirator or a face mask (if a respirator is not available) with a face shield or goggles as part of their personal protective equipment, while patients with suspected or confirmed SARS-CoV-2 infection should wear a face mask or cloth face covering during transport.[71] As crisis strategy for known shortages of N95 respirators in healthcare settings, among other sequential measures, the CDC suggests use of respirators beyond the manufacturer-designated shelf life, use of respirators approved under standards used in other countries that are similar to NIOSH-approved respirators, limited re-use of respirators, use of additional respirators beyond the manufacturer-designated shelf life that have not been evaluated by NIOSH, and prioritizing the use of respirators and face masks by activity type.[72]

Early in the pandemic, the CDC said that it did not recommend the use of face masks for the general public.[73][74] However, on 3 April 2020, the CDC changed its advice to recommend that people wear cloth face coverings "in public settings when around people outside their household, especially when social distancing measures are difficult to maintain."[75] In response to a media inquiry by the NPR, the CDC said that this change in guidelines was due to the increasing and widespread transmission of the virus, citing studies published in February and March showing presymptomatic and asymptomatic transmission.[76] In an interview with 102.3 KRMG on 28 July 2020, the CDC director Robert R. Redfield explained that they assumed that the disease was a symptomatic illness when they originally looked at masks, not understanding at the time how much of the viral infection was asymptomatic or presymptomatic, but came to understand the critical role of face coverings for source control once they understood that.[77]

Larry Gostin, a professor of public health law, said that initial CDC and WHO guidance had given the public the wrong impression that mask do not work, even though scientific evidence to the contrary was already available.[76] The confusing changing advice from discouraging to recommending public masking has led to decreasing public trust in the CDC.[59][78] In June 2020 Anthony Fauci, a leading infectious disease expert for the United States government, admitted that the delay in recommending general mask use was motivated by a desire to conserve dwindling supplies for medical professionals.[79]

In an interview with JAMA on 14 July 2020, Redfield said that "The data is clearly there that masking works. [...] Masking is not a political issue. It is a public health issue. It really is a personal responsibility for all of us."[80] He and two other CDC officials explained in a JAMA editorial, published on the same day, that "Covering mouths and noses with filtering materials serves 2 purposes: personal protection against inhalation of harmful pathogens and particulates, and source control to prevent exposing others to infectious microbes that may be expelled during respiration. When asked to wear face coverings, many people think in terms of personal protection. But face coverings are also widely and routinely used as source control."[81] In regards to the changes in CDC recommendations towards universal masking, they clarified that "Early in the pandemic, the Centers for Disease Control and Prevention (CDC) recommended that anyone symptomatic for suspected coronavirus disease 2019 (COVID-19) should wear a face covering during transport to medical care and prior to isolation to reduce the spread of respiratory droplets. After emerging data documented transmission of SARS-CoV-2 from persons without symptoms, the recommendation was expanded to the general community, with an emphasis on cloth face coverings that could be made more widely available in the community than surgical masks and to preserve personal protective equipment such as N95 respirators to the highest-risk exposures in health care settings. Now, there is ample evidence that persons without symptoms spread infection and may be the critical driver needed to maintain epidemic momentum."[81]

China and Asia[edit]

China has specifically recommended the use of disposable medical masks by the public, including its healthy members,[82][83] particularly when coming into close contact (1 metre (3 ft) or less) with other people.[84] Hong Kong recommends wearing a surgical mask when taking public transport or in crowded places.[85][86] Thailand's health officials are encouraging people to make cloth face masks at home and wash them daily.[87] The Republic of China (Taiwan), South Korean, and Japanese governments have also recommended the use of face masks in public.

In March 2020, when asked about the mistakes that other countries were making in the pandemic, the Chinese Center for Disease Control and Prevention director-general George Fu Gao said:

"The big mistake in the U.S. and Europe, in my opinion, is that people aren't wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role − you've got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others."[88]

Europe[edit]

Most countries in Europe have introduced mandatory face mask rules for public places,[89][90] but there was initial hesitation among health officials in the Nordic countries, and the state epidemiologist of Sweden, Anders Tegnell, maintains his position that they are unnecessary.[91][90]

The main reasoning against masks recommendations given by officials in the Nordic countries was that public masking is deemed an unnecessary precaution when infection levels remain low.[92] In June 2020, the Norwegian Institute of Public Health said that the wearing of face masks by asymptomatic individuals was not to be recommended due to the low prevalence of COVID-19 in the country, but noted that it should be reconsidered if cases rise.[93] Similarly, on 30 July 2020, the Danish Health Authority director Soren Brostrom said that face covers did not make sense in the current situation with low infection levels, but that they needed to evaluate whether it could make sense in the long term.[94][95] From October 29, face masks will be mandatory inside in any building in Denmark that has public access – from supermarkets and kiosks to hospitals and schools.[96] In many Norwegian local municipalities, face masks are mandatory on public transport where a social distance of one metre is impossible to maintain.[97]

Rationale for wearing masks[edit]

Schlieren image showing the interaction of exhaled airflows between two persons.[98]
Masks are used to limit the transmission of SARS-CoV-2 by respiratory droplets and aerosols, which are thought to be the major pathways of infection, exhaled from infected individuals during breathing, speaking, coughing, and sneezing.[99][100]

The National Health Commission of China cited the following reasons for the wearing of masks by the public, including healthy individuals:

  1. Asymptomatic transmission. Many people can be infected without symptoms or only with mild symptoms.[101]
  2. Difficulty or impossibility of appropriate social distancing in many public places at all times.[101]
  3. Cost-benefit mismatch. If only infected individuals wear masks, they would possibly have a negative incentive to do so. An infected individual might get nothing positive, but only bear the costs such as inconvenience, purchasing expenses, and even prejudice.[101]
  4. There is no shortage of masks in China. The country has the production capacity to meet the demand on masks.[101]

Yuen Kwok-yung, a microbiologist from the University of Hong Kong, cites a high amount of virus strands in saliva of infected people and transmission by asymptomatic carriers as the reasons why even seemingly healthy individuals should wear a mask.[102] Kelvin Kai-Wang To et al. (February 2020) detected live SARS-CoV-2 in the saliva of infected patients, which indicated that the virus may be transmitted directly or indirectly through saliva with or without respiratory symptoms, and stated that the findings reinforced the use of surgical masks as a control measure.[103]

In a comment to The Lancet, Kar Keung Cheng, Tai Hing Lam, and Chi Chiu Leung argued that a public health rationale for mass masking is source control to protect others from respiratory droplets and underscored the importance of this approach due to asymptomatic transmission.[104] Wang Linfa, an infectious disease expert who heads a joint Duke University and National University of Singapore research team, stated that masking is about "preventing the spread of disease rather than preventing getting the disease", remarking that the point is to cover the faces of people who are infected but do not know it, so it is imperative for everyone to wear one in public.[58]

Monica Gandhi, a medical professor at the University of California, San Francisco, states that viral shedding at high quantities from the upper respiratory tract, characterized by unusually high levels of viral particles, means that universal mask wearing is one of the best ways to limit the asymptomatic spread of the virus.[105] Yixuan Hou et al. (July 2020) found that the nasal cavity is seemingly the dominant initial site for SARS-CoV-2 infection with subsequent aspiration-mediated virus seeding into the lungs; the authors note that these findings argue for the widespread use of masks to prevent exposure to the nasal passages.[106]

In a perspective, Monica Gandhi, Chris Beyrer, and Eric Goosby posit that masking reduces the inoculum of the virus for the wearer and thus helps lower the severity of infection.[107] They highlighted that the proportion of asymptomatic and mild infection increased in settings adopting population-level masking.[107] One example involved a comparison of outbreaks on cruise ships: the Diamond Princess had 18% asymptomatic cases among all the infected people, but this was 81% in the Greg Mortimer where masks were given to passengers and staff members.[107]

According to Stephen Griffin, a virologist at the University of Leeds, "Wearing a mask can reduce the propensity for people to touch their faces, which is a major source of infection without proper hand hygiene."[108]

Trisha Greenhalgh et al. argue for the precautionary principle as a reason to adopt policies encouraging the wearing of face masks in public, given that there's much to gain and little to lose from adopting masks considering the seriousness of the outbreak.[109] Others agreed, based on the evidence-based principle that the likely benefits outweighed the likely harms.[110][111]

A paper by Miyu Moriyama et al. (September 2020), which links seasonality of respiratory viral diseases to decreased air humidity due to indoor heating, argues that mask wearing helps limiting respiratory virus transmission in winter, because masks keep the nose warm and moist.[112]

Efficacy studies for COVID-19[edit]

A WHO-funded systematic review by Chu et al. (27 June 2020) published in The Lancet found that the usage of face mask could result in a large risk reduction of infection with epidemic-causative betacoronaviruses, in which N95 or similar respirators accounted for a larger risk reduction than disposable surgical or other similar masks.[45] Masks were found to be protective for both healthcare workers and people in communities exposed to infection; evidence supported masking in both healthcare and non-healthcare settings, with no striking differences detected in the effectiveness of masks between the settings.[45]

A study by Chan et al. (30 May 2020), using SARS-CoV-2-challenged and non-infected Syrian hamsters placed in closed units with unidirectional airflow to test the effect of surgical mask partitions, concluded that SARS-CoV-2 can be transmitted by respiratory droplets or airborne droplet nuclei and that such transmission could be reduced by usage of surgical masks, especially when worn by infected individuals.[113] The results showed that transmission was reduced from 66.7% to 25% and that the exposed hamsters who became infected showed less severe manifestations of the infection than their virus-challenged counterparts as measured by clinical scoring, histopathology, and viral nucleocapsid antigen expression.[113] Yuen Kwok-yung, one of the researchers, said that "The findings implied to the world and the public is that the effectiveness of mask-wearing against the coronavirus pandemic is huge,"[114][115][116] but cautioned that a risk of infection still remains.[114]

A report by Hendrix et al. (17 July 2020) detailed that 139 clients exposed to two symptomatic hair stylists with confirmed COVID-19—with both the clients and stylists wearing face coverings—resulted in no symptomatic cases reported among all clients and no positive tests among those who volunteered to be tested.[117] This case was highlighted when the CDC reiterated that Americans should wear masks.[118]

A preprint study surveying families in Beijing, China concluded that the wearing of face masks by infected individuals at home before symptom onset was effective in reducing the risk of spreading the disease to family members, but that it did little to provide additional protection after symptoms start appearing.[119] Primary research, also in preprint, from Germany showed significant decreases in case rates with widespread mask compliance, without, however, controlling for other measures such as social distancing.[120]

Controlling for social distancing and handwashing, a preprint study from Thailand found that wearing masks all the time during contact was independently associated with lower risk for SARS-CoV-2 infection compared with not wearing masks, while wearing a mask sometimes during contact did not lower infection risk.[121] The study also reported that contacts who always wore masks were more likely to practice social distancing. The authors suggested that clear and consistent public messaging on personal protective recommendations was essential.

Correct handling and wearing of masks[edit]

A properly-worn face mask covers the nose, mouth, and chin.[122][123]
A face mask is carefully taken off by handling the ties or loops without touching the front.[122][123]

As masking became widespread during the pandemic, it gave rise to the issue that many individuals of the public are not correctly handling and wearing their masks.[124][125][126] Suzanne Willard, a clinical professor at Rutgers School of Nursing, remarked that the general public is not used to wearing masks and that lay people are asked to use a tool that health care professionals are trained to use.[127]

A commonly-seen issue is that people are wearing masks pulled down below the nose, which is an incorrect way to wear a mask.[128][129] Zane Saul, the chief of infectious disease at Bridgeport Hospital, remarked that "I really have observed people not covering their noses and just covering their mouths. It's just as important to cover your nose."[128] Daniel Gottschall, the vice president of medical affairs for the Fairfield region of Hartford HealthCare and St. Vincent's Medical Center in Bridgeport, explained that "By wearing a mask you’re keeping a lot of those secretions inside of you. If you wear it just over your nose or just over your mouth and you’re not diligent (about keeping it in place), you're exposing the secretions that come out of that part of the body to other people."[128]

Zeynep Tufekci, a professor of information science, remarked that messaging on masking should have been used to provide proper instructions to the public—as was done for hand washing—rather than used to discourage people from masking because of the possibility that they would wear them improperly, as had happened early in the pandemic.[59] The European Centre for Disease Prevention and Control highlighted that the appropriate usage of face masks in communities could be improved through education campaigns and is key for its effectiveness as a measure.[130] Health institutions such as the World Health Organization have provided public guidance on the dos and don'ts on masking.[122]

Shortages of face masks[edit]

Early epidemic in mainland China[edit]

People in Wuhan lining up in front of a drug store to buy surgical masks.
A notice at a supermarket in Beijing, which says each person can only buy one pack of surgical masks and one bottle of 84% disinfectant liquid a day.
Chinese electronics manufacturers, such as BYD Electronic, began to produce surgical masks after the outbreak.

As the epidemic accelerated, the mainland market in China saw a shortage of face masks due to increased public demand.[131] Face masks were quickly sold out in stores throughout China.[132] Hoarding and price gouging drove up prices, so the market regulator said it would crack down on such acts.[133][134] In January 2020, price controls were imposed on all face masks on Taobao and Tmall.[135] Other Chinese e-commerce platforms – JD.com,[136] Suning.com,[137] Pinduoduo[138]—did likewise; third-party vendors would be subject to price caps, with violators subject to sanctions.

By March, China had quadrupled its production capacity to 100 million masks per day.[101]

National stocks and shortages[edit]

At the beginning of the COVID-19 outbreak in the United States, the U.S.'s Strategic National Stockpile contained just 12 million N95 respirators, far fewer than estimates of the amount required.[139] Millions of N95s and other supplies were purchased from 2005 to 2007 using congressional supplemental funding, but 85 million N95s were distributed to combat the 2009 swine flu pandemic, and Congress did not make the necessary appropriations to replenish stocks.[139] The Stockpile's primary focus has also primarily been on biodefense (defense against a terrorist or weapon of mass destruction attack) and response to natural disaster, with infectious disease a secondary focus.[139] By 1 April 2020, the Stockpile was nearly emptied of protective gear.[140] In January and February 2020, U.S. manufacturers, with the encouragement of the Trump administration, shipped millions of face masks and other personal protective equipment to the PRC, a decision that subsequently prompted criticism given the mask shortage that the U.S. faced during the pandemic.[141]

In France, 2009 H1N1-related spending rose to €382 million, mainly on supplies and vaccines, which was later criticized.[142][143] It was decided in 2011 to not replenish its stocks and rely more on supply from China and just-in-time logistics.[142] In 2010, its stock included 1 billion surgical masks and 600 million FFP2 masks; in early 2020, it was 150 million and zero respectively.[142] While stocks were progressively reduced, a 2013 rationale stated the aim to reduce costs of acquisition and storage, now distributing this effort to all private enterprises as an optional best practice to ensure their workers' protection.[142] This was especially relevant to FFP2 masks, more costly to acquire and store.[142][144] As the COVID-19 pandemic in France took an increasing toll on medical supplies, masks and PPE supplies ran low, causing national outrage. France needs 40 millions masks per week, according to French president Emmanuel Macron.[145] France instructed its few remaining mask-producing factories to work 24/7 shifts, and to ramp up national production to 40 million masks per month.[145] French lawmakers opened an inquiry on the past management of these strategic stocks.[146] The mask shortage has been called a "scandal d'État" (State scandal).[147]

In late March and early April 2020, as Western countries were in turn dependent on China for supplies of masks and other equipment, China was seen as making soft-power play to influence world opinion.[148][149] However, a batch of masks purchased by the Netherlands was reportedly rejected as being sub-standard. The Dutch health ministry issued a recall of 600,000 face masks from a Chinese supplier on 21 March which did not fit properly and whose filters did not work as intended despite them having a quality certificate.[148][149] The Chinese Ministry of Foreign Affairs responded that the customer should "double-check the instructions to make sure that you ordered, paid for and distributed the right ones. Do not use non-surgical masks for surgical purposes".[149] Eight million of 11 million masks delivered to Canada in May also failed to meet standards.[150][151]

Theft[edit]

Thefts of face masks and other personal protective equipment have been reported at hospitals in the United States and other countries.[152]

The Naval Medical Center San Diego began mandatory random bag checks for staff members, after several incidents of theft.[153] Hospitals in Canada reported that theft of PPE had become so commonplace that face masks had to be locked away. According to hospital staff, the policy of locking up PPE often resulted in staff requests for PPE being denied.[154] Thefts of N95 masks were reported from a locked hospital office in South Carolina and off loading docks at the University of Washington.[155]

Two thousand surgical masks were stolen from a hospital in Marseilles, France during the early months of the COVID-19 outbreak, in March. The masks were stolen from an area of the hospital that could only be accessed by surgery patients and staff.[156] A hospital employee in Cooperstown, New York was charged with misdemeanor larceny for a similar incident.[157] Hospital employees in West Java were arrested for stealing hundreds of boxes of face masks and selling them on the black market.[158]

One month later an Indiana hospital pharmacy reported a theft to the Drug Enforcement Agency. Along with morphine, with a street value estimated at $3000, the thieves, one of whom was an employee of the hospital and had an access card, had stolen masks and other in-demand goods. In the criminal complaint, filed in Indiana federal court, a DEA task force officer said:[152]

"Based on my training and experience, I know these items are highly sought after in the secondary market due to shortages resulting from the Coronavirus pandemic and that these types of items are being sold on the secondary market at an increased price well over fair market value."

A former hospital employee in Georgia was arrested on allegations of stealing masks and gloves from the hospital on five separate occasions after he was fired.[159] Also in April, an employee of the Charlie Norwood VA Medical Center was charged with a misdemeanor for stealing disposable gowns and surgical masks from the hospital.[160] PPE, including masks, were reported stolen by a member of the housekeeping staff at a hospital in Arizona and a physician's assistant in Florida.[161][162]

According to a BBC News report from August hospital staff in Ghana were selling PPE on the black market.[163]

Two government workers from the Federal Law Enforcement training Center in North Charleston, South Carolina were charged in October for conspiracy to steal PPE, obstruction of justice and lying to the FBI.[164]

N95 and FFP masks[edit]

N95 and FFP masks were in short supply and high demand during the COVID-19 pandemic.[165][142] Production of N95 masks was limited due to constraints on the supply of nonwoven polypropylene fabric (which is used as the primary filter), as well as the cessation of exports from China.[32][166] China controls 50 percent of global production of masks, and facing its own coronavirus epidemic, dedicated all its production for domestic use, only allowing exports through government-allocated humanitarian assistance.[32]

United States[edit]

In March 2020, US President Donald Trump applied the Defense Production Act against the American company 3M, which allows the Federal Emergency Management Agency to obtain N95 respirators from 3M.[167][168] White House trade adviser Peter Navarro stated that there were concerns that 3M products were not making their way to the US.[167] 3M replied that it has not changed the prices it charges, and was unable to control the prices its dealers or retailers charge.[167]

Jared Moskowitz, the head of the Florida Division of Emergency Management, accused 3M of selling N95 masks directly to foreign countries for cash, instead of the US. Moskowitz stated that 3M agreed to authorized distributors and brokers to represent they were selling the masks to Florida, but instead his team for the last several weeks "get to warehouses that are completely empty." He then said the 3M-authorized US distributors later told him the masks Florida contracted for never showed up because the company instead prioritized orders that came in later, for higher prices, from foreign countries (including Germany, Russia, and France).[169][170][171]

Forbes reported that "roughly 280 million masks from warehouses around the US had been purchased by foreign buyers [on March 30, 2020] and were earmarked to leave the country, according to the broker—and that was in one day", causing massive critical shortages of masks in the US.[172][173]

Masks were still in short supply in late September, eight months into the pandemic. The Defense Production Act powers that averted a ventilator shortage were not used as extensively to increase N95 production, despite outcry from healthcare workers. Even though 3M has increased domestic production from 20 million to 95 million masks a month, they say "the demand is more than we, and the entire industry, can supply for the forseeable future."[174][175] N95 manufacturers and other companies have been reluctant to invest more in domestic mask production because manufacturing in the United States is not profitable for them. There are some American companies who can shift production temporarily to meet the demand for masks but most of them have not received any funding through the DPA. Some have taken the initiative but there were problems with the fit of the masks and obtaining regulatory approvals. 3M and other N95 manufacturers have not entered into any corporate partnerships to share intellectual property or increase N95 production.[174]

Trump gave Rear Admiral John Polowczyk the responsibility for the logistics of PPE. Polowczyk said that he believed "hospital systems are making management decisions that might lead to an appearance that we still don't have masks, which is the farthest from the truth."[174]

Germany[edit]

In early April 2020, the Berlin politician Andreas Geisel alleged that a shipment of 200,000 N95 masks that it had ordered from American producer 3M's China facility were intercepted in Bangkok and diverted to the United States. 3M said they had no knowledge of the shipment, stating "We know nothing of an order from the Berlin police for 3M masks that come from China," and the US government denied that any confiscation had taken place and said that they use appropriate channels for all their purchases.[176][177] Berlin police later confirmed that the shipment was not seized by US authorities.

This revelation outraged the Berlin opposition, whose CDU parliamentary group leader Burkard Dregger accused Geisel of "deliberately misleading Berliners" in order "to cover up its own inability to obtain protective equipment". FDP interior expert Marcel Luthe also criticized Geisel.[178] Politico Europe reported that "the Berliners are taking a page straight out of the Trump playbook and not letting facts get in the way of a good story."[179] The Guardian also reported that "There is no solid proof Trump [nor any other American official] approved the [German] heist".[180]

Canada[edit]

As more and more countries restricted the export of N95 masks, Novo Textiles in British Columbia announced plans to start producing N95 masks in Canada.[181] AMD Medicom in Quebec had long been the main Canadian company producing N95s, but China, France, the Republic of China (Taiwan) and the United States all banned exports of medical equipment, barring Medicom's factories there from exporting the masks to Canada. The Government of Canada subsequently awarded Medicom a 10-year contract to build a factory to produce masks in Montreal.[182]

The mask industry[edit]

Manufacturing[edit]

With population of 24 million, Taiwan has been producing 13 million masks per day since March.

As of 2019, mainland China manufactured half the world output of masks.[183] As COVID-19 spread, enterprises in several countries quickly started or increased the production of face masks.[184] Cottage industries and volunteer groups also emerged, manufacturing cloth masks for localized use. They used various patterns, including some with a bend-to-fit nose piece inserts. Individual hospitals developed and requested a library of specific patterns.[185][186][187][188]

In the first five months of 2020, 70,802 new companies registered in China to make or trade face masks, a 1256% increase compared to 2019, and 7296 new companies registered to make or trade melt blown fabrics, a key component of face masks, a 2277% rise from 2019.[189]

In April, however, the Chinese government stepped in with tighter regulations. 867 producers of the meltblown fabric were shut down in Yangzhong city alone. Many speculative manufacturers have been forced to quit due to changing export rules and tighter licensing requirements in China and weaker demand for lower quality products globally.[189]

Distribution[edit]

Some clinical stockpiles have proved inadequate in scale, and the non-medical market demand expanded dramatically as the general public determined that masks were essential, or they began obeying public health mandates, or both.[190]

Between April and June 2020, sellers on Etsy sold 29 million cloth face masks worth an estimated 364 million. Approximately 4 million people, or about 7 percent of buyers on Etsy, came there just to purchase cloth masks.[191]

Society and culture[edit]

Attitudes[edit]

Slovakia was one of the first countries in the world to introduce universal masking in public places.[192]

In East Asian societies, a primary reason for mask-wearing is to protect others from oneself.[193][194] The broad assumption behind the act is that anyone, including seemingly healthy people, can be a carrier of the coronavirus.[194] The usage of masks is seen as a collective responsibility to reduce the transmission of the virus.[195] A face mask is thus seen as a symbol of solidarity in Eastern countries.[195] Elsewhere, the need for mask-wearing is still often seen from an individual perspective where masks only serve to protect oneself.[193] However, over the course of the pandemic, people began promoting a new meaning of masking as an act of solidarity to each other.[196][197][198][199] Masking is gradually shifting to become a new social norm.[200][201]

Existing cultural norms and social pressure may impede mask-wearing in public, which explains why masking has been avoided in the West.[202] According to Joseph Tsang, a Hong Kong doctor and infectious disease expert, the promotion of universal masking may resolve perceptions against mask-wearing, because mask-wearing is intimidating if few people wear masks due to cultural barriers, but if all people wear masks it shows a message that people are in this together.[58] A study surveying people in Spain showed that an individual's likelihood of voluntarily wearing a mask is positively correlated with the proportion of uptake in the surrounding area.[203]

Helene-Mari van der Westhuizen et al. point out that the successful implementation of public masking policies, especially in communities that has no cultural traditions for such interventions, requires a reframing of social meanings and moral worth, and that public messages help to conceptualize who typically wear masks and what the moral valence of masking is.[204] They note that the earliest members who wear face coverings may be seen as deviant when the community starts to adopt masking, but that changing narratives will generate new meanings that construe those that do not mask as deviant.[204] Their argument is that public health messaging about face coverings should shift from masks as a medical intervention to masks as a social practice based on values such as social responsibility and solidarity, as a successful uptake requires face coverings to be grounded in the social and cultural realities of affected communities.[204]

In the Western world, the public usage of masks still often carries a large stigma,[193][195][205] as it is seen as a sign of sickness.[205] This stigmatization is a large obstacle to overcome, because people may feel too ashamed to wear a mask in public and therefore opt to not wear one.[206] There is also a divide within the Western world, as seen in the Czech Republic and Slovakia where mass mobilization has occurred to reinforce the solidarity in mask-wearing since March 2020.[193]

The Egyptian Theater in Boise, Idaho presents a public health message on its marquee

Mask-wearing has been called a prosocial behavior in which one protects others within their community.[207][208][209] On social media, there has been an effort with the #masks4all campaign to encourage people to use masks.[210] Nevertheless, there have been many occurrences of violence and hostility by people who became aggressive after they were requested to wear a mask or saw people wearing masks in customer-based service industry establishments.[211][212][213][214] People have even been killed due to attacks by people who refused to mask.[215] It has led to concerns about worker safety, so employees have been discouraged to actively enforce masking policies due to the potential of hostile situations, while enforcement by official authorities is severely lacking.[216]

Masking has been subjected to racial politics in Western countries.[217] For instance, it has been heavily racialized as an Asian phenomenon.[195] This has been reinforced in a lot of media discourses, where stories about the pandemic are often accompanied by unrelated imagery of Asian people in masks.[217][218] The focus on race has brought hostility towards Asians who are confronted with the choice to mask as precaution while they face discrimination for it.[217][219] Huang Yinxiang, a sociologist from the University of Manchester, described maskaphobia—negative prejudice, fear or hatred against people wearing face masks—as making Asians in Western countries into targets for racists who want to legitimize xenophobia during the COVID-19 outbreak.[220] Likewise, people from certain groups such as Black Americans may not feel comfortable wearing masks, especially those that are not clearly medical but homemade masks, due to concerns of racial profiling.[221][222][223]

Gender plays a role in the willingness to wear masks during the pandemic; men are overall less inclined to mask in public than women.[224][225][226] There are indications that men are more likely to feel negative emotions (such as shame) and stigma for wearing masks.[224][225] It is suggested that this male behavior is driven by a sense of masculinity, where the act of masking is possibly perceived to run counter to it, which leads to an increase in men not wearing masks during the pandemic.[227][228] A survey among participants recruited from Amazon Mechanical Turk about face mask perceptions indicates that men and women may have different reasons when they do not wear masks in public: Men were more likely to see masks as an infringement upon their independence and women were more likely to perceive masks as being uncomfortable, while perceptions on efficacy, accessibility, compensation, inconvenience, appearance, and attention did not differ.[229]

A sign language interpreter (on the right) is wearing a transparent mask to allow lip reading.

There have also been concerns that the wearing of masks may also further isolate disadvantaged communities. Concerns had been expressed that masks would make communication difficult for people who are deaf or hard-of-hearing.[230][231] This led to calls for wider distributions of transparent masks, which allow for lip reading.[230][231] Similar concerns over difficulty in communicating have been expressed by those who may depend on dogs for therapeutic or social reasons, as the animals depend on body language such as facial expressions.[232] Conversely, people who are exempt from wearing masks on medical grounds or due to a disability, fear they will be subjected to abuse for not wearing a mask, even if they are legally exempt from doing so.[233] For instance, in the United Kingdom, the charity Disability Rights UK received numerous reports about people being confronted on trains and buses.[233] Health organizations such as the American Lung Association commented that, even though there may be people who will seek an exemption, the individual's concerns needs to be weighed against the societal needs to limit the spread of the virus.[234][235] However, anti-maskers have called upon bogus claims about legal or medical exemptions in their refusal to mask.[234] They have, for instance, claimed that the Americans with Disabilities Act (designed to prohibit discrimination based on disabilities) allows exemption from mask requirements, but the United States Department of Justice responded by stating that the act "does not provide a blanket exemption to people with disabilities from complying with legitimate safety requirements necessary for safe operations."[236]

Trends[edit]

Among the European countries surveyed by YouGov, the likelihood for people to mask has been split: In Northern Europe (e.g., Finland, Sweden, Norway, and Denmark), people are very unlikely to wear a mask.[237] In Western Europe (e.g., Italy, Spain, France, and Germany), people were initially unlikely to use a mask, but mask wearing greatly changed from low levels in March to higher levels in May.[237] An exception was the United Kingdom where mask usage only grew gradually during this time,[237] but it rose very quickly after official policy changes in July mandated masking in stores.[238]

Governmental role[edit]

The heads of state and government of Portugal and Spain wearing face masks during an official ceremony in July 2020.

The pandemic has raised questions about the role of governments in mask policies, either voluntary or mandatory policies, especially in terms of the social and behavioral consequences involving the general public.[209]

The results from a study surveying people in Germany indicate that the act of wearing a mask, independent of the policy, is considered a social contract in which compliant people perceive each other more positively and noncompliance is negatively evaluated.[209] However, it also suggests that voluntary policies have the potential effect to increase polarization and thus cause more stigmatization.[209] The authors recommended that countries and communities should adopt a mandatory policy along with explicit communication of the benefits of both masking (e.g., risk reduction, mutual protection, positive social signaling) and mandatory policies (e.g., fairness, less stigmatization, higher effectiveness) to encourage the public to wear masks.[209]

World leaders as role models for masking have also received much scrutiny, as they are key to convey the critical public health message to the public.[239][240] For example, Slovakia has been cited as a country where its public figures—including President Zuzana Čaputová and her administration—set the example by wearing masks and played a crucial role to normalize masks.[241] In contrast, in the United States, President Donald Trump and his administration have come under criticism for communicating an inconsistent and confusing message about masking.[242][243]

Politics[edit]

U.S. Surgeon General Jerome Adams urged people to wear face masks and acknowledged that it is difficult to correct earlier messaging that masks do not work for the general public.[244]

Although authorities, especially in Asia, have been recommending people to wear face masks in public, in many other parts of the world, conflicting advice has caused much confusion among the general population.[245] Several governments and institutions, such as in the United States, initially dismissed the use of face masks by the general population, often with misleading or incomplete information about the usefulness of masks.[246][247][248] Commentators have attributed the anti-mask messaging to efforts to manage the mask shortages, as governments did not act quickly enough, remarking that the claims go beyond the science or were simply lies.[248][249][250][251] On 12 June 2020, Anthony Fauci, a key member of the White House coronavirus task force, confirmed that the American public were not told to wear masks from the beginning due to the shortages of masks and explained that masks do actually work.[252][253][254][255][256]

Anti-pandemic precautions during the 2020 Czech regional elections.

In the United States, public masking has become a political issue, as opponents argue that it inhibits personal freedom and proponents emphasize the importance of masks for public health.[257] Some people may see it as a political statement.[258] Party affiliation partly determined how likely people were to embrace the wearing of masks in public.[258][259] Democrats were more likely to wear masks than Republicans.[258][259] Masks have become an aspect of the culture war that has emerged over the course of the pandemic.[257][258][259] Commentators argue that the resistance against masks partly stems from the confusing and mixed messaging about masking.[257][260][261]

Matthew Facciani, a sociologist at Vanderbilt University, states that the uncertainty from health experts during the early days of the pandemic paved the way for political leaders to become a prominent source for guidance and clarity.[262] He argues that, once mask wearing became informed by political beliefs, it is difficult to correct due to the motivation to protect one's identity in relation to a political group and the reinforcement from political echo chambers, no matter that scientists began to better understand the severity of the virus and the evidence in favor for mask wearing became clearer.[262]

Despite widespread implementation of masking policies globally, in some countries, large rallies have taken place in protest against masking mandates.[263][264][265] In Canada, the anti-mask crowd has hailed their protests as the so-called "March to Unmask".[265][266] In the United Kingdom, new protests came in the wake of the official announcement that masking will be compulsory in shops.[263] The feminist slogan "my body, my choice" has also been co-opted by some anti-mask protestors.[267][268][269]

In April 2020, health officials from Taiwan's Central Epidemic Command Center (CECC) pushed back on school bullying of boys in pink face masks.[270] The CECC officials and Minister of Health and Welfare Chen Shih-chung wore pink masks to challenge gender norms at a press conference, while various government agencies demonstrated solidarity by changing the colors on their Facebook pages to pink.[270] The minister later tweeted "Pink is for everyone and no colour is exclusive for girls or boys. Gender Equality lies at the heart of Taiwan values."[270] The press conference was held amid reports that male students were too embarrassed to wear their pink face masks, jeopardizing their safety and the safety of others in the face of COVID-19.[270]

Religion[edit]

Christian clergy from the Lutheran, Catholic, Presbyterian, Anglican, Baptist and Mormon traditions, as well as those from the Jewish, Buddhist and Unitarian religions have implored people to wear masks.[271]

James Martin, a Jesuit Catholic priest, who affirmed a belief in a consistent life ethic, specifically stated that a "reverence for life includes a desire to care for the unborn child in the womb, the elderly person in danger of euthanasia, the refugee starving on the border, the L.G.B.T. youth tempted to suicide and the inmate being readied for execution on death row".[272] Martin stated that to that list, sacred lives also include "the woman standing in line at the grocery store checkout counter, the elderly man seated in a church pew or the office worker who has just stepped aboard public transportation."[272] Because masks prevent of contagion, the act of wearing a mask, in Martin's view, is being pro-life.[272]

Fashion[edit]

Cloth face mask in a style that matches the outfit.

As the pandemic progressed, people began embracing face masks as fashion items in addition to their primary function as a health measure and made them a means of self-expression.[273][274][275][276]

Early in the pandemic, people and businesses from the fashion industry responded to official calls for help in overcoming the shortages of protective personal equipement including face masks.[277] These masks were made to be straightforward and standard, as the main consideration at the time was function.[278] Fashion brands eventually reopened their factories for production due to the increasing demand for masks and started to manufacture masks in a wider variety of styles.[274] Smaller brands, who primarily sold their products online, found that selling masks was a good strategy to maintain sales.[279] Some designers sold their masks on online platforms like Etsy.[279] Designers started to make masks that matched other pieces of clothing and accessories,[280][281] which may have started unintentionally by some designers as remaining fabrics were being repurposed for masks during the health crisis.[281]

The city of Vilnius in Lithuania held a "Mask Fashion Week" in May 2020, which was promoted with billboards (with no catwalk or displays) around the city featuring local people including Mayor Remigijus Simasius wearing face masks.[282]

The Walt Disney Company introduced uniform face masks for their employees at Disney World and Disneyland in the United States.[283][284]

Comparison by countries and territories[edit]

% of population wearing face masks in public, by country/territory (as of 9 August)[285]
Country/territory %
Singapore Singapore 92
Spain Spain 90
Thailand Thailand 88
Hong Kong Hong Kong 86
Japan Japan 86
Malaysia Malaysia 85
Indonesia Indonesia 85
Philippines Philippines 84
France France 83
India India 82
Italy Italy 81
China China 80
Taiwan Taiwan 80
Vietnam Vietnam 79
United Arab Emirates United Arab Emirates 79
United Kingdom United Kingdom 75
United States United States 75
Canada Canada 74
Saudi Arabia Saudi Arabia 71
Mexico Mexico 67
Germany Germany 65
Australia Australia 41
Poland Poland 23
Greece Greece 19
Russia Russia 10
Egypt Egypt 8
Finland Finland 7
Sweden Sweden 6
Norway Norway 5
Denmark Denmark 4
  • Argentina Argentina: After appearance of three asymptomatic cases, the capital Buenos Aires introduced compulsory masking since 14 April. Wearing a mask was made obligatory for everyone on public transit and everyone who contacts with the public in their position. Violators can face a fine. Authorities also prohibited the sale of N95 face masks to non-medical workers, suggesting the general public to use home-made masks instead.[286]
  • Australia Australia: The federal Department of Health does not recommend the wearing of face masks by the general public, but in regions where there is community transmission people may consider using a mask. In places where there is community transmission and it is difficult to keep a distance, masks are recognized as an important protective measure, but only if used properly.[287] In the state of Victoria, face coverings became compulsory on 22 July in the metropolitan Melbourne or Mitchell Shire areas when outside of your home.[288] This was later extended to all of Victoria from August 3.
  • Austria Austria: Everyone entering a supermarket, a grocery store, or a drug store or using public transportation must wear a face mask, mandatory since 14 April.[289][290][291]
  • The Bahamas Bahamas: On 19 April, the prime minister announced that wearing a mask or covering one's face with clothing is mandatory in public. Employers must provide their employees who are serving the general public with masks.[292]
  • Bahrain Bahrain: The Kingdom made wearing face masks in public areas compulsory for citizens and residents as well as shop workers.[293]
  • Benin Benin: From 8 April, Benin's authorities began enforcing the mandatory wearing of face masks to halt the coronavirus.[294]
  • Bosnia and Herzegovina Bosnia and Herzegovina: Wearing a face mask is compulsory.[295][296]
  • Bulgaria Bulgaria: Bulgaria's government passed an order imposing an obligation to wear face masks on 30 March. The order was cancelled the next day and changed into a recommendation, due to legal complaints.[297]
  • Cambodia Cambodia: Many Cambodians started wearing face masks soon after the outbreak began in Wuhan. Businesses started to require customers to wear masks.[298]
  • Cameroon Cameroon: On 6 April, mayor of Douala announced that wearing a mask will be mandatory to slow the spread of coronavirus.[299]
  • Canada Canada: Since 6 April, health officials recommend wearing non-medical masks in situations where physical distancing from others is difficult (like buying groceries, or public transit).[10] The use of face masks is mandatory in most of Alberta[300] and Manitoba,[301] and in all of Ontario,[302] Quebec,[303] Nova Scotia,[304] New Brunswick,[305] and Newfoundland and Labrador.[306]
  • Chile Chile: From 8 April, Chilean Health Minister announced wearing a mask is mandatory in public transit.[307]
  • China China: Healthy individuals are advised to wear disposable medical masks in public places.[82][84] Some local governments require wearing masks when going outside. Shanghai makes wearing masks mandatory in public places.[308]
    • Hong Kong Hong Kong: Members of the public are recommended to wear a surgical mask when taking public transport or staying in crowded places.[85]
  • Colombia Colombia: In response to recommendations from the WHO, Colombia changed its policy on the use of masks and made it mandatory throughout the country for the use of public transport during the coronavirus emergency.[309]
  • Croatia Croatia: Since 8 July, everyone entering any enclosed place, like shops and other buildings, must wear a face mask.[310]
  • Cuba Cuba: On 11 March, the government urged citizens to make their own masks, while the textile industry was drafted to fabricate them. People were advised to carry several cloth masks with them, depending on how many hours they plan to spend in public areas.[311] Later, wearing a mask was made mandatory.[312]
  • Czech Republic Czech Republic: From mid March it was forbidden to go out in public without wearing a mask, or covering one's nose and mouth until 25 May.[313]
  • Dominican Republic Dominican Republic: Since 16 April, the use of face masks is mandatory in all public spaces and in the workplace.[314]
  • Democratic Republic of the Congo DR Congo: Since 20 April, wearing masks in the capital of Kinshasa is mandatory.[315]
  • Denmark Denmark: The Danish Health Authority generally does not recommend the wearing of face masks in public places by healthy residents, but does recommend that masks should be worn by anyone who is forced to break self-isolation (for example, if someone who suspects he/she might be infected leaves self-isolation to get tested), has returned from a visit to a high-risk country (until fully home and able to isolate in the recommended period), or if the person takes care of an at-risk relative/loved one where distancing rules are impossible to follow.[316][317] Since 15 June 2020, face masks have been mandatory in all airports.[318] If a mask is worn, the authorities have emphasised on doing it correctly (arguing that if done incorrectly, a mask can do more harm than good) and that general isolation, distancing and hygiene guidelines should still be followed as closely as possible.[316][317] It is recommended that masks should be CE marked and have Danish labelling; homemade masks are advised against.[319][320][321] Levels of the virus in Denmark are low, but if there is an increase of transmission, the authorities will review the guidelines again.[322]
  • Ecuador Ecuador: On 8 April, the Emergency Operations Committee (COE) decided to make face masks obligatory in public spaces.[323]
  • Egypt Egypt: On 30 May 2020, the wearing of face masks in public places and on public transportation became mandatory; failure to comply can result in fines of up to EGP4,000 (US$247).[324]
  • Ethiopia Ethiopia: The Council of Ministers approved a regulation that outlaws handshakes, and obligates the use of face masks in public places.[325]
  • Finland Finland: Initially the Government did not recommended face masks to be used by the general public, but said that they can be used in situations where it is not possible to keep a distance. If someone choses to wear a mask, the Finnish Institute for Health and Welfare notes that it is important that it is used correctly, and that general distancing and hygiene guidelines should still be followed. On 13 August 2020, an official recommendation was given to use face masks in public transportation in hospital districts that have had new COVID-19 cases within the previous 14 days.[326]
  • France France: On 3 March, the government issued a degree announcing requisition of stocks of FFP2 and anti-splash masks until 31 May 2020.[327] On 8 May 2020, the government announced that 200 million masks per week will be available starting on 11 May: 100 million for medical workers and 100 million for the general public.[328] From July, France makes it compulsory for people to wear masks in shops and other enclosed public spaces.[329]
  • Gabon Gabon: On 10 April, the Gabonese government announced individuals in all parts of the country are required to wear masks in public to limit the spread of COVID-19.[330]
  • Germany Germany: On 31 March, city-county Jena, Thuringia, was the first large German city to introduce an obligation to wear masks, or makeshift masks including scarves, in supermarkets, public transport, and buildings with public traffic, from 6 April. On 2 April, the Robert Koch Institute, the federal epidemic authority, changed its previous recommendation that only people with symptoms should wear masks to also include people without symptoms.[331][332] Later in April, Germany made the wearing of cloth face masks mandatory on public transport, as well as for shopping in most German states.[333] Some German states expanded the regulations to include outdoor markets.[334]
  • Ghana Ghana: Use of face masks would be made mandatory in public spaces including public transport. However, surveys show about 22% of public transport vehicles would have fewer than 3 people without masks, with the vast majority having only partial or non-compliance to the policy on face masks.[335]
  • Guatemala Guatemala: From 8 April, Guatemalan president Alejandro Giammattei makes it mandatory to wear a face mask in public.[336]
  • Guinea Guinea: Guinean President Alpha Conde decided to make wearing masks compulsory.[337]
  • Honduras Honduras: From 7 April, Honduras President announced all citizens will now be required to cover their mouths when they are outside.[338]
  • Iceland Iceland: Masks are not widely worn and are not recommended by the authorities.[339]
  • India India: On 3 April, the Office of the Principal Scientific Adviser to the Government of India issued an advisory and manual, asking healthy people to wear handmade reusable face covers when stepping out of their homes, especially for those in densely populated areas.[340][341] Some individual states, like Odisha, West Bengal, Maharashtra and Uttar Pradesh made wearing of masks compulsory in public places.[342][343][344]
  • Indonesia Indonesia: Citizens were ordered to wear face masks when they leave the house.[345]
  • Republic of Ireland Ireland: From 18 May, the use of cloth face covering is recommend in enclosed public spaces where it's difficult to maintain social distance.[346][347]
  • Israel Israel: All residents are asked to wear face masks when in public.[348]
  • Italy Italy: Regions of Lombardy and Tuscany made wearing a face mask compulsory before going out in early April.[349]
  • Ivory Coast Ivory Coast: From April, 26 masks have become compulsory to enter shopping malls or supermarkets in the Southern suburb of Abidjan, Marcory.[350]
  • Japan Japan: Masks have been widely used by healthy individuals despite absence of official advice to do so.[351] On 1 March, prime minister Shinzo Abe enacted a policy in Hokkaido instructing manufacturers to sell face masks directly to the government, which would then deliver them to residents.[352]
  • Kenya Kenya: Wearing a face mask is compulsory since 4 April. The government has Kenyans to strictly observe social distancing, which has been proved to one of the most efficient ways of preventing infection risks.[353]
  • Liberia Liberia: From 21 April, it is now compulsory to wear a face mask or covering in public.[354]
  • Lithuania Lithuania: Wearing a face mask or any other means of covering one's nose and mouth in public places is compulsory since 10 April 2020.
  • Luxembourg Luxembourg: From 20 April, wearing a mask is mandatory in places where it is not possible to keep enough distance to others such as supermarkets or on public transport.[355]
  • Malaysia Malaysia: Masks have been widely used by healthy individuals despite absence of official advice to do so.[356] On 17 March, Malaysia banned exports of medical and surgical masks, to meet local demand.[357] In April, the government was set to distribute 24.62 million masks, four for each household, while advising people to only use them if they have symptoms.[345] On 23 July, the government announced that the wearing of face masks (including homemade cloth masks) in public transportation and "crowded" public areas will be mandatory from 1 August, adding that those who did not comply could be given a RM1,000 (USD235) fine under the nation's Prevention and Control of Infectious Diseases Act.[358][359][360]
  • Mexico Mexico: From 17 April, all Mexico City Metro passengers must wear masks while inside stations and on trains, Mayor Claudia Sheinbaum announced on 15 April.[362]
  • Mongolia Mongolia: Wearing a mask is now mandatory while riding public transportation in Ulaanbaatar. Public officials and news broadcasters had even adopted to wearing masks through press conferences and news broadcasts.[363]
  • Morocco Morocco: Wearing a face mask is compulsory.[364]
  • Mozambique Mozambique: The Mozambican government announced on 8 April that wearing face masks is now compulsory on all forms of passenger transport, and wherever groups of people are gathered.[365]
  • Netherlands Netherlands: Facemasks became mandatory in Dutch public transport on June 1[366] and were mandatory in parts of the busy inner cities of Amsterdam and Rotterdam between August 5 and August 31.[367][368] In other places face masks are not mandatory but on September 30 the government for the first time encouraged people to wear face masks in public indoor places.[369][370]
  • New Zealand New Zealand: At alert level 1 face masks are not mandatory, but are encouraged on public transport by the Ministry of Health. Community transmission rates in New Zealand are low, but an increase in alert level will instate different advice around the types and use of face masks.[371]
  • North Macedonia North Macedonia: As of 22 April, citizens of Kumanovo, Tetovo, and Prilep must wear protective masks and gloves outside their homes, at public places, outdoor and indoor areas, markets, and shops announced the government.[372]
  • Norway Norway: The Norwegian Institute of Public Health does not recommend the wearing of face masks by the general public. Levels of the virus in Norway are low, but if there is an increase in virus transmission, the authorities will review the guidelines again.[373]
  • Pakistan Pakistan: The Balochistan government on 18 April told citizens to wear face masks when going outside. According to provincial government spokesperson Liaquat Shahwani, citizens have been urged to wear masks or to cover their faces with any cloth in the wake of the COVID-19 outbreak.[374]
  • Panama Panama: Panama has made it obligatory to wear a face mask whenever going outside, while also recommending the manufacture of a homemade cloth face mask to those who cannot purchase face masks.[375]
  • Peru Peru: From 7 April, the Peruvian government started distributing free masks after decreeing their mandatory use in the streets to chase away the new coronavirus, said President Martin Vizcarra.[376]
  • Philippines Philippines: From 2 April, the government required all those living in areas under enhanced community quarantine to wear face masks.[377]
  • Poland Poland: Since 16 April, covering lips and nose was compulsory before leaving one's house (e.g., by a disposable mask, cloth mask, or scarf).[378] After 30 May, covering lips and nose was obligatory only on public transport and public indoor areas (e.g.shopping centre,medical facilities, libraries.). Since 10 of October mask are obligatory again in every public place excluding parks, fields, forests, beaches.
  • Russia Russia: Khabarovsk has made the wearing of face masks obligatory to fight the spike in respiratory diseases and prevent the spread of the coronavirus.[379]
  • Rwanda Rwanda: On 20 April, Cabinet Minister of Health Daniel Ngamije said the latest guidelines require everyone to wear a mask in public, and at home during the lockdown and thereafter.[315]
  • Serbia Serbia: Wearing face masks has been required since June 29 in public indoor places, including public transportation.[380]
  • Singapore Singapore: Masks have been widely used by healthy individuals despite initial absence of official advice to do so.[381] General mask-wearing was no longer discouraged from 3 April,[382] and made mandatory outside of one's residence from 14 April.[383]
  • Spain Spain: Wearing masks has been required since 4 May while on public transportation, which includes taxis, trains and buses. The government is providing masks to the majority of people riding public transportation, regardless of if they have a mask on.[384][385] On 9 June, the Spanish Ministry of Health and the Ministry of Transport maintains the mandatory nature of masks on public roads, in open air spaces, and in closed spaces for public use[386]
  • Slovakia Slovakia: Face masks were compulsory in public transport and shops since 15 March.[387] On 25 March, it became forbidden to go out in public without wearing a mask or covering one's nose and mouth.[388] Since 20 May, face masks are no longer mandatory when distance between people is at least 5 meters.[389]
  • Slovenia Slovenia: From 29 March, wearing a face mask, even one made at home, or equivalents such as scarves that cover the mouth and nose is mandatory along with protective gloves; the decree stipulates that masks and gloves need to be worn in indoor public spaces.[390] As of 15th of October 2020 face masks or equivalent face coverings are required everywhere in public spaces (including outdoors) for any of the statistical regions designated as "red" (more than 140 confirmed infected per 100k population).[391]
  • South Africa South Africa: On 10 April, Minister of Health recommended that the general public use cloth face masks when going out in public (in addition to hand-washing and social distancing).[392] After 1 May, covering one's nose and mouth will be mandatory in public (with a cloth mask, scarf, T-shirt, etc.).[393]
  • South Korea South Korea: Masks have been widely used by healthy individuals despite absence of official advice to do so.[394] The government implemented a policy of centralized procurement and rationing of face masks, purchasing 80 percent of national production since early March.[395] On 25 May, the Korean government / Central Disaster and Safety Countermeasure Headquarters required passengers on buses, taxis, subways, and flights to wear masks.[396]
  • Sweden Sweden: Sweden's Public Health Agency states that the scientific evidence does not support public use of face masks, and that public use of face masks would undermine Sweden's COVID-19 response. The government has also warned that wearing them might create a false sense of security, and that public use of masks could do more harm than good.[397][398]
  • Taiwan Taiwan: On 21 January, the government announced a temporary ban on the export of face masks.[399] On 6 February, the government instituted a mask rationing system.[400] The ROC has been producing ten million masks per day since mid-March.[401] On 1 April, passengers on trains and intercity buses were required to wear face masks,[402] unmasked riders facing a fine.[403]
  • Turkey Turkey: Residents will be required to wear masks at markets, as Turkish president announced.[404]
  • Ukraine Ukraine: Since 6 April, wearing a face mask is required by the government in public places. In Kyiv, public places were clarified to include parks and streets.[405]
  • United Kingdom United Kingdom: Health is a devolved policy in the United Kingdom, resulting in different policies across the four nations:
    • England England: From 15 June, face coverings were made compulsory on public transport in England and from 24 July, they were also compulsory in shops and other public buildings such as shopping centres and banks in England.[406][407] From the 8th of August the number of places where face coverings are compulsory was expanded to other indoor venues where customers are not eating or drinking on the premises.[408] In August 2020, Nottinghamshire County Council's Director of Public Health, Jonathan Gribbin, called on businesses & residents in Newark and Sherwood to enforce the mandatory wearing of face coverings in public spaces in order to avoid a local lockdown.[409]
    • Northern Ireland: The wearing of face masks on public transport was compulsory from 10 July.[410] While the wearing of face masks in retail stores is currently voluntary, Deputy First Minister Michelle O'Neill has advised this may become mandatory, if sufficient number of people were not wearing them by 20 August.[411]
    • Scotland Scotland: On 28 April, the First Minister for Scotland Nicola Sturgeon advised the voluntary use of cloth face masks in enclosed spaces such as shops and public transport (but not generally in public), while noting their limitation.[412] As of 10 July, face coverings were made compulsory on public transport and in shops in Scotland.[413]
    • Wales Wales: Face masks became compulsory on public transport on Wales on 27 July.[414] While face masks are not compulsory in shops, First Minister Mark Drakeford has warned people may be turned away from healthcare settings if they refuse to wear a mask when asked.[415]
  • United States United States: In March 2020, the CDC recommended that if neither respirators nor surgical masks are available, as a last resort, it may be necessary for healthcare workers to use masks that have never been evaluated or approved by NIOSH or homemade masks, though caution should be exercised when considering this option.[416] On 6 April, the CDC recommended the wearing of non-medical cloth face coverings when in public places.[11][417] As of 4 August 34 states and the District of Columbia have implemented health orders requiring the wearing of face coverings in most public spaces.[418][419][420]
  • Uzbekistan Uzbekistan: Officials made protective masks mandatory in all major cities to prevent the spread of coronavirus. Officials on 22 March said citizens not wearing masks in public in major cities would be fined $22 for the first offense and $67 for repeat offenses.[421]
  • Venezuela Venezuela: The government ordered the country's citizens to wear face masks in public in response to the arrival of the novel coronavirus.[422]
  • Vietnam Vietnam: Since 16 March, everyone must wear a face mask when going to public places (such as grocery stores, transportation hubs, and public transport).[423]
  • Zambia Zambia: The government made it mandatory to wear face masks to minimise the spread in the country.[424]

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