Updated: Apr 13, 2020
Amid #coronavirus mass hysteria that is currently spreading through the US, lots of people are focusing on masks as means to protect themselves from the scary, novel virus. To wear, or not to wear, that is really the question!
Majority of stores have already faced an ongoing shortage of masks that are flying off the shelves. Even the mighty Amazon proved to be no match for the current demands of mask hoarders. Recently, they suspended many seller’s accounts for price gouging of masks and other coronavirus related products, which goes against their fair pricing policy. Masks are almost impossible to come by. But do we really know what we are doing when it comes to stocking up and hoarding them? If it’s up to the US Surgeon General, we do not. His to-the-point tweet sums up his frustration perfectly:
“Seriously people - STOP BUYING MASKS!”
Not that I place a lot of trust in the US government when it comes to public health and regulations in general (hello EPA and DuPont decades-long disgraceful handling of PFOA issue - more on that and Dark Waters movie in my next post). But I do have to say I agree with US Surgeon General' statement, if for nothing else then for my main beef in general (no pun intended), that lots of people are making scientifically uninformed decisions, in this case, fueled by only fear.
Hence (and since many of you have asked me), I put together this comprehensive summary of all scientific facts I could find regarding this topic. All the links to the original sources are embedded, for those of you who want more details. And for those who are looking for just topline information, check out the Summary paragraphs.
So, what really is the issue with masks? Well there are a few...
ISSUE NO. 1: Mask Shortage
SUMMARY: There is a huge mask shortage, needed just for US healthcare workers, that can have disastrous consequences in effectively fighting the virus outbreak. Hence, it is irresponsible for healthy individuals to stockpile the masks that health workers use.
Thanks to inadequacy of US emergency preparedness, we are already facing a huge shortage of masks needed just for US healthcare workers. As reported by Time, in case of a serious outbreak US hospitals would be 270 million masks short. The mask shortage is shocking, especially taking into account that the outbreak is still in very early stages in the US and according to many experts, the worst is yet to come. It comes as no surprise that the main manufacturer of masks, just like in the case of many other consumer products, is China and they are currently struggling to keep up with their own demand. WHO (World Health Organization) warned us a month ago that stockpiling the masks by the general population is interfering with effective fight against the outbreak.
Hence, for me, the shortage is probably one of the most compelling reasons for NOT stockpiling the masks, respirators, and other personal protective equipment that healthcare workers and first responders use. If our healthcare workers don’t have adequate personal protective equipment to protect themselves and their patients, not only from coronavirus, but from many other serious infectious diseases (that are infamously rampant in hospital settings), the consequences of coronavirus potentially spreading like a wildfire could be exponentially disastrous.
ISSUE NO. 2: Proper Mask Use
SUMMARY: In order for a mask to work it has to fit properly (no children and no people with beards can wear respirators, for example), to be changed on a daily basis (if not more often), and not to be touched by hands or taken on and off (which is highly unrealistic if you consider that you have to eat, drink, etc). In addition, just wearing a mask is not enough to protect you from the outbreak. You still have to be vigilant about hand washing (20 seconds minimum), social distancing (from sick people and crowded places), and staying home when you are sick.
Proper Fit: In order for masks to be the most effective, they have to fit properly on your face. Many healthcare workers get professionally fitted for their masks and respirators, something that none of us regular people are able to do. Additionally, according to the FDA, N95 respirators for example, are not designed for children and people with facial hair. Experts agree, improper fit decreases mask effectiveness.
Single Use: Masks used in healthcare setting, like surgical masks and N95 respirators, require frequent change. This is because moist air that you breathe out will make the mask damp, which will make it easier for pathogens to “stick” onto the mask. Hence, likelihood of you breathing them right in increases, if mask is worn for long periods of time. According to the FDA: “All N95 respirators are labeled as "single use", disposable devices. If your respirator is damaged or soiled, or if breathing becomes difficult, you should remove it, discard it properly, and replace it with a new one.” And let’s face it, with the current shortage, there is no way you will be able (or should be able) to stockpile enough to follow these recommendations.
Proper Handling: Masks also have to be put on and taken off properly. WHO has a whole page dedicated to how to do this. Before and after touching the mask you should always wash or disinfect your hands, otherwise germs from your hands will transfer to the mask, again increasing the likelihood that you will breathe them back in. In this way, a mask becomes liability. One of the main recommendations for preventing virus spread is avoiding touching your face as much as possible, especially mouth and nose. However, if you wear a mask on a regular basis, you will simply have to take it off and on all the time, when you eat, drink, blow your nose, etc. I see people wearing a mask on their mouth but not on their nose, or taking a mask on and off when they are talking, or when they need to scratch their face. Every time you do this, you increase the likelihood of transferring germs from your hands onto the mask. And if you ever observe doctors, you will see that they put on a new mask any time they take the previous one off their face. And again, none of us can stockpile nearly enough masks to be changing them this frequently.
I’m wearing a mask, I’m fine: Accoridng to infection prevention specialist Dr Eli Perencevich there is also an issue with false sense of security that some people have from wearing a mask, which decreases frequency of proper hand washing and other effective protective measures, like coughing in your sleeve, staying away from sick people, staying at home when you are sick, etc. Few weeks ago at an airport, I saw a woman with a mask coming out of a bathroom stall and then walking straight past the sinks without washing her hands. Whaaaat?!
ISSUE NO. 3: Realistic Wear
SUMMARY: Many respirators that are highly effective against viruses are nearly impossible to wear for an extended period of time, they quickly get very hot, damp, and uncomfortable. They can also be dangerous for people with existing respiratory and cardiac conditions.
Surgical masks are primarily meant to protect the patient from the doctor, and they are not as effective other way around, protecting the wearer from very small particles, like viruses, coming from the outside. For this purpose, respirators like N95 are used. While N95 are highly effective at filtering viruses and other extremely small particles, they are very difficult to breathe in on a long term basis. N95 respirator without a valve gets very hot and moist very quickly (even 3M admits it - see image below from 3M website about N95 without and with a cool valve).
N95 with a cool valve is a little better, as we can see from the image above, but it gets hard to breath in for more than an hour or so. Trust me, I’ve tried it a while back and took it off quickly, as I felt I’m running out of oxygen. And if you don’t trust me, trust Dr William Schaffner, professor of preventive medicine and infectious diseases at the Vanderbilt University School of Medicine, who admits himself to not being able to wear it for more than 30 minutes.
In addition, masks without valves partially recirculate exhaled carbon dioxide, so they have a potential for decreasing the amount of oxygen you breathe in. This can be problematic for people with already reduced lung function. According to the FDA: “People with chronic respiratory, cardiac, or other medical conditions that make breathing difficult should check with their healthcare provider before using an N95 respirator because the N95 respirator can make it more difficult for the wearer to breathe.” If you just take a look at 3M N95 respirator, you will see that it carries a warning right on it: “Misuse may result in sickness or death”. Excuse me?! Now what does that leave us with? More explanation and reading of the instructions is definitely warranted.
So all this taken into account, even healthy people should take a moment to think about how long they would realistically wear a mask/respirator like this, before ripping it off their face in frustration.
ISSUE NO. 4: Mask Effectiveness
SUMMARY: Not all masks work for filtering particles as small as viruses. Check the graph below to see which masks are the most effective.
No surprise here, not all masks are created equal when it comes to effectively filtering particles as small as viruses. Coronavirus has an average size of 0.125 microns. Below is a comparison of different particle sizes, for better understanding of what this means.
So before thinking about buying a mask or a respirator you should at least know:
1. What particle sizes they filter:
Surgical masks filter particles of 5 microns in size (that’s 40 times larger than coronavirus particle size) and are meant to be used to protect from large droplets of blood and bodily fluids. They are not designed or certified to prevent the inhalation of small airborne contaminants.
Filters marked as PM2.5 are effective for particles of 2.5 microns in size (20 times larger than coronavirus) and are typically used for filtering inhalable particulate matter from polluted city air.
3M N95 respirators filter 95% of particles as small as 0.3 micron. They are also highly effective for coronavirus and other particles smaller than 0.3 micron (fun fact: it is actually the most difficult to capture and filter 0.3 micron particles, even more difficult than smaller particles, thanks to a cool science phenomena called Brownian Motion). These respirators are designed to reduce exposure to airborne contaminants.
2. How effectively the masks / respirator filters the virus:
Below is a chart showing effectiveness of different masks for filtering virus sized particles, while being worn on an actual face. As you can see, some of them are pretty useless and some do a great job. Interestingly, some PM2.5 masks that are marketed as pollution masks for everyday wear, for general population, like Vogmask and ICanBreathe, tested really well for capturing virus-sized particles. And some other popular masks, like Japanese Pitta mask are, well... pretty much useless for this purpose (which is not surprising considering that Pitta masks are advertised for protection against pollen and dust).
CONCLUSION: If and When to Mask
As per WHO recommendation, you should wear a mask if you are already sick, to protect the others (family members or when going outside). Surgical masks are made to primarily protect a patient from doctor’s germs, hence they work well in this case. If you are taking care of a person who is sick with coronavirus, you should also wear a surgical mask or a respirator like N95, to protect yourself.
As per FDA recommendation, people with compromised immunity and pre-existing respiratory conditions should consult their doctor to discuss pros and cons of mask wearing, as they may be appropriate for them.
Scientists estimate that coronavirus can spread within 3 to 6 feet from a sick person who is coughing or sneezing. Hence, wearing an appropriate mask in particularly crowded public places during an outbreak can make sense (for example: public transportation, subway, airplanes, large and dense social gatherings like church, sports events, concerts etc). Although, in the case of significant outbreak and communal spread, you would do yourself a favor and avoid places like these as much as possible.
So if you do end up deciding that a mask is the right choice for you, which one should you pick? For me, the criteria is clear:
Do NOT use masks used by healthcare professionals (seriously people, we talked about this enough). If you are healthy, please stay away from N95 respirators and surgical masks. Thank you!
Use only masks with confirmed performance in filtering virus-sized particles (see the chart above).
Use masks that are easy to breathe in. Again, respirators like N95 are not a viable long-term choice for more reasons than one. While wearing a mask, you should make sure you can breathe comfortably and not jeopardize your health, as well as refraining form frequently putting a mask on and off, or just throwing it in the garbage in frustration.
Below is a list of recommended brands that, based on our research, fit all the above criteria. In my opinion, any of these masks would be a great choice. Due to current state of global panic, it will be a challenge to find many of them in stock. Hence, your final choice of which mask to buy might be guided solely by their availability.
LIVING PUR RECOMMENDATION
Vogmask - Based on testing data this mask, from San Francisco based company, is 95.2% effective in filtering virus-sized particles. It is affordable ($30-$44) for the fact that it lasts for several months. This mask is also the most stylish out of the bunch, with many patterns and sizes available, for those of you who care about this. As of March 4th, 2020 the mask is unfortunately backordered on the website, so you will have to keep an eye on when the next batch will hit the store, or check eBay if you are ready for some bidding wars.
Cambridge Mask - This respirator comes from UK and is built using some really impressive filtering technology developed by US Ministry of Defense. It is independently tested, and model PRO N99 claims to filter impressive 99% of particles, including viruses, bacteria, and VOCs. It is affordable (£25, approx. $32) and lasts around 220 hours on average. Unfortunately, the mask is currently backordered until May 2020, so the only choice is to order it from eBay.
ICanBreathe - This mask is less effective than Vogue and Cambridge masks, filtering 86.5% of virus-sized particles, but it is still a very good option, and definitely more efficient than a surgical mask. The website unfortunately lacks more detailed information on the mask performance. The mask is comparable in price to the other two ($29-$39) and it is currently available for purchase!
In case that you are sick a surgical mask would be a good option for a long-wear.
And in case that you are taking care of a sick person, 3M N95 respirators are the safest and the most effective choice.
Lastly, there are some other masks that claim to be highly effective in filtering viruses, like O2 Safe Air, designed by the famous designer Marcel Wanders, Airinum, a premium Swedish brand, and some other ones. However, at the time of writing they are all out of stock with no availability on other websites and stores.