tag:theconversation.com,2011:/us/topics/facemasks-96010/articlesFacemasks – The Conversation2023-02-06T19:04:54Ztag:theconversation.com,2011:article/1989922023-02-06T19:04:54Z2023-02-06T19:04:54ZYes, masks reduce the risk of spreading COVID, despite a review saying they don’t<figure><img src="https://images.theconversation.com/files/508261/original/file-20230206-504-kijojf.jpg?ixlib=rb-1.1.0&rect=0%2C68%2C4593%2C2984&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/calm-black-woman-with-coffee-wearing-medical-mask-standing-in-metro-6280959/">Pexels/Uriel Mont</a></span></figcaption></figure><p>The question of whether and to what extent face masks work to prevent respiratory infections such as COVID and influenza has split the scientific community for <a href="https://www.baltimoresun.com/news/bs-xpm-2007-03-06-0703060040-story.html">decades</a>. </p>
<p>Although there is strong evidence face masks <a href="https://www.sciencedirect.com/science/article/pii/S0020748920301139?via%3Dihub">significantly reduce transmission of such infections</a> both in health-care settings and in the community, some experts do not agree. </p>
<p>An updated <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006207.pub6/full">Cochrane Review</a> published last week is the latest to suggest face masks don’t work in the community. </p>
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<p>However there are problems with the review’s methodology and its underpinning assumptions about transmission. </p>
<p>The Cochrane Review combined randomised controlled trials (RCTs) using <a href="https://ebn.bmj.com/content/16/1/3">meta-analysis</a>. RCTs test an intervention in one group and compare it with a “control” group that doesn’t receive the intervention or receives a different intervention. A meta-analysis pools the results of multiple studies. </p>
<p>This approach assumes (a) RCTs are the “best” evidence and (b) combining results from multiple RCTs will give you an average “effect size”.</p>
<p>But RCTs are only the undisputed gold standard for certain <em>kinds</em> of questions. For other questions, a mix of study designs is better. And RCTs should be combined in a meta-analysis <em>only</em> if they are all addressing the same research question in the same way. </p>
<p>Here are some reasons why the conclusions of this Cochrane Review are misleading. </p>
<h2>It didn’t consider how COVID spreads and how masks work</h2>
<p>COVID, along with influenza and many other respiratory diseases, is transmitted primarily <a href="https://theconversation.com/covid-how-the-disease-moves-through-the-air-173490">through the air</a>. </p>
<p>Respirators (such as N95s) are designed and regulated to prevent airborne infections by fitting <a href="https://theconversation.com/high-filtration-masks-only-work-when-they-fit-so-we-created-a-new-way-to-test-if-they-do-155987">closely to the face</a> to prevent air leakage and by filtering out 95% or more of potential infectious particles. </p>
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Read more:
<a href="https://theconversation.com/high-filtration-masks-only-work-when-they-fit-so-we-created-a-new-way-to-test-if-they-do-155987">High-filtration masks only work when they fit – so we created a new way to test if they do</a>
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<p>In contrast, surgical masks are designed to prevent splatter of fluid on the face and are loose-fitting, causing unfiltered air to leak in through the gaps around the mask. The filtration of a surgical mask is not regulated. </p>
<p>In other words, respirators are designed for respiratory protection and cloth and surgical masks are not. </p>
<p>The review starts with an assumption that masks provide respiratory protection, which is flawed. An understanding of these differences should inform both studies and reviews of those studies. </p>
<h2>The studies addressed quite different questions</h2>
<p>A common mistake in meta-analysis is to combine apples and oranges. If apples work but oranges don’t, combining all studies in a single average figure may lead to the conclusion that apples do not work. </p>
<p>This Cochrane Review combined RCTs where face masks or respirators were worn <em>part</em> of the time (for example, when caring for patients with known COVID or influenza: “occasional” or “targeted” use) with RCTs where they were worn at <em>all</em> times (“continuous use”). </p>
<p>Because both SARS-CoV-2 and influenza viruses are airborne, an unmasked person could be infected anywhere in the building and even after an infectious patient has left the room, especially since some people have <a href="https://www.pnas.org/doi/10.1073/pnas.2109229118">no symptoms</a> while contagious. </p>
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<img alt="Clinicians in PPE pulls up her gloves" src="https://images.theconversation.com/files/508255/original/file-20230206-21-bn9aws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508255/original/file-20230206-21-bn9aws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=480&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508255/original/file-20230206-21-bn9aws.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=480&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508255/original/file-20230206-21-bn9aws.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=480&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508255/original/file-20230206-21-bn9aws.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=603&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508255/original/file-20230206-21-bn9aws.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=603&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508255/original/file-20230206-21-bn9aws.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=603&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The results will depend on whether they’re occasionally or continuously used.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/hYcSP6SpoK0">Unsplash/Viki Mohamad</a></span>
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<p>Most RCTs of masks and N95s included in the review have not had a <a href="https://jamanetwork.com/journals/jama/fullarticle/184819">control arm</a> – therefore finding no difference could indicate equal efficacy or equal inefficacy. </p>
<p><a href="https://jamanetwork.com/journals/jama/fullarticle/2749214">Studies</a> examining wearing a surgical mask or respirator (such as an N95) only when in contact with sick people or when doing a high-risk procedure (occasional use) have generally shown that, when worn in this way, there is no difference. </p>
<p>An RCT comparing occasional versus continuous use of respirators in health care workers <a href="https://www.atsjournals.org/doi/10.1164/rccm.201207-1164OC?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubme">showed</a> N95 respirators and surgical masks were equally <em>ineffective</em> when only worn occasionally by hospital workers. They had to wear them <em>all the time at work</em> to be protected. </p>
<p>We also combined only apples and apples in a <a href="https://onlinelibrary.wiley.com/doi/10.1111/irv.12474">meta-analysis</a> of two RCTs conducted in exactly the same way and measuring the same interventions and outcomes. We found N95 respirators provide <em>significant protection</em> against respiratory infections when surgical masks did not, even against infections assumed to be “droplet spread”. </p>
<h2>Most trials addressed only half the question</h2>
<p>Face masks and respirators work in two ways: they protect the wearer from becoming infected <em>and</em> they prevent an infected wearer from spreading their germs to other people. </p>
<p>Most RCTs in this Cochrane Review looked only at the former scenario, not the latter. In other words, the researchers had asked people to wear masks and then tested to see if those people became infected. </p>
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Read more:
<a href="https://theconversation.com/as-viral-infections-skyrocket-masks-are-still-a-tried-and-true-way-to-help-keep-yourself-and-others-safe-195788">As viral infections skyrocket, masks are still a tried-and-true way to help keep yourself and others safe</a>
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<p>A previous <a href="https://pubmed.ncbi.nlm.nih.gov/20092668/">systematic review</a> found face masks worn by sick people during an influenza epidemic reduced the risk of them transmitting the infection to family members or other carers. Preventing an infection in one person also prevents onward transmission to others within a closed setting, which means such RCTs should use a special method called “cluster randomisation” to account for this. </p>
<p>Data from a RCT of N95 respirator use by <a href="https://journals.sagepub.com/doi/full/10.1177/0300060516665491?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org">health workers</a> showed even their unmasked colleagues were protected. Yet some of the trials included in the review did not use cluster randomisation.</p>
<h2>The new paper combined health and community settings</h2>
<p>This is another apples-plus-oranges issue. Different settings have widely differing risks of transmission, since airborne particles build up when sick patients are exhaling the virus in <a href="https://theconversation.com/heres-where-and-how-you-are-most-likely-to-catch-covid-new-study-174473">underventilated, crowded settings</a> especially if many infected people are present (such as in a hospital). </p>
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<p>A genuine protective effect of masks or respirators shown in a RCT in a high-risk setting will be obscured if that trial is combined in a meta-analysis with several other RCTs that were conducted in low-risk settings. </p>
<p>A large <a href="https://www.science.org/doi/10.1126/science.abi9069">RCT in the community in Bangladesh</a> found face masks reduced the risk of infection by 11% overall and 35% in people over 60 years. In contrast, in <a href="https://onlinelibrary.wiley.com/doi/10.1111/irv.12474">hospitals</a>, N95 reduce risk by 67% against bacterial infections and 54% against viral infections.</p>
<p>Viruses like influenza also vary substantially from year to year – some years there is very little influenza, and if a RCT is conducted during such a year, it will not find enough infections to show a difference. The review failed to account for such seasonal effects.</p>
<h2>But did they actually wear the mask?</h2>
<p>The authors of the Cochrane Review acknowledged compliance with masking advice was poor in most studies. In the real world, we can’t force people to follow medical advice, so RCTs should be analysed on an “intention to treat” basis. </p>
<p>For example, people who are prescribed the active drug but who choose not to take it should not be shifted to the placebo group for the analysis. But if in a study of masking, most people don’t actually wear them, you can’t conclude that <em>masks</em> don’t work when the study shows no difference between the groups. You can only conclude that the <em>mask advice</em> didn’t work in this study. </p>
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<img alt="Woman fits a facemask" src="https://images.theconversation.com/files/508256/original/file-20230206-17-y18dj7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508256/original/file-20230206-17-y18dj7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508256/original/file-20230206-17-y18dj7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508256/original/file-20230206-17-y18dj7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508256/original/file-20230206-17-y18dj7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508256/original/file-20230206-17-y18dj7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508256/original/file-20230206-17-y18dj7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People don’t always wear masks when advised to do so.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-wearing-face-mask-3873197/">Pexels/Polina Tankilevitch</a></span>
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<p>There is a great deal of <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246317">psychological evidence</a> on why people do or don’t choose to comply with advice to mask and how to improve uptake. The science of masking needs to separate the impact of the <em>mask itself</em> from the impact of the <em>advice to mask</em>. </p>
<p>Mask-wearing <a href="https://www.ijidonline.com/article/S1201-9712(21)00274-5/fulltext">goes up</a> substantially to over 70% if there is an actual mandate in place.</p>
<h2>It didn’t include other types of research</h2>
<p>A comprehensive review of the evidence would also include other types of study besides RCTs. For example, a <a href="https://www.sciencedirect.com/science/article/pii/S0140673620311429">large systematic review</a> of 172 various study designs, which included 25,697 patients with SARS-CoV-2, SARS, or MERS, concluded masks were effective in preventing transmission of respiratory viruses. </p>
<p>Well-designed <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7106e1.htm?s_cid=mm7106e1_w">real-world studies</a> during the pandemic showed any mask reduces the risk of COVID transmission by 50–80%, with the highest protection offered by N95 respirators. </p>
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Read more:
<a href="https://theconversation.com/which-mask-works-best-we-filmed-people-coughing-and-sneezing-to-find-out-143173">Which mask works best? We filmed people coughing and sneezing to find out</a>
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<p><a href="https://pubmed.ncbi.nlm.nih.gov/20095070/">Many lab-based studies</a> have shown respirators are superior to masks at preventing airborne respiratory infections and the <a href="https://thorax.bmj.com/content/75/11/1024.long">incremental superiority</a> from a single to two layered cloth mask to a three-layered surgical mask in blocking respiratory aerosols.</p>
<h2>Yes, masks reduce the spread of COVID</h2>
<p>There is strong and consistent evidence for the effectiveness of masks and (even more so) respirators in protecting against respiratory infections. Masks are an important protection against serious infections. </p>
<p>Current COVID vaccines protect against death and hospitalisation, but do <a href="https://fortune.com/well/2023/01/06/kraken-xbb15-omicron-covid-variant-most-transmissible-yet-could-spawn-more-immune-evasive-variants-study-china-vaccine-monoclonal-antibodies-breakthrough-infection/">not prevent infection</a> well due to waning vaccine immunity and substantial immune escape from new variants. </p>
<p>A systematic review is only as good as the rigour it employs in combining similar studies of similar interventions, with similar measurement of outcomes. When very different studies of different interventions are combined, the results are not informative.</p><img src="https://counter.theconversation.com/content/198992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from mask manufacturer Detmold for testing of their masks and is on an advisory board for mask manufacturer Ascend. She receives funding from Sanofi for investigator-driven influenza research, and from NHMRC and MRFF. She has been an expert advisor for Ontario Nurses Association (ONA) In the matter of a proceeding under the Labour Relations Act, 1995 between ONA and Hamilton Health Sciences Corporation.
</span></em></p><p class="fine-print"><em><span>Abrar Ahmad Chughtai had testing of filtration of masks by 3M for his PhD. 3M products were not used in his research. He also has worked with Paftec on research in respirators (no funding was involved).</span></em></p><p class="fine-print"><em><span>Dr Fisman has served as an expert witness for the Ontario Nurses Association and the Elementary Teachers' Federation of Ontario in legal challenges related to safer working conditions in healthcare and schools. Dr. Fisman has served on advisory boards for Pfizer, Astrazeneca, Merck, Seqirus and Sanofi vaccines against SARS-CoV-2, influenza, and S. pneumoniae. He holds current funding from the Canadian Institutes for Health Research and Health Canada.</span></em></p><p class="fine-print"><em><span>Trish Greenhalgh receives funding from UK National Institute for Health and Care Research and the NIHR School for Primary Care Research. She is affiliated with University of Oxford and University of Oslo. She has served as an unpaid adviser tot he philanthropic fund BALVI and is a member of Independent SAGE. </span></em></p>An updated Cochrane Review suggests face masks don’t reduce the spread of COVID in the community. But there are several reasons why this conclusion is misleading.C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyAbrar Ahmad Chughtai, Senior lecturer, UNSW SydneyDavid Fisman, Professor in the Division of Epidemiology, University of TorontoTrish Greenhalgh, Professor of Primary Care Health Sciences, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1976022023-01-16T23:55:32Z2023-01-16T23:55:32ZFAQ on COVID-19 subvariant XBB.1.5: What is it? Where is it prevalent? How does it differ from Omicron? Does it cause serious illness? How can I protect myself? Why is it nicknamed ‘Kraken’?<figure><img src="https://images.theconversation.com/files/504746/original/file-20230116-14-fkca7k.jpg?ixlib=rb-1.1.0&rect=281%2C32%2C6216%2C3757&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">XBB.1.5 is rapidly spreading across the globe and will likely become the next dominant COVID-19 subvariant.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/faq-on-covid-19-subvariant-xbb-1-5--what-is-it-where-is-it-prevalent-how-does-it-differ-from-omicron-does-it-cause-serious-illness-how-can-i-protect-myself-why-is-it-nicknamed--kraken-" width="100%" height="400"></iframe>
<p>Despite intensive public health efforts to grind the COVID-19 pandemic to a halt, the recent emergence of the highly transmissible, extensively drug-resistant and profoundly immune system-evading XBB.1.5 SARS-CoV-2 subvariant is putting the global community on edge.</p>
<h2>What is XBB.1.5?</h2>
<p>In the naming convention for SARS-CoV-2 lineages, the <a href="https://virological.org/t/pango-lineage-nomenclature-provisional-rules-for-naming-recombinant-lineages/657">prefix “X” denotes a pedigree that arose through genetic recombination</a> between two or more subvariants. </p>
<p>The XBB lineage emerged following natural <a href="https://www.who.int/news/item/27-10-2022-tag-ve-statement-on-omicron-sublineages-bq.1-and-xbb">co-infection of a human host with two Omicron subvariants, namely BA.2.10.1 and BA.2.75</a>. It was <a href="https://doi.org/10.1007/s12291-022-01109-w">first identified by public health authorities in India during summer 2022</a>. XBB.1.5 is a direct descendent, or more accurately, the “fifth grandchild” of the original XBB subvariant.</p>
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<a href="https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram of the genetic lineage of a COVID-19 subvariant" src="https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=355&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=355&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=355&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=446&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=446&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504369/original/file-20230113-24-li24wl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=446&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Genetic lineage of COVID-19 subvariant XBB.1.5.</span>
<span class="attribution"><span class="source">(Sameer Elsayed)</span>, <span class="license">Author provided</span></span>
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<h2>How does XBB.1.5 differ from Omicron?</h2>
<p>XBB.1.5 is one of many Omicron subvariants of concern that have appeared on the global pandemic scene since the onset of the <a href="https://www.who.int/news-room/feature-stories/detail/one-year-since-the-emergence-of-omicron">first Omicron wave in November 2021</a>. In contrast to other descendants of the original Omicron variant (known as B.1.1.529), XBB.1.5 is a mosaic subvariant that <a href="https://doi.org/10.1007/s12291-022-01109-w">traces its roots to two Omicron subvariant lineages</a>. </p>
<p>XBB.1.5 is arguably the most genetically rich and <a href="https://www.scientificamerican.com/article/why-covids-xbb-1-5-kraken-variant-is-so-contagious/">most transmissible</a> SARS-CoV-2 Omicron subvariant yet. </p>
<h2>Where is XBB.1.5 prevalent?</h2>
<p><a href="https://www.who.int/docs/default-source/coronaviruse/11jan2023_xbb15_rapid_risk_assessment.pdf">According to the World Health Organization</a>, XBB.1.5 is circulating in at least 38 countries, with the highest prevalence in the United States, where it <a href="https://covid.cdc.gov/covid-data-tracker/#variant-proportions">accounts for approximately 43 per cent of COVID-19 cases nationwide</a>. Within the U.S., there is wide geographic variation in the proportion of cases caused by XBB.1.5, ranging from <a href="https://www.beckershospitalreview.com/public-health/xbb-1-5-prevalence-by-region.html">seven per cent in the Midwest to over 70 per cent in New England</a>. </p>
<p>XBB.1.5 has also been officially reported by governmental agencies in <a href="https://www.health.nsw.gov.au/Infectious/covid-19/Documents/weekly-covid-overview-20230107.pdf">Australia</a>, <a href="https://www.publichealthontario.ca/-/media/documents/ncov/epi/covid-19-sars-cov2-whole-genome-sequencing-epi-summary.pdf">Canada</a>, the <a href="https://www.ecdc.europa.eu/en/news-events/update-sars-cov-2-variants-ecdc-assessment-xbb15-sub-lineage">European Union</a>, <a href="https://www3.nhk.or.jp/nhkworld/en/news/20230112_36/">Japan</a>, <a href="https://www.kuna.net.kw/ArticleDetails.aspx?id=3077268&Language=en">Kuwait</a>, <a href="https://tass.com/world/1561313">Russia</a>, <a href="https://cov-spectrum.org/explore/Singapore/AllSamples/Past6M/variants?nextcladePangoLineage=xbb.1.5*&">Singapore</a>, <a href="https://www.nicd.ac.za/covid-19-update-xbb-1-5-variant/">South Africa</a> and the <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1128554/variant-technical-briefing-49-11-january-2023.pdf">United Kingdom</a>. <a href="https://outbreak.info/situation-reports?xmin=2022-07-13&xmax=2023-01-13&loc&pango=XBB.1&selected">Real-time surveillance data</a> reveals that XBB.1.5 is rapidly spreading across the globe and will likely become the next dominant subvariant.</p>
<p>XBB.1.5 has also been detected in municipal wastewater systems in the <a href="https://health.hawaii.gov/coronavirusdisease2019/files/2023/01/Wastewater-Report-01-03-23.pdf">United States</a>, <a href="https://thl.fi/en/web/thlfi-en/-/monitoring-wastewater-for-coronavirus-xbb-sublineage-of-omicron-variant-found-in-wastewater-follow-up-results-coming-in-january?redirect=%2Ffi%2Fajankohtaista%2Ftiedotteet-ja-uutiset%2Fkaikki-uutiset">Europe</a> and other places.</p>
<h2>How likely is XBB.1.5 to cause serious illness?</h2>
<figure class="align-center ">
<img alt="Illustration of five coronaviruses of different colours in a line" src="https://images.theconversation.com/files/504766/original/file-20230116-12-o1ah4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504766/original/file-20230116-12-o1ah4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=217&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504766/original/file-20230116-12-o1ah4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=217&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504766/original/file-20230116-12-o1ah4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=217&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504766/original/file-20230116-12-o1ah4n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=272&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504766/original/file-20230116-12-o1ah4n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=272&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504766/original/file-20230116-12-o1ah4n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=272&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The XBB lineage emerged following natural co-infection of a human host with two Omicron subvariants, namely BA.2.10.1 and BA.2.75.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>There is limited data about the ability of XBB.1.5 to cause serious illness. According to the <a href="https://www.who.int/docs/default-source/coronaviruse/11jan2023_xbb15_rapid_risk_assessment.pdf">World Health Organization</a>, XBB.1.5 does not have any specific mutations that make it any more dangerous than its ancestral subvariants. </p>
<p>Nonetheless, XBB.1.5 is perceived as being equally capable of causing serious illness in elderly and immunocompromised persons compared to previous Omicron subvariants of concern.</p>
<h2>Are current mRNA vaccines effective against XBB.1.5?</h2>
<p>XBB.1.5 and XBB.1 are the Omicron subvariants with the <a href="https://www.who.int/docs/default-source/coronaviruse/11jan2023_xbb15_rapid_risk_assessment.pdf">greatest immune-evasive properties</a>. Therefore, one of the most contentious issues surrounding XBB.1.5 relates to the degree of protection afforded by currently available mRNA vaccines, including the latest bivalent booster formulations. </p>
<p><a href="https://doi.org/10.1038/s41591-022-02162-x">Researchers from the University of Texas</a> determined that first-generation and bivalent mRNA booster vaccines containing BA.5 result in lacklustre neutralizing antibody responses against XBB.1.5. A report (yet to be peer reviewed) from investigators at the <a href="https://doi.org/10.1101/2022.12.17.22283625">Cleveland Clinic</a> found that bivalent vaccines demonstrate only modest (30 per cent) effectiveness in otherwise healthy non-elderly people when the variants in the vaccine match those circulating in the community. </p>
<p>Furthermore, some experts believe the administration of bivalent boosters for the prevention of COVID-19 illness in otherwise healthy young individuals is <a href="http://doi.org/10.1056/NEJMp2215780">not medically justified</a> nor <a href="https://doi.org/10.1136/jme-2022-108449">cost-effective</a>. </p>
<p>In contrast, <a href="http://doi.org/10.1056/NEJMc2214293">public health experts from Atlanta, Ga. and Stanford, Calif.</a> reported that although the neutralizing antibody activity of bivalent booster vaccines against XBB.1.5 is 12 to 26 times less than antibody activity against the wild-type (original) SARS-CoV-2 virus, bivalent vaccines still perform better than monovalent vaccines against XBB.1.5. </p>
<p>However, <a href="https://doi.org/10.1016/j.cell.2022.12.018">investigators from Columbia University</a> in New York found that neutralizing antibody levels following bivalent boosting were up to 155–fold lower against XBB.1.5 compared to levels against the wild-type virus following monovalent boosting. </p>
<p>This suggests that neither monovalent nor bivalent booster vaccines can be relied upon to provide adequate protection against XBB.1.5.</p>
<h2>How can you protect yourself against XBB.1.5?</h2>
<figure class="align-center ">
<img alt="A blue sign reading 'wearing a mask is recommended,' in French and English" src="https://images.theconversation.com/files/504744/original/file-20230116-18-xo2zgu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504744/original/file-20230116-18-xo2zgu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504744/original/file-20230116-18-xo2zgu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504744/original/file-20230116-18-xo2zgu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504744/original/file-20230116-18-xo2zgu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=536&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504744/original/file-20230116-18-xo2zgu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=536&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504744/original/file-20230116-18-xo2zgu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=536&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Standard infection control precautions including indoor masking, social distancing and frequent handwashing are effective measures against XBB.1.5 and other subvariants of concern.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>The rapid evolution of SARS-CoV-2 continues to pose a challenge for the management of COVID-19 illness using available preventive and therapeutic agents. Of note, all currently available monoclonal antibodies targeting the spike protein of SARS-CoV-2 are <a href="https://doi.org/10.1016/j.cell.2022.12.018">deemed to be ineffective against XBB.1.5</a>. </p>
<p>Antiviral medicines such as remdesivir and Paxlovid may be considered for the treatment of eligible infected patients at high risk of progressing to severe disease.</p>
<p>Standard infection control precautions including indoor masking, social distancing and frequent handwashing are effective measures that can be employed for personal and population protection against XBB.1.5 and other subvariants of concern.</p>
<p>Although bivalent boosters may be considered for elderly, immunocompromised and other risk-averse individuals, their effectiveness in preventing COVID-19 illness due to XBB.1.5 remains uncertain. </p>
<h2>Why is XBB.1.5 nicknamed ‘Kraken’?</h2>
<p><a href="https://www.mountainviewtoday.ca/amp/lifestyle-news/kraken-subvariant-name-beats-alphabet-soup-moniker-for-xbb15-biologist-6351664">Some scientists have coined unofficially-recognized nicknames for XBB.1.5</a> and other SARS-CoV-2 subvariants of concern, arguing that they are easier to remember than generic alphanumeric designations. </p>
<p><a href="https://news.uoguelph.ca/2023/01/biologist-makes-headlines-on-new-covid-subvariant/">The ‘Kraken’ label for XBB.1.5 is currently in vogue</a> on social media sites and news outlets, and the nicknames ‘Gryphon’ and ‘Hippogryph’ have been used to denote the ancestral subvariants XBB and XBB.1, respectively. <a href="https://www.merriam-webster.com/dictionary/kraken">Kraken</a> refers to a mythological Scandinavian sea monster or giant squid, Gryphon (or <a href="https://www.merriam-webster.com/dictionary/griffin">Griffin</a>) refers to a legendary creature that is a hybrid of an eagle and a lion, while Hippogryph (or <a href="https://www.merriam-webster.com/dictionary/hippogriff">Hippogriff</a>) is a fictitious animal hybrid of a Gryphon and a horse. </p>
<p>Notwithstanding their potential utility as memory aids, the use of nicknames or acronyms in formal scientific discussions should be avoided.</p><img src="https://counter.theconversation.com/content/197602/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sameer Elsayed does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The XBB.1.5 subvariant — nicknamed ‘Kraken’ — is arguably the most genetically rich and most transmissible SARS-CoV-2 Omicron subvariant yet.Sameer Elsayed, Professor of Medicine, Pathology & Laboratory Medicine, and Epidemiology & Biostatistics, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1873772022-08-01T15:32:07Z2022-08-01T15:32:07ZLiving with COVID: how treating masks like umbrellas could help us weather future pandemic threats<figure><img src="https://images.theconversation.com/files/475681/original/file-20220722-18-dygv4z.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5363%2C3559&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When cases rise, we can make small changes to our behaviour.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/rainy-day-young-man-holding-blue-452725810">Jaromir Chalabala/Shutterstock</a></span></figcaption></figure><p>Thankfully, the UK now looks to be past the peak of both the recent heatwave and the <a href="https://www.theguardian.com/commentisfree/2022/jul/22/covid-wave-prepare-new-variants-nhs-hospital-admissions-england">latest COVID wave</a>. But there will be more of both – and in future, we might think about how we protect ourselves from COVID in the same way we protect ourselves from the weather. </p>
<p>An umbrella is a useful analogy. If we look out the window or check the weather forecast and see rain, we would probably take an umbrella out with us. Similarly, if COVID cases are starting to rise or if a new wave is forecast, we might consider grabbing a face mask, for example.</p>
<p>But just as there’s no need to carry an umbrella with us when it’s sunny, we needn’t be expected to wear masks all the time. Of course, some people may choose to wear masks more consistently in certain settings, while others may forgo wearing them altogether. This is the nature of the current phase of the pandemic we’re in, a big part of which is based on personal choice and responsibility. </p>
<p>Thanks largely to the impact of vaccines, we no longer need the kind of rules-based approach to risk management we saw earlier in the pandemic. But the umbrella analogy can guide our behaviour and choices in a variety of areas of our response moving forward. Beyond masks, these include testing, ventilation and social distancing.</p>
<p>The idea is that we can pick up or step up precautions when we most need them (when COVID cases are on the rise), before relaxing them, if we want to, when infection rates and risk are lower.</p>
<h2>What might this look like in practice?</h2>
<p>Let’s say we start to see COVID cases rising again come autumn. This is a <a href="https://www.who.int/europe/news/item/19-07-2022-rapidly-escalating-covid-19-cases-amid-reduced-virus-surveillance-forecasts-a-challenging-autumn-and-winter-in-the-who-european-region">distinct possibility</a>.</p>
<p>It then becomes even more important to <a href="https://theconversation.com/i-have-covid-symptoms-should-i-do-a-test-186368">take a test</a> if we have any symptoms that might be COVID-related. This will help inform our decision of whether, and to what extent, to minimise contact with others.</p>
<p>Isolation is no longer a legal requirement, and I think this should remain the case. However, if possible, staying at home while we’re unwell is a sensible and considerate thing to do, particularly when COVID rates are high.</p>
<p>Distancing should also remain a choice. But during a wave of infections, people might wish to maintain more distance between themselves and others in shops, or may choose to avoid crowded venues.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-covid-symptoms-should-i-do-a-test-186368">I have COVID symptoms. Should I do a test?</a>
</strong>
</em>
</p>
<hr>
<p>Back on <a href="https://www.science.org/doi/10.1126/science.abg6296?keytype2=tf_ipsecsha&ijkey=d490dbfa143fcca104ba377624e90c6c8d084108">masks</a>, when cases begin to rise, the risk of contracting and transmitting COVID also rises, so masks become a more useful and reasonable precaution. They can be particularly valuable in certain circumstances – for example, if someone is unwell but can’t isolate, when visiting people who are vulnerable, or in crowded indoor spaces.</p>
<p>Opening windows even a little can increase fresh air indoors and also help <a href="https://www.gov.uk/government/publications/emg-role-of-ventilation-in-controlling-sars-cov-2-transmission-30-september-2020">reduce the likelihood</a> of transmitting the virus. </p>
<p>Finally, the number of people in the UK who have had <a href="https://coronavirus.data.gov.uk/details/vaccinations">a COVID booster vaccine</a> is considerably lower than the number who received their first and second doses. We know immunity from vaccines wanes, and boosters <a href="https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(22)00146-3/fulltext">restore vaccine effectiveness</a>. So if we start to see rising cases, or looking ahead to <a href="https://www.who.int/europe/news/item/19-07-2022-rapidly-escalating-covid-19-cases-amid-reduced-virus-surveillance-forecasts-a-challenging-autumn-and-winter-in-the-who-european-region">future waves</a>, it would make good sense for people who are behind on their vaccines to get up-to-date.</p>
<figure class="align-center ">
<img alt="A woman administers a rapid COVID test to her son on the couch." src="https://images.theconversation.com/files/475684/original/file-20220722-14-oimal7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/475684/original/file-20220722-14-oimal7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/475684/original/file-20220722-14-oimal7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/475684/original/file-20220722-14-oimal7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/475684/original/file-20220722-14-oimal7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/475684/original/file-20220722-14-oimal7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/475684/original/file-20220722-14-oimal7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Testing becomes more important during a COVID wave.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/small-boy-having-rapid-covid19-test-1895185210">Dragana Gordic/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Shared responsibility</h2>
<p>It’s been a year since England’s “<a href="https://www.gov.uk/government/speeches/pm-statement-at-coronavirus-press-conference-19-july-2021">freedom day</a>”, when most legal COVID measures were removed. But <a href="https://news.un.org/en/story/2022/05/1118752">the pandemic</a> is far from over. Along with high numbers of daily infections, <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/7july2022">long COVID</a> is very common, and the <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/an-nhs-under-pressure#:%7E:text=The%20NHS%20is%20experiencing%20some,planning%20and%20chronic%20under%2Dresourcing.">pressure on the NHS</a> is still unsustainable.</p>
<p>In a recent article in the <a href="https://www.bmj.com/content/378/bmj.o1803">British Medical Journal</a>, Professor Susan Michie and I reflected on some of the lessons we’ve learned over the past year.</p>
<p>Among these, the pandemic has shown us that behaviour is not purely down to an individual’s choice or motivation. People’s actions are also shaped by the <a href="https://www.nature.com/articles/s41591-021-01345-2">opportunities and supports</a> they’re given – or not given. For example, while some people might want to stay home if they have symptoms, they may not if neither their employer or the government provides financial support.</p>
<p>People should be encouraged and supported as much as possible to stay home when they’re sick, particularly when cases are high. Amidst a winter COVID wave, Australia has re-instated its <a href="https://www.theguardian.com/australia-news/2022/jul/15/state-and-territory-leaders-urge-labor-to-extend-pandemic-leave-payments-as-covid-case-numbers-rise">pandemic leave disaster payments</a> to enable those with COVID and without proper sick pay to stay home and not lose out financially.</p>
<p>Further, governments could ensure that free at-home tests are available during times when infections are likely to, or starting to, rise.</p>
<p>And it’s important that, to mitigate the impacts of future waves, vaccination coverage is as high as possible. Public health campaigns should target both the unvaccinated and partially vaccinated, as well as encouraging people (particularly the most vulnerable) to take up booster offers.</p>
<p>We also need more action to ensure adequate ventilation. In the US, billions of dollars are being made available for <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/17/fact-sheet-biden-administration-launches-effort-to-improve-ventilation-and-reduce-the-spread-of-covid-19-in-buildings/">improving air quality</a> in schools and other public buildings.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/caught-covid-heres-what-you-should-and-shouldnt-do-when-self-isolation-isnt-mandatory-179441">Caught COVID? Here’s what you should and shouldn't do when self-isolation isn’t mandatory</a>
</strong>
</em>
</p>
<hr>
<p>I’ve previously argued that the UK government puts <a href="https://blogs.bmj.com/bmj/2020/03/17/uks-coronavirus-policy-places-too-much-responsibility-in-the-hands-of-the-public/">too much responsibility</a> in the hands of the public. Just like climate change, pandemics are global problems, and addressing them requires a collective effort.</p><img src="https://counter.theconversation.com/content/187377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Nicholas Williams has received funding from Swansea University, the University of Manchester, Senedd Cymru and Public Health Wales for research on COVID-19. However, this article reflects the views of the author only and no funding bodies were involved in the writing or content of this article.</span></em></p>The latest COVID wave in the UK might be on the decline, but there will be more to come.Simon Nicholas Williams, Lecturer in Psychology, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1772372022-03-29T20:06:14Z2022-03-29T20:06:14ZWhat’s next with face masks? Keep wearing them in public, wear the best mask available and pay attention to fit<figure><img src="https://images.theconversation.com/files/454820/original/file-20220328-13-18zbelz.jpg?ixlib=rb-1.1.0&rect=338%2C206%2C2960%2C1681&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fit, fabric and design affect mask effectiveness. </span> <span class="attribution"><a class="source" href="https://wesf.ca/">(Windsor Essex Sewing Force)</a>, <span class="license">Author provided</span></span></figcaption></figure><p>Early in the pandemic, mask-wearing policies were <a href="https://www.clothmasks.org/masks-in-context">consistently associated</a> with decreased transmission of SARS-CoV-2. At that time, the masks worn were generally made of cloth and often improvised.</p>
<p>The highly-transmissible Omicron variant <a href="https://www.publichealthontario.ca/-/media/documents/ncov/voc/2021/12/omicron-variant-community-masking.pdf?sc_lang=en">focused attention on mask performance</a>. </p>
<p>Although most provinces are lifting official mask mandates, we agree with <a href="https://globalnews.ca/news/8692613/covid-phac-omicron-mask-province-mandate/">public health authorities</a> in recommending that people <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html">wear the best mask available</a>. We have been working to improve and test reusable masks for community use. </p>
<p>We are an interdisciplinary group of engineers, scientists, a doctor and a community mask-maker. We test novel personal protective equipment (PPE), advocate for mask use and summarize the best available evidence at <a href="https://www.clothmasks.org/">clothmasks.org</a>.</p>
<h2>Hierarchy of mask performance</h2>
<p>There is an accepted <a href="https://www.clothmasks.org/mask-hierarchy">hierarchy of mask performance</a> based on mask materials, certification standards and use, confirmed by a <a href="http://dx.doi.org/10.15585/mmwr.mm7106e1">2022 California population health study</a>. The best protection is obtained by wearing a respirator such as an N95, CAN95 or CAN99, or in Europe, an FFP2 or FFP3. Performance is typically lower for KN95s, KF94s and certified medical masks meeting ASTM <a href="https://www.astm.org/products-services/standards-and-publications/covid-19.html">levels 1 to 3</a>. (ASTM is <a href="https://www.astm.org">an international standards organization</a>.)</p>
<figure class="align-center ">
<img alt="A man wearing a cloth face mask with a tube extending from it to a machine on the table in front of him" src="https://images.theconversation.com/files/451676/original/file-20220311-13-pxlo75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451676/original/file-20220311-13-pxlo75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=385&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451676/original/file-20220311-13-pxlo75.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=385&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451676/original/file-20220311-13-pxlo75.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=385&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451676/original/file-20220311-13-pxlo75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=484&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451676/original/file-20220311-13-pxlo75.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=484&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451676/original/file-20220311-13-pxlo75.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=484&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Testing Essex-pleated cotton masks using a PortaCount fit tester at McMaster University.</span>
<span class="attribution"><a class="source" href="https://wesf.ca/">(Windsor Essex Sewing Force)</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The materials used in all these masks offer similar, excellent, aerosol filtration, but the masks differ in their fit and seal on the face, with KN95s and KF94s fitting better than certified medical masks. </p>
<p>Cloth masks are typically ranked lower in their performance and may or may not be certified (for example, meeting <a href="https://www.astm.org/f3502-21.html">ASTM-F3502 standard</a>). However, <a href="https://doi.org/10.1371/journal.pone.0264090">we recently showed</a> that well-fitted cloth masks comprising high quality two-ply cotton material can perform as well as Level 1 medical masks.</p>
<h2>Fabric types</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Six squares showing highly magnified images of different fabrics" src="https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=836&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=836&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=836&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1050&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1050&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451678/original/file-20220311-3190-1uhvdng.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1050&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some examples of the variations in fabric structure seen with scanning electron microscopy: A) Bandana, B) High quality quilting fabric, C) Tea towel, D) Bed sheet, E) Outer layer L1 nonwoven medical mask, F) Middle layer of L1 nonwoven medical mask. We found that pore diameter (the size of the gaps) and fabric weight predicted filtration, however consumers would not know the pore diameter for retail or wholesale cloth. For this reason, we focus on the categories used when cloth is sold, and recommend 100 per cent cotton quilters’ fabric, fashion fabric and T-shirt fabric.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1371/journal.pone.0264090">(Drouillard et. al. PLOS)</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>When health-care professionals are issued N95s or other certified respirators, they are fit tested to verify mask performance on the wearer. But fit testing is typically not an option for the public. </p>
<p><a href="https://doi.org/10.1371/journal.pone.0264090">Our research</a>, explained in <a href="https://www.clothmasks.org/cotton-fabrics-community">plain language here</a>, underscores that fit can be achieved by good design and is as important as mask materials. For our research, we adapted the same method used in quantitative mask fit testing: a PortaCount fit tester that counts particles inside and outside the mask.</p>
<p>We tested 16 different cottons from nine recognizable categories. All except bandana cotton showed filtration equivalent to a medical mask. These findings apply to the carefully designed two-layer cloth mask with ties we used — other masks that fit less well will not provide the same protection.</p>
<p>Our results show that two-layer cotton masks made from quilters’ cotton, fashion fabric and T-shirt fabric filtered 55 to 60 per cent of aerosol particles measuring one micron or smaller, the size relevant for infectious aerosol particles. This was similar to the performance of a Level 1 medical mask. The breathability of the two-layer cotton masks was also acceptable as per medical mask standards. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bar graph showing filtration rates for nine types of fabric." src="https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451675/original/file-20220311-14-12gyjj6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This graph shows the filtration of two-layer masks, all the same design, worn by a human volunteer. All except bandana cotton showed filtration equivalent to a medical mask. Mass market QC = mass market quilting cotton, HQ QC = high quality quilting cotton, HQ Batik = high quality batik quilting fabric. The medical masks we tested are represented by dotted lines showing their 50 to 60 per cent filtration.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1371/journal.pone.0264090">(Drouillard et. al. PLOS)</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Filtration in the same range was provided by batiks, home décor fabric and bed-sheet fabric, but some examples of these materials failed the breathability testing. Tea towel fabrics also filtered well, but some were too thick to sew. Bandana fabrics performed worst at 46 per cent filtration. </p>
<h2>Fit and design</h2>
<figure class="align-center ">
<img alt="Close-up of an ear showing improper and proper fit of a blue face mask" src="https://images.theconversation.com/files/454819/original/file-20220328-19-645813.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/454819/original/file-20220328-19-645813.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/454819/original/file-20220328-19-645813.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/454819/original/file-20220328-19-645813.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/454819/original/file-20220328-19-645813.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/454819/original/file-20220328-19-645813.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/454819/original/file-20220328-19-645813.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A close fit at the ear prevents unfiltered air from entering the mask at the sides.</span>
<span class="attribution"><a class="source" href="https://wesf.ca/">(Windsor Essex Sewing Force)</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Our research showed that cloth masks performed similarly to medical masks because they fit better, were <a href="https://www.clothmasks.org/patternsinstruction"> designed thoughtfully</a> and had overhead ties. Although medical masks are composed of materials with better filtration performance, they exhibit greater leakage, with completely unfiltered air passing around the mask.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bar graph showing breathability of different fabrics." src="https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=575&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=575&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451677/original/file-20220311-23-10vpv26.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=575&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">As a test of breathability, we measured the pressure across fabrics using the same methods that are used for testing certified medical masks. The threshold for medical masks is shown with dotted lines.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1371/journal.pone.0264090">(Drouillard et. al. PLOS)</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The cloth masks included in past studies may have been haphazardly selected: their filtration, using the same methods that we used, was found to be <a href="https://doi.org/10.1016/j.ajic.2021.10.041">between 23</a> and <a href="https://doi.org/10.1371/journal.pone.0245688">52 per cent</a>. A thoughtfully designed two-layer T-shirt mask with overhead ties, tested on human volunteers, filtered <a href="https://dx.doi.org/10.1017%2Fdmp.2013.43">50 per cent of aerosols</a>, in keeping with our study, and again highlighting the importance of fit. </p>
<p>To compare like with like, when we looked at other studies, the filtration percentages that we quote above were taken from studies using a similar design: protection of a human wearer, using particles <a href="https://doi.org/10.1001/jamainternmed.2020.8168">0.02 to 3 microns</a>, <a href="https://doi.org/10.1371/journal.pone.0264090">0.02 to 1 microns</a> <a href="http://doi.org/10.1017/dmp.2013.43">and</a> <a href="https://doi.org/10.1371/journal.pone.0245688">0.02</a> <a href="https://doi.org/10.1080/15459624.2021.1925124">to 0.1</a> <a href="https://doi.org/10.1097/MD.0000000000023709">microns</a>. Other studies examining <a href="https://doi.org/10.1016/j.ajic.2021.10.041">source control</a>, using <a href="https://doi.org/10.1128/mSphere.00637-20">mannikins</a> and using <a href="http://dx.doi.org/10.15585/mmwr.mm7007e1">larger particles</a> come to similar conclusions.</p>
<p>Good masks fit well, with minimal obvious leaking at the edges. <a href="https://doi.org/10.1001/jamainternmed.2020.8168">Nosewires, overhead ties</a> or <a href="https://doi.org/10.1016/j.ajic.2021.10.041">earloop adjusters</a> all <a href="https://www.clothmasks.org/getting-best-fit">contribute to fit</a>. <a href="https://www.clothmasks.org/summary-of-advice">Two layers</a> or more, and a middle layer of non-woven <a href="https://www.clothmasks.org/polypropylene">polypropylene</a> improve overall filtration. </p>
<p><a href="https://wwwn.cdc.gov/PPEInfo/RG/FaceCoverings">Masks meeting the new U.S. Centers for Disease Control and Prevention standard</a> for community masks, <a href="https://www.astm.org/f3502-21.html">ASTM-F3502</a>, are likely to filter well, though generally not as well as respirators.</p>
<h2>N95 masks</h2>
<p>Hospitals report that the current supply of N95-type masks meets but doesn’t exceed demand, and supply of these masks is insufficient for the general population. Access and cost issues require public health and economic solutions along with consideration of <a href="https://doi.org/10.1007/s11356-021-17430-5">environmental impact</a> of disposable PPE. </p>
<p>If <a href="https://www.clothmasks.org/finding-n95-masks">buying respirators</a> for personal use, we recommend buying only what you need and practising <a href="https://www.clothmasks.org/extended-use">extended reuse</a>. If buying KN95s and equivalent certified medical masks, we advise paying close attention to the fit of the mask. We recommend <a href="https://www.clothmasks.org/double-masking">double masking</a> medical masks or using minor modifications or <a href="https://www.clothmasks.org/mask-hacks">mask hacks</a> that enhance fit and reduce leakage. </p>
<figure class="align-center ">
<img alt="A completed blue cloth mask, two masks in progress and a piece of green fabric" src="https://images.theconversation.com/files/454821/original/file-20220328-17770-13vyoj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/454821/original/file-20220328-17770-13vyoj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/454821/original/file-20220328-17770-13vyoj3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/454821/original/file-20220328-17770-13vyoj3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/454821/original/file-20220328-17770-13vyoj3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/454821/original/file-20220328-17770-13vyoj3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/454821/original/file-20220328-17770-13vyoj3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pattern and instructions for the Essex pleated mask — a two-layer, three-pleat design created by the Windsor-Essex Sewing Force — are available from West Essex Sewing Force or from clothmasks.org/patternsinstruction.</span>
<span class="attribution"><a class="source" href="https://wesf.ca/">(Windsor Essex Sewing Force)</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p><a href="https://www.clothmasks.org/patternsinstruction">Carefully designed</a>, <a href="https://www.clothmasks.org/getting-best-fit">well-fitting</a>, multilayer reusable cloth masks still have an important ongoing role in reducing transmission of SARS-CoV-2, especially in lower risk settings.</p>
<p>Protection is highest and transmission is lowest when <a href="https://www.clothmasks.org/masks-in-context">everyone wears masks</a>, because masks both protect the wearer while also <a href="https://doi.org/10.1016/j.ajic.2021.10.041">reducing the number of contaminated particles reaching the environment</a> (source control). There are important reductions to individual risk from wearing any mask, which have been <a href="http://dx.doi.org/10.15585/mmwr.mm7106e1">observed in the community</a> and <a href="https://doi.org/10.1371/journal.pone.0264090">quantified in the lab</a>. We can protect ourselves, others and vulnerable people. Let’s all wear the best mask available.</p>
<p><em>Rebecca Rudman, co-founder of the <a href="https://wesf.ca/">Windsor Essex Sewing Force</a> and member of McMaster’s Cloth Mask Knowledge Exchange, and Amanda Tomkins, an undergraduate student in engineering at McMaster University, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/177237/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Clase is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group that includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article. She is a member of McMaster's Centre of Excellence in Protective Equipment and Materials, and editor-in-chief of clothmasks.org. Catherine has received consultation, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter. In 2018 she co-chaired a KDIGO potassium controversies conference sponsored at arm's length by Fresenius Medical Care, AstraZeneca, Vifor Fresenius Medical Care, Relypsa, Bayer HealthCare and Boehringer Ingelheim. Catherine Clase receives funding from CIHR, and is a member of the Green Party, the American Society of Nephrology, the Canadian Society of Nephrology, the American Association of Textile Chemists and Colorists and ASTM International.
</span></em></p><p class="fine-print"><em><span>Charles-Francois de Lannoy receives funding from the Natural Sciences and Engineering Research Council (NSERC) of Canada, the Global Water Futures (GWF) Research organization, Ontario Centres of Excellence (OCE), Federal Economic Development Agency for Southern Ontario (FedDev), Canadian Foundation for Innovation (CFI), the French Embassy, and McMaster University. He has received funding in partnership with Pall Water, Trojan Technologies, Hatch Ltd., and PW Fabrication. He has engaged in various research projects and testing/validation of facemasks for several private companies in Ontario. He is affiliated with the Cloth Mask Knowledge Exchange as an expert advisor.</span></em></p><p class="fine-print"><em><span>Ken G. Drouillard receives funding from Natural Sciences and Engineering Research Council of Canada (NSERC), Ontario Ministry of Environment, Conservation and Parks, Environment and Climate Change Canada, Great Lakes Fisheries Commission, WE-SPARK Health Discovery Institute, University of Windsor, City of Windsor. He is affiliated with the Detroit River Canadian Clean-Up Committee and holds membership with International Association for Great Lakes Research. </span></em></p><p class="fine-print"><em><span>Scott Laengert does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We tested well-fitting cloth masks made from 16 kinds of cotton, on human participants, to see how many provided filtration comparable with a certified medical mask. Most of them did.Catherine Clase, Physician, epidemiologist, professor, McMaster UniversityCharles-Francois de Lannoy, Assistant Professor, Chemical Engineering, McMaster UniversityKen G. Drouillard, Professor, Great Lakes Institute for Environmental Research, University of WindsorScott Laengert, PhD Student, Chemical Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1772382022-03-10T20:57:37Z2022-03-10T20:57:37ZShould public health measures like masking continue beyond the pandemic? Data on viral infections shows their benefits<figure><img src="https://images.theconversation.com/files/450321/original/file-20220307-84100-jira1v.jpg?ixlib=rb-1.1.0&rect=166%2C98%2C2717%2C1675&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman wears a face mask as she walks by the sculpture ‘The Illuminated Crowd’ on a street in Montréal. Vulnerable people may benefit from measures like face masks even after the COVID-19 pandemic.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span></figcaption></figure><p>Public health measures, such as masking and physical distancing, that have been a high-profile part of the COVID-19 response for the past two years <a href="https://www.cbc.ca/news/canada/edmonton/jason-kenney-copping-alta-covid-restrictions-lift-1.6368297">are now</a> <a href="https://www.cbc.ca/news/canada/toronto/covid19-ontario-march-9-mask-mandates-1.6378148">beginning to lift</a>. However, surprisingly little attention has been paid to the remarkable effects of these measures on other respiratory illnesses that are caused or exacerbated by viral infections.</p>
<p>These effects are a valuable research discovery from the pandemic. It’s a discovery that suggests that selective, non-mandated use of public health measures like masking, physical distancing and hand-washing may have a continued role as we enter the endemic phase of COVID-19. Collectively, these measures are known as non-pharmacologic public health interventions (NPIs).</p>
<h2>Decreases in acute care</h2>
<p>Following the onset of the pandemic in March 2020, many regions around the world reported a dramatic decrease in demand for <a href="https://doi.org/10.1371/journal.pone.0252441">acute health-care services</a>, including urgent care visits to emergency departments and inpatient hospital stays.</p>
<p>Early on, this was likely driven by stringent lockdown measures, patients avoiding health-care settings due to fears of contracting COVID-19 or the perception that hospitals were overwhelmed and unable to accommodate non-emergency cases. </p>
<p>However, as public health measures were relaxed over the following months, there was a rapid rebound in health-care services for conditions such as heart disease and appendicitis. Meanwhile, the decrease persisted for respiratory illnesses attributed to <a href="http://doi.org/10.1007/s11739-022-02932-y">non-COVID-19 viruses</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A sign above a row of sinks shows an image of a man washing his hands with the message 'Clean hands keep you healthy. Wash your hands with soap and water for at least 20 seconds. Life is better with clean hands.'" src="https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450460/original/file-20220307-126102-ix8ztx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Public health measures such as masking, hand-washing and physical distancing are collectively known as non-pharmacologic public health interventions (NPIs).</span>
<span class="attribution"><span class="source">(AP Photo/David Zalubowski)</span></span>
</figcaption>
</figure>
<p>In Canada, the usual annual surge in influenza infections has not occurred during the <a href="https://doi.org/10.1016/j.lana.2021.100015">two winters since the beginning of the pandemic</a>. </p>
<p>Our research group — all front-line health-care workers — analyzed nationwide admissions data. Our analysis revealed that hospital admissions for major respiratory illnesses dropped sharply in the year following the start of the first lockdown. </p>
<p>Specifically, flare-ups of chronic obstructive pulmonary disease (COPD), a severe lung disease related to long-term smoking, and community-acquired non-COVID-19 pneumonia decreased by nearly 40 per cent across Canada <a href="http://doi.org/10.1007/s11739-022-02932-y">following the implementation of NPIs like masking and physical distancing</a>. </p>
<p>These findings were supported by another study of 15,677 patients from nine countries. That study reported a 50 per cent reduction in the hospital admissions for COPD <a href="https://doi.org/10.1371/journal.pone.0255659">following the onset of the pandemic</a>. This is not entirely surprising as <a href="https://doi.org/10.1111/resp.12780">both COPD and non-COVID-19 pneumonia</a> are often triggered by <a href="https://doi.org/10.1007/s10741-017-9614-7">common cold viruses</a>. If you are like most Canadians, you have not caught a cold in nearly two years. </p>
<h2>Impact on vulnerable patients</h2>
<p>So, what’s the big fuss about a few runny noses and colds? While a viral infection such as the common cold or influenza is unlikely to significantly harm a healthy individual, it can be <a href="https://doi.org/10.1503/cmaj.201748">debilitating and sometimes deadly</a> for someone who is <a href="https://dx.doi.org/10.1016%2FS2213-2600(18)30496-X">elderly, immunocompromised or suffering from a lung disease</a>. It can result in the need for acute care in the hospital, or even the ICU in severe cases, and some patients do not survive. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Two people in masks sitting on a park bench." src="https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=456&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=456&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=456&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=573&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=573&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450462/original/file-20220307-84591-12fhn71.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=573&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A viral infection, such as the common cold or influenza, is unlikely to significantly harm a healthy individual, but it can be debilitating and sometimes deadly for someone who is elderly, immunocompromised or living with a lung disease.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>In Canada, acute and chronic respiratory diseases are the third greatest cause of death, trailing behind only <a href="https://www150.statcan.gc.ca/n1/daily-quotidien/201126/t001b-eng.htm">cancer and heart disease</a>. This also means virally linked respiratory illnesses place a substantial burden on limited health-care resources. </p>
<p>There were several periods during the pandemic when our <a href="https://cmajnews.com/2022/01/11/covid-update-beds-duong-1095984/">health-care systems</a> were <a href="https://www.cbc.ca/news/health/tam-omicron-more-restrictions-better-masks-1.6293347">over capacity</a>, and there was a fear that hospitals would need to <a href="https://www.theglobeandmail.com/canada/article-alberta-preps-critical-care-triage-plan-amid-surge-in-covid-19-cases/">triage resources</a> and deny ICU care to some critically ill patients. </p>
<p>Thankfully, this did not come to pass, and it seems that the likely reason was the significant additional capacity that became available due to hospitalizations avoided for other <a href="http://doi.org/10.1007/s11739-022-02932-y">virally linked respiratory illnesses</a>.</p>
<h2>Ending COVID-19 prevention measures</h2>
<p>As the pandemic drags on, people have become fatigued with ongoing public health restrictions. With <a href="https://ourworldindata.org/covid-vaccinations">vaccination rates in Canada among the highest in the world</a> and expected to reach even higher with the <a href="https://www.canada.ca/en/public-health/services/vaccination-children/making-decisions-5-11-years-age.html">approval of vaccinations for pediatric populations</a>, many are looking forward to a time when NPIs may no longer be needed. </p>
<p>However, before dispensing with the measures entirely, it is important to consider whether their demonstrated benefits warrant continued use. The fact that hospitalizations for non-COVID-19 respiratory illnesses have remained low, despite the relaxation of stringent lockdown measures, suggests that these benefits may be sustained with the use of masking and practices such as frequent hand-washing. </p>
<figure class="align-center ">
<img alt="Close-up image of a red social distancing circle on asphalt, with two shoe-prints and the message 'Please keep 2M distance'" src="https://images.theconversation.com/files/450465/original/file-20220307-109743-4ln58a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/450465/original/file-20220307-109743-4ln58a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/450465/original/file-20220307-109743-4ln58a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/450465/original/file-20220307-109743-4ln58a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/450465/original/file-20220307-109743-4ln58a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/450465/original/file-20220307-109743-4ln58a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/450465/original/file-20220307-109743-4ln58a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is no consensus on which specific NPIs may be most effective in preventing disease spread.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Even prior to the pandemic, <a href="https://www.asiapacific.ca/publication/great-mask-divide-lessons-asia">public masking was a common practice</a> in many Asian countries. With this now being the norm in Canada as well, continuing these practices may have significant merit and offer protection to the most vulnerable demographics of our society. </p>
<p>This will certainly be challenging given <a href="https://www.reuters.com/world/americas/canadian-cities-brace-more-anti-vaccine-mandate-protests-2022-02-05/">opposition from a vocal minority</a> and the lack of awareness among the general public about the benefits of continuing use of NPIs. Currently, most available evidence is largely observational, as no randomized trials have yet evaluated the efficacy of NPIs for reducing non-COVID-19 viral respiratory illnesses at a population level. </p>
<p>Additionally, there is no consensus on which specific NPIs may be most effective in preventing disease spread. It’s also unknown whether reductions in acute care use have translated into a reduction in mortality rates for specific conditions. </p>
<h2>Future prevention</h2>
<p>These limitations are currently being addressed in a large-scale Albertan study of over 500,000 patients. The preliminary results — which will be published in the proceedings of the 2022 American Thoracic Society International Conference — show that NPIs are an effective strategy for preventing both acute care visits and mortality related to respiratory illnesses. </p>
<p>However, in the interim, public policy-makers should consider this compelling evidence and weigh in on whether the continued use of masking and other NPI measures is warranted, especially for individuals at high-risk for serious illness from viral respiratory infections and those close to them. </p>
<p>Recommendations, policies or, if deemed necessary, mandates can be amended in the future as new evidence emerges. Until then, NPI use, even on an interim basis, may reduce the strain on our health-care system and help protect the most vulnerable members of our society.</p><img src="https://counter.theconversation.com/content/177238/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Decreases in respiratory infections during the pandemic suggest there may be a continued role for the selective, non-mandated use of measures like masks and social distancing even post-COVID-19.Rutvij A. Khanolkar, Medical Student, University of CalgaryEddy S. Lang, Professor, Cumming School of Medicine, University of CalgaryLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1756252022-02-17T13:12:05Z2022-02-17T13:12:05ZWant better child care? Invest in entrepreneurial training for child care workers<figure><img src="https://images.theconversation.com/files/445730/original/file-20220210-1970-unavhe.jpg?ixlib=rb-1.1.0&rect=20%2C0%2C6689%2C4476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Entrepreneurial leadership values expertise from providers, educators and parents. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/license/886934186?adppopup=true"> SDI Productions/E+ via Getty Images</a></span></figcaption></figure><p>Christine Heer – a veteran preschool teacher – had long harbored a passion to run a nature-based preschool. So in 2015 she opened <a href="https://www.growbloomandthrive.com/">Sprouts Farm and Forest Kindergarten</a> in central Massachusetts.</p>
<p>Diana Stinson did something similar in 2018 when she co-founded <a href="https://www.massaudubon.org/get-outdoors/wildlife-sanctuaries/long-pasture/programs-classes-activities/nature-preschool">Nature Explorers Preschool</a>, which is housed on a wildlife sanctuary on Cape Cod.</p>
<p>Five months into the COVID-19 pandemic, <a href="https://blogs.umb.edu/earlyed/2020/07/08/building-community/">Dottie Williams</a>, a Boston child care provider, was invited to testify before Massachusetts lawmakers. She spoke about how child care providers were <a href="https://www.salemnews.com/news/state_news/covid-19-forcing-innovation-at-child-care-centers/article_b608ff39-c7ef-5e78-b7fa-20f7c3b11305.html">helping children adapt</a> during the pandemic.</p>
<p>In the fall of 2021, as very young children exhibited anxiety about playing with other children without a mask – something they had previously been taught was unsafe – <a href="https://blogs.umb.edu/earlyed/2021/11/08/teaching-young-children-about-post-pandemic-social-interaction/">Emilee Johnson</a> wrote a <a href="https://blogs.umb.edu/earlyed/2021/11/08/teaching-young-children-about-post-pandemic-social-interaction/">children’s book</a> about <a href="https://eyeonearlyeducation.org/2021/07/27/a-book-for-young-children-on-the-pandemics-new-normal/">how to stay safe</a>.</p>
<p>All of these early educators have one thing in common – they were all trained in entrepreneurial leadership.</p>
<h2>A different kind of leadership</h2>
<p>As a researcher who studies <a href="https://scholar.google.com/citations?user=58-4rKcAAAAJ&hl=en&oi=sra">how to develop effective leadership skills among early childhood educators</a>, I know that <a href="https://www.tcpress.com/leading-for-change-in-early-care-and-education-9780807758359">entrepreneurial leadership training</a> is not like other kinds of leadership training. For instance, it doesn’t emphasize hierarchy. Rather than elevate the expertise of administrators and authorities, it recognizes the expertise of those who work directly with children – that is, the child care providers, educators and parents. </p>
<p>When directors and administrators of early learning centers are trained in entrepreneurial leadership, <a href="https://files.eric.ed.gov/fulltext/ED593623.pdf">innovation becomes a bigger part</a> of what they do. They build relationships that <a href="https://www.acf.hhs.gov/sites/default/files/documents/opre/ccl-report-summary-508_qc.pdf">value “curiosity, questions, and reflections about current practices,”</a> according to a 2021 federal report. Staff members contribute ideas to improve teaching practices, enhance program quality, implement strategies for improving workplace culture, promote equity and welcome feedback from parents. </p>
<h2>Benefits to children</h2>
<p>Children benefit when early educators are trained in <a href="https://doi.org/10.1186/s40723-022-00095-z">entrepreneurial leadership</a>, research <a href="https://www.acf.hhs.gov/sites/default/files/documents/opre/understanding-leadership-ECE-march-2021.pdf">shows</a>. This is largely because classroom quality is <a href="https://doi.org/10.1080/02568543.2012.739589">connected to</a> the improved workplace culture, parental engagement and support for experimentation – all things brought about by entrepreneurial leadership. The quality of leadership and the organizational climate set by early educational leaders are “<a href="https://doi.org/10.1080/02568540709594621">critical variables</a>” for the quality of early education.</p>
<p>Entrepreneurial leadership training transforms how early educators think. It leads them to <a href="https://doi.org/10.1007/s10643-017-0871-9">redefine leadership</a>. They begin to see leadership as collaborative and purpose-driven rather than hierarchical.</p>
<p>Some early educators use their new skills and confidence to open new schools, as Stinson and Heer did. Some develop new resources for educators, as Johnson did. Some become highly effective advocates, as Williams has. But most early educators trained in this form of leadership return to their programs to make <a href="https://doi.org/10.1186/s40723-022-00095-z">seemingly small but powerful changes</a> that result in better care and education for children.</p>
<h2>Opportunities limited</h2>
<p>Despite the positive effects of entrepreneurial leadership training, it’s not widely available. One survey found only <a href="https://goffinstrategygroup.com/wp-content/uploads/2021/10/2021-Early-Care-and-Education-Leadership-Development-Compendium.pdf">35 leadership programs</a> for early educators in the entire country. Of those, 32 focus on the “positional responsibilities” of directors and administrators.</p>
<p>As the pandemic continues to <a href="https://www.tbf.org/news-and-insights/reports/2021/dec/when-the-bough-breaks-20211213">disrupt early care and education programs</a>, with <a href="https://edpolicy.umich.edu/sites/epi/files/uploads/BPS_ECE_COVID_Policy_Brief.pdf">reduced student enrollment</a> and teachers <a href="https://www.washingtonpost.com/business/2021/09/19/childcare-workers-quit/">leaving the profession</a> because of fears of exposure to COVID-19, resources must be used wisely. Investing in entrepreneurial leadership training for early educators is one way to make sure that happens.</p>
<p>[<em>Interested in science headlines but not politics? Or just politics or religion?</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-interested">The Conversation has newsletters to suit your interests</a>.]</p><img src="https://counter.theconversation.com/content/175625/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anne Douglass receives funding from the Massachusetts Department of Early Education and Care, and the Office of Planning, Research, and Evaluation at the Administration for Children and Families in the U.S. Department of Health and Human Services, as well as the Robert Wood Johnson Foundation and The Boston Foundation.
Anne Douglass designs, implements, and evaluates leadership development programs in the early care and education sector.
</span></em></p>When early childhood education providers become more entrepreneurial, the quality of their programs improves, research shows.Anne Douglass, Professor of Early Care and Education Leadership, Policy, and Practice, UMass BostonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1705462021-11-10T01:42:08Z2021-11-10T01:42:08ZHow to help your child get the most protection out of their face mask<figure><img src="https://images.theconversation.com/files/430923/original/file-20211108-25-1we6tgj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-face-mask-going-back-school-1751409791">Shutterstock</a></span></figcaption></figure><p>With many children around the country required to wear masks in classrooms, including <a href="https://www.coronavirus.vic.gov.au/face-masks">those as young as eight in Victoria</a>, parents are wondering how they can support their kids’ mask use.</p>
<p>Schools are a breeding ground for respiratory viruses. When a large number of people are gathered together for extended periods of time within indoor areas, it’s a perfect recipe for aerosol transmission. </p>
<p>Along with proper ventilation, physical distancing and good hygiene, face masks can help reduce the spread of COVID.</p>
<p>So what masks are best for kids? And how can children increase the likelihood their mask will protect them from COVID?</p>
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<p>
<em>
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Read more:
<a href="https://theconversation.com/from-vaccination-to-ventilation-5-ways-to-keep-kids-safe-from-covid-when-schools-reopen-166734">From vaccination to ventilation: 5 ways to keep kids safe from COVID when schools reopen</a>
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<h2>Masks cut COVID transmission</h2>
<p>The dominant route for COVID transmission is through the inhalation of infectious aerosols. When someone with COVID coughs, sneezes, talks or even breathes, they are exhaling scores of tiny virus-laden particles into the air that others around them can breathe in. </p>
<p>Evidence from the <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7039e3.htm?s_cid=mm7039e3_w">United States</a> shows wearing masks in classrooms may reduce the chance of children contracting COVID from their classmates. Regions with school mask mandates have roughly half the rates of COVID infection among children than those without.</p>
<p>While randomised clinical studies focusing on mask use in schools are not available, data from <a href="https://www.poverty-action.org/publication/impact-community-masking-covid-19-cluster-randomized-trial-bangladesh">larger community mask use</a> trials support their ability to reduce the number of symptomatic COVID cases in the community.</p>
<figure class="align-center ">
<img alt="Afrian Australian child in a light pink top wearing a mask stands in front of a brick wall." src="https://images.theconversation.com/files/430932/original/file-20211108-19-g2sext.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/430932/original/file-20211108-19-g2sext.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430932/original/file-20211108-19-g2sext.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430932/original/file-20211108-19-g2sext.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430932/original/file-20211108-19-g2sext.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430932/original/file-20211108-19-g2sext.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430932/original/file-20211108-19-g2sext.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Masks stop infected children releasing the virus, and other children inhaling viral particles.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/student-wearing-surgical-face-mask-backpack-1800931201">Shutterstock</a></span>
</figcaption>
</figure>
<p>The World Health Organization <a href="https://www.who.int/news-room/q-a-detail/q-a-children-and-masks-related-to-covid-19">recommends</a> mask use in students 12 years or older, and in students from six to 11 years old under appropriate supervision. </p>
<p>Masks <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2776928">don’t impact the air exchange in children</a> or their ability to breathe, so they’re safe to use. However, masking students with specific needs should be evaluated on a case-by-case basis.</p>
<p>Mask use in children aged five and younger is not recommended, in part because facial expressions are important for <a href="https://doi.org/10.3389/fpsyg.2021.669432">social and emotional learning</a>.</p>
<h2>What masks are best for kids?</h2>
<p>When selecting a mask, pay close attention to the fit; a mask will lose much of its effectiveness if it’s not worn appropriately. There shouldn’t be any gaps around the nose or along the sides of the face. </p>
<p>While many masks are capable of preventing the release of large droplets in those who are infected, a tighter fit will improve the filtration of the smaller aerosol particles. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/cant-get-your-kid-to-wear-a-mask-here-are-5-things-you-can-try-166648">Can't get your kid to wear a mask? Here are 5 things you can try</a>
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<hr>
<p>Of the available mask varieties, N95 or P2 types have the best filtration efficiency, capturing more than 95% of particles. Though they need to be tested to ensure a proper fit to be most effective, and they may prove uncomfortable when worn for long periods.</p>
<p>Surgical masks (the disposable kind you can buy at supermarkets and pharmacies) are the next best at filtration, with <a href="https://informedfutures.org/wp-content/uploads/Improving-mask-use-to-reduce-Covid-19-transmission.pdf">efficiencies from 50–75%</a>. </p>
<p>Surgical mask efficiency can be improved if a tighter fit is created around the face, such as by wearing the surgical mask underneath a cloth mask, or through the “knot & tuck” method.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/m1yzpmqVF34?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Here’s what we mean by knot & tuck.</span></figcaption>
</figure>
<p>While useful for older students, N95s and most surgical masks may not be as effective in protecting young children, as many of these masks were designed for adults. </p>
<p>Cloth varieties, on the other hand, usually fit children much better. Being able to use fun prints and colours can help kids feel more comfortable with mask-wearing.</p>
<p>However, single-layer cloth masks are typically not recommended due to their low filtration efficiency. <a href="https://youtu.be/iYE0A-5wd14">Well-fitting triple-layered masks</a> are much better, and they are as effective as surgical varieties.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/iYE0A-5wd14?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Three layers are better than one.</span></figcaption>
</figure>
<h2>Tips for young mask-wearers</h2>
<p>The recommendations for children’s mask use mirror those for adults, so:</p>
<ul>
<li><p>try to avoid touching the outside of the mask. This means using the ear loops to put on and remove the mask. If the mask is doing its job effectively, there <a href="https://link.springer.com/article/10.1186/s12879-019-4109-x">could be virus particles on the outside of the mask</a>. Always wash or sanitise hands after touching the mask</p></li>
<li><p>use a separate bag for storage. It’s important that a mask does not contaminate or be contaminated by other items</p></li>
<li><p>ensure the mask covers both the mouth and nose</p></li>
<li><p>wash cloth masks after every use. It may help to have several cloth masks so a fresh one can be used daily</p></li>
<li><p>throw out surgical and N95 masks after each use</p></li>
<li><p>don’t use a mask with valves. These won’t prevent an infected person spreading the virus.</p></li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/7-tips-for-making-masks-work-in-the-classroom-164777">7 tips for making masks work in the classroom</a>
</strong>
</em>
</p>
<hr>
<h2>Focus on masks indoors</h2>
<p>While the advice might feel relatively complicated, research shows that even children in the first two years of school are <a href="https://doi.org/10.1111/josh.13033">very compliant with mask guidelines</a>, using them appropriately for 77% of the school day, on average. </p>
<p>For best results, instructions on mask use and safety are needed alongside the rollout of masks in schools. </p>
<p>The use of masks is less important during outside recess and breaks, because outdoor areas are generally well-ventilated. </p>
<p>In indoor areas where masks can’t be used, such as during lunch, physical distancing is encouraged.</p><img src="https://counter.theconversation.com/content/170546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joel Rindelaub does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>It’s important kids’ masks fit well and are removed and stored properly.Joel Rindelaub, Research Fellow, School of Chemical Sciences, University of Auckland, Waipapa Taumata RauLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1653642021-08-15T11:50:03Z2021-08-15T11:50:03ZFacts, fears and the evolution of masking throughout the COVID-19 pandemic<figure><img src="https://images.theconversation.com/files/415679/original/file-20210811-15-za6fe6.jpg?ixlib=rb-1.1.0&rect=33%2C0%2C7445%2C4978&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A group of people are out for a walk during COVID-19 in Milan, Italy.</span> <span class="attribution"><span class="source">(Matteo Jorjoson/Unsplash)</span></span></figcaption></figure><p>Do you remember the beginning of the pandemic, when for months a major debate was whether people should or shouldn’t wear a mask? </p>
<p>Around March 2020, I <a href="https://safecast.org/covid19/">made my own mask using directions I found online</a>. I was the only masked customer at my local grocery store the day I made it, but instead of following an impulse to rip it off and stuff it in my back pocket when the eyes of the maskless set on me, I thought: why don’t I turn this into a research opportunity?</p>
<p>I turned on my phone’s voice memo recorder and made audio notes about my experiences, narrating my way around customers veering their carts and between dwindling stocks of bathroom tissue and instant yeast. Listening to my notes, I appear to have pondered: </p>
<blockquote>
<p>“Why am I the only one wearing a mask? … My voice sounds weird in this. I feel like I’m breathing through a straw. I don’t know. It’s kind of comfortable, I guess. Are people actually looking at me? I can’t tell. It’s when the rules start to change that everyone notices basic things like walking and what we do with our faces.” </p>
</blockquote>
<p>The rules didn’t seem to change for everyone. Canada took time before recommending the public wear masks — Dr. Theresa Tam, Canada’s chief medical officer, <a href="https://www.theglobeandmail.com/canada/article-tam-offers-new-advice-wear-a-non-medical-mask-when-shopping-or-using/">first recommended homemade masks while using public transit and shopping in early April 2020</a>.</p>
<p>After my first masked day, I slowly saw faces vanish under cotton folds, and have since made hundreds of hours of audio notes on masks and mask culture, mask debates and mask challenges, in something I’m calling <em>the new maskscape</em>. </p>
<h2>Masking up: A tangled web of facts and fears</h2>
<p>Why did it take Canada as long as it did to start advising people to wear masks? Part of the reason is that masks were incorporated into our reopening period (May-August 2020) since at-home isolation <a href="https://voxeu.org/article/face-mask-mandates-slowed-spread-covid-19-canada">required little use of a mask</a>. Early in the pandemic, from February to April 2020, the global story related to masks was a tangled web of facts and fears:</p>
<ul>
<li><p>Fact: <a href="https://doi.org/10.1016/j.ssci.2020.104830">There was a worldwide shortage of masks</a>.</p></li>
<li><p>Fear: <a href="https://dx.doi.org/10.3390%2Fma13153339">Hospitals would run out of medical supplies</a>.</p></li>
<li><p>Fact: <a href="https://dx.doi.org/10.1016%2Fj.ijid.2020.06.098">Emergent research was concluding that COVID-19 could possibly spread through asymptomatic carriers</a>.</p></li>
<li><p>Fear: This information could lead to a full-scale global panic, so that <a href="https://doi.org/10.1016/S2213-2600(20)30134-X">the already dwindling supplies in masks would be completely overtaken and exhausted</a>.</p></li>
<li><p>Fear: The result — <a href="https://doi.org/10.1016/S2468-2667(20)30060-8">the total collapse of the global medical system</a>.</p></li>
</ul>
<figure class="align-center ">
<img alt="A pile of various coloured masks" src="https://images.theconversation.com/files/415677/original/file-20210811-23-1p0jajv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415677/original/file-20210811-23-1p0jajv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415677/original/file-20210811-23-1p0jajv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415677/original/file-20210811-23-1p0jajv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415677/original/file-20210811-23-1p0jajv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415677/original/file-20210811-23-1p0jajv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415677/original/file-20210811-23-1p0jajv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canada took some time before recommending that the public wear masks.</span>
<span class="attribution"><span class="source">(Anton/Unsplash)</span></span>
</figcaption>
</figure>
<p>If the World Health Organization (WHO) and other professional medical venues <a href="https://doi.org/10.1007/s10900-021-00971-8">were expressing a certain ambivalence towards the mask</a>, a global DIY community of scientists, mask manufacturers and mask makers, social media influencers, celebrities and community members pushed for its widespread adoption. </p>
<h2>The case of the Czech Republic</h2>
<p>Influencers in the Czech Republic were amongst the first to start publicly and globally campaigning for people to wear masks. YouTuber Petr Ludwig <a href="https://www.youtube.com/watch?v=2_8hojsF-nY">posted a video referring to a University of Cambridge study</a> that recommended people wear homemade masks to reduce the spread — emphasizing that masks were intended, in such a situation, <a href="https://dx.doi.org/10.1017/dmp.2013.43">to protect the community and not the masked individuals themselves</a>.</p>
<p>As people were on stay-at-home orders and perhaps paying more attention to social media, they heard the call to start making masks at home. In the Czech Republic, influencers donned masks and spread messages with the hashtag <a href="https://masks4all.co/">#Masks4All</a>, <a href="https://doi.org/10.1136/bmj.m3021">which hit global sewing circles in a matter of days</a>. </p>
<p>The #Masks4All hashtag resulted in a national call to make masks, to convert factories into workstations and to <a href="https://doi.org/10.1177/1536504220950404">share mask design instructions</a>. People worldwide responded to this call: They began making masks, delivering many to frontline workers and <a href="https://people.com/human-interest/woman-hangs-masks-on-tree-social-distancing-coronavirus/">leaving them hanging in public on “Mask trees”</a>.</p>
<p>It took about a week for the #Masks4All hashtag to go online and by April 2020, 36 countries followed suit. Canada hopped on board in early April with its recommendation to wear masks on public transit and while shopping, then announced on May 20 that Canadians <a href="https://www.cbc.ca/news/politics/masks-covid-19-pandemic-public-health-1.5576895">should consider wearing masks when unable to social distance</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2_8hojsF-nY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">YouTuber Petr Ludwig makes the case for using DIY masks.</span></figcaption>
</figure>
<h2>Valuing masks</h2>
<p>As mask policies were put in place globally, certain values began to emerge. In Canada, those who came to be mask compliant were generally aware of the reasons people were asked to wear them. An exploratory survey with questions on attitudes to mask-wearing, <a href="https://www.csa-scs.ca/conference/paper/the-new-canadian-maskscape-preliminary-remarks-on-an-emerging-technology-of-health/">which I conducted in November 2020 (the findings, yet to be published)</a>, indicated respondents were in line with a community health model of reasoning.</p>
<p>Responses indicated that their attitudes were in line with the values that mask-wearing performs. This was often expressed in common phrases that were explicitly relational, affective and community-driven: “to protect others as well as myself,” “to protect the vulnerable,” “wearing a mask is ‘the right thing to do’,” that it promotes “social responsibility” and sets a “good example.” </p>
<p>Answers also included that wearing a mask was “common sense” and a few times respondents mentioned that it “keeps my face warm.” I still have that first mask I made. It’s a reminder of the kind of performance and ritual that the mask has become. </p>
<p>But is science ever stable? Recently, the chief medical officer of Alberta has announced that the province will begin to relax social distancing measures, <a href="https://edmonton.ctvnews.ca/dr-hinshaw-explains-alberta-s-easing-of-mandatory-masks-isolation-requirements-1.5527391">including revoking mandatory mask mandates</a> (except in schools). </p>
<p>The situation is obviously still changing, as we likely settle into a long-term relationship with COVID-19. This new relationship will not likely leave masks forgotten. Instead, masks may become more complex, political and performative. Science informs how governments, communities and the media make the best decisions for themselves and one another.</p><img src="https://counter.theconversation.com/content/165364/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mickey Vallee does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As we likely settle into a long-term relationship with COVID-19, this new relationship will not likely leave masks forgotten.Mickey Vallee, Associate Professor and Canada Research Chair (Tier II) in Community, Identity and Digital Media, Athabasca UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1564562021-03-07T14:35:47Z2021-03-07T14:35:47ZStates drop COVID-19 mask mandates but still expect people to mask up – will they?<figure><img src="https://images.theconversation.com/files/388141/original/file-20210306-13-19um44d.jpg?ixlib=rb-1.1.0&rect=32%2C0%2C3573%2C2257&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Texas' announced it is ending its COVID-19 restrictions. Its vaccination rate is among the lowest in the U.S., and its case numbers are still high.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/san-jose-hotel-engineering-manager-rocky-ontiveros-wears-a-news-photo/1231493646">Montinique Monroe/Getty Images</a></span></figcaption></figure><p>The <a href="https://open.texas.gov/uploads/files/organization/opentexas/EO-GA-34-opening-Texas-response-to-COVID-disaster-IMAGE-03-02-2021.pdf">governors of Texas</a> and <a href="https://www.sos.ms.gov/content/executiveorders/ExecutiveOrders/1549.pdf">Mississippi</a> announced that they were rescinding their statewide mask mandates and allowing restaurants and other businesses to return to 100% capacity in early March. The moves come while new infection numbers in the U.S. <a href="https://covid.cdc.gov/covid-data-tracker/#trends_dailytrendscases">are still higher</a> than they were in September and just ahead of school spring breaks, known for large gatherings and crowded bars where the <a href="https://doi.org/10.1016/j.jue.2020.103311">coronavirus can quickly spread</a>.</p>
<p>Along with <a href="https://www.aarp.org/health/healthy-living/info-2020/states-mask-mandates-coronavirus.html#Iowa">Iowa</a>, <a href="https://news.mt.gov/governor-gianforte-issues-new-directives-executive-order">Montana</a> and <a href="https://www.thedickinsonpress.com/news/government-and-politics/6846684-As-statewide-mandate-expires-North-Dakota-cities-hang-onto-mask-requirements">North Dakota</a>, which recently lifted their mask orders, these states are part of an emerging trend of some states bucking national and international public health recommendations. </p>
<p><a href="https://www.cnbc.com/2021/03/04/alabama-gov-ivey-lifts-statewide-covid-mask-mandate-beginning-april-9.html">Alabama</a> and <a href="https://www.sltrib.com/news/2021/03/06/utahs-mask-mandate-will/">Utah</a> plan to end their mask requirements in April. <a href="https://governor.wyo.gov/media/news-releases/2021-news-releases/governor-gordon-announces-removal-of-statewide-mask-requirement-lifts-all">Wyoming</a>’s governor announced on March 8 that he would drop his mask order, too.</p>
<p>Residents and visitors in these states will face a situation where masks are no longer required. Yet, many of the <a href="https://www.dallasnews.com/news/politics/2021/03/04/gov-abbott-ended-texas-mask-mandate-without-input-from-all-his-covid-19-medical-advisors/">same governors lifting the mandates</a> are still urging people to take precautions. </p>
<p>These mixed messages can be confusing. Dropping mask mandates and capacity limits contradicts public health recommendations that were established to <a href="https://www.cdc.gov/coronavirus/2019-ncov/your-health/need-to-know.html">impede the spread of COVID-19</a>. Research shows the public health effect of wearing masks is clear: <a href="http://doi.org/10.1016/j.annepidem.2021.02.006">Mask mandates reduce the spread of COVID-19</a>. </p>
<p>As <a href="https://scholar.google.com/citations?user=G7AWX0QAAAAJ&hl=en">public</a> <a href="https://scholar.google.com/citations?user=me4Q9y4AAAAJ&hl=en">health</a> <a href="https://temag.tamu.edu/directory/walter-t-casey/">researchers</a>, we study how changing policies have affected the trajectory of the pandemic in the U.S. The end of mask mandates and other restrictions poses three important questions about responsibility, safety and public health. </p>
<h2>What does it mean for individual responsibility?</h2>
<p>Hearing from state leaders that there is no longer a mandate to wear a mask, but that individuals should choose to wear masks and remain vigilant, can be confusing.</p>
<p>If the end of stay-at-home orders last summer and <a href="https://doi.org/10.3389/fcomm.2019.00056">resistance</a> to <a href="https://doi.org/10.1016/j.paid.2020.110491">health guidelines</a> over time are any indication of <a href="https://theconversation.com/covid-19-messes-with-texas-what-went-wrong-and-what-other-states-can-learn-as-younger-people-get-sick-141563">what to expect</a>, mask wearing will fall rapidly without a mandate. The <a href="https://www.bloomberg.com/opinion/articles/2020-06-25/coronavirus-in-texas-covid-19-gives-greg-abbott-a-reality-check">result will likely be less compliance</a> with other practices to reduce COVID-19 spread in public places, such as social distancing, and a related uptick in cases.</p>
<figure class="align-center ">
<img alt="Vistors, many without masks, walk the beachfront boardwalk" src="https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388144/original/file-20210306-17-vfbrpz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Ocean City, Maryland, boardwalk filled up quickly in May 2020 after the town dropped many of its COVID-19-related restrictions. The state now has a mask mandate and doesn’t plan to lift it soon.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-enjoy-the-boardwalk-during-the-memorial-day-holiday-news-photo/1214812758">Alex Edelman/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>This effect may be even stronger when residents’ <a href="https://www.pewresearch.org/politics/2020/06/25/republicans-democrats-move-even-further-apart-in-coronavirus-concerns/">political affiliation is considered</a>, as ending a mask mandate could be viewed as the partisan difference between the belief in working collectively to protect each other and <a href="https://www.nbcnews.com/think/opinion/covid-vaccine-mask-conspiracies-succeed-when-they-appeal-identity-ideology-ncna1251761">the fear that mandates</a> limit individual freedoms. And if <a href="http://doi.org/10.1056/NEJMp2100351">polling</a> about <a href="https://www.cbc.ca/news/canada/toronto/anti-masking-group-tied-to-anti-vaccination-covid-19-1.5661790">vaccine hesitancy</a> is an indicator, when mask mandates are loosened, it is not unreasonable to expect <a href="https://www.vox.com/science-and-health/21546014/mask-mandates-coronavirus-covid-19">mask wearing to be cut in half</a> – <a href="https://www.prnewswire.com/news-releases/83-of-americans-report-that-they-always-wear-a-face-mask-when-out-in-public-according-to-new-state-by-state-survey-findings-from-slickdeals-301164658.html">or decline even more</a>. </p>
<h2>Does it mean that residents of these states are now safer from COVID-19 risks?</h2>
<p>The short answer is “no.” The message that masks are no longer required may lead to a false sense of increased safety from the virus. </p>
<p>Yet, new daily cases and hospitalizations for COVID-19 in the U.S., and particularly in Texas, were <a href="https://coronavirus.jhu.edu/data/state-timeline/new-confirmed-cases/texas">higher on March 1, 2021, than they were on Oct. 1, 2020</a>. Unfortunately, several more-contagious variants of the virus are also now starting to spread – <a href="https://www.houstonchronicle.com/news/houston-texas/health/article/Houston-is-first-city-to-record-all-major-COVID-15990299.php">Houston has had cases of all the major variants</a>. Wearing masks is a known and effective barrier that reinforces the immunity gained from vaccinations or illness recovery and avoid spreading viruses.</p>
<p>While no state is fully vaccinated yet, Texas and Mississippi have an even longer way to go than most. They <a href="https://covid.cdc.gov/covid-data-tracker/#vaccinations">rank 45th and 44th</a> among states by the percentage of their population fully vaccinated. Vaccinations are also only <a href="https://www.statnews.com/2021/02/10/vaccines-alone-wont-end-pandemic/">one piece</a> of the public health response.</p>
<p>Public health guidance still recommends vaccinated people wear masks, practice social distancing and wash their hands to avoid spreading the coronavirus to those who are not protected. <a href="https://doi.org/10.1186/s40249-020-00759-3">These mitigation efforts have been shown to work</a>, especially when applied consistently and broadly.</p>
<p><iframe id="lFl6N" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/lFl6N/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Several studies have demonstrated a decline in infection rates from having mask mandates in place. A <a href="http://dx.doi.org/10.15585/mmwr.mm7010e3">study released March 5</a> by the Centers for Disease Control and Prevention found that implementing mask mandates had been associated with a drop in the growth of daily COVID-19 cases within 20 days of being implemented, while allowing in-restaurant dining was associated with an increase in daily cases. Another study determined that mask mandates in 15 states and the District of Columbia helped <a href="https://doi.org/10.1377/hlthaff.2020.00818">avoid more than 200,000 cases</a> in April and May 2020.</p>
<p>“With the emergence of more transmissible COVID-19 variants, community mitigation measures are increasingly important as part of a larger strategy to decrease exposure to and reduce transmission of SARS-CoV-2,” the CDC authors wrote. </p>
<h2>Why isn’t there a consistent message?</h2>
<p>Rescinding the mask order also places burdens on businesses to decide which, if any, guidelines to follow. </p>
<p>Not surprisingly, education and health care have generally responded in favor of <a href="https://www.nbcnews.com/news/us-news/texas-doctors-say-gov-greg-abbott-s-decision-scrap-mask-n1259513">continuing to require masks and follow public health guidelines</a>. Some other industries and retailers took the opportunity to <a href="https://www.houstonpublicmedia.org/articles/news/business/2021/03/03/392771/heres-how-retail-chains-are-responding-to-texas-lifting-its-covid-19-mask-mandate/">revise their COVID-19 policies</a>. </p>
<p><iframe id="ylmXy" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ylmXy/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Businesses in some areas <a href="https://www.texastribune.org/2021/03/07/texas-businesses-masks-threats/">have faced</a> <a href="https://www.texastribune.org/2020/05/22/texas-coronavirus-masks/">a backlash</a> for requiring patrons to wear masks when the state did not mandate it. Those that operate in multiple states may also need to address differing mask requirements and balance the public health and business cases for masks. Federal requirements for wearing masks on airplanes and certain other places can further confound business operations when patrons are unclear about the requirements and potential for penalties if they do not comply.</p>
<h2>Past experience shows the value of mandates</h2>
<p>Already, Texas is seeing the result of the state rescinding its mask mandate and gathering restrictions as <a href="https://www.dallasnews.com/news/politics/2021/03/02/tarrant-county-ends-its-mask-mandate-after-texas-gov-greg-abbott-says-statewide-covid-19-orders-will-end-next-week/">municipalities follow suit</a>. </p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>We know from earlier attempts to rely on personal responsibility, <a href="https://www.history.com/news/seat-belt-laws-resistance">like seat belt laws</a>, as well as with <a href="https://www.washingtonpost.com/lifestyle/food/when-it-comes-to-nutrition-were-all-too-eager-to-ignore-the-evidence-heres-why/2020/02/23/d4dd8534-54a8-11ea-9e47-59804be1dcfb_story.html">nutrition</a> choices and <a href="https://www.who.int/bulletin/archives/78(7)902.pdf">tobacco use</a>, that some people <a href="https://doi.org/10.1016/j.glt.2020.06.003">will do the safe thing</a> only if <a href="http://doi.org/10.1016/j.socscimed.2013.10.035">the law requires</a> it. </p>
<p>After all, people tend to follow the maxim that “<a href="https://www.jstor.org/stable/40711861">what isn’t forbidden is permitted</a>.”</p>
<p><em>This story was updated March 9 with Wyoming also planning to lift restrictions.</em></p><img src="https://counter.theconversation.com/content/156456/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The COVID-19 case spike in the summer of 2020 and earlier attempts to rely on personal responsibility, like wearing seat belts, showed that mandates make a difference.Murray J. Côté, Associate Professor of Health Policy and Management, Texas A&M UniversityTiffany A. Radcliff, Associate Dean for Research and Professor of Health Policy and Management, Texas A&M UniversityWalter Thomas Casey II, Associate Professor of Political Science, Texas A&M University-TexarkanaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1554502021-02-17T04:40:12Z2021-02-17T04:40:12ZVictoria’s statewide lockdown ends. Data can tell us what to do next time<p>Victorian Premier Daniel Andrews announced today the state’s five-day circuit-breaker lockdown would end at midnight tonight. The state’s health department reported zero new cases overnight from nearly 40,000 tests — the highest number of daily tests recorded in Victoria since the start of the pandemic.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1361790297232076801"}"></div></p>
<p>Under the latest changes:</p>
<ul>
<li>the “four reasons to leave your home” rule will lift</li>
<li>so does the 5km travel limit</li>
<li>masks are still mandatory indoors when away from home</li>
<li>masks are still mandatory outdoors when you can’t physically distance</li>
<li>schools, hospitality and retail can reopen on Thursday</li>
<li>household gatherings will be restricted to five guests (but 20 outdoors).</li>
</ul>
<p>Around 3,400 close contacts remain in isolation, some of whom may yet return positive tests before the end of their quarantine period.</p>
<p>Victoria’s lockdown is the latest in a string of recent shutdowns, following similar circuit-breakers in South Australia, Queensland and Western Australia. </p>
<p>Andrews said a five-day lockdown is “infinitely better” than taking a chance and ending up with a five-week lockdown or worse.</p>
<p>But in truth, we don’t know for sure what that chance is.</p>
<p>The fact Victoria uses comprehensive “contacts of contacts” tracing means we have rich data to explore how testing and tracing would stand up under more dire transmission scenarios involving the UK variant and a multi-case seeding event.</p>
<p>Mapping case and contact quarantine timing and overlaying this with various transmission scenarios will allow us to learn more from this contained outbreak. We can create virtual situations where additional close contacts are infected and learn whether tracing of their contacts would still have contained the outbreak.</p>
<p>That would generate a deeper understanding of when we might need to back up our contact tracing with a lockdown or other measures, and identify a range of options that could achieve this. This will give policy-makers options beyond the dichotomy of business as usual or lockdown, so we do as much as is needed, and no more.</p>
<p>This isn’t a criticism of short, sharp lockdowns used so far. But let’s not miss this opportunity to interrogate the data and learn from it. The government, and the public, need more guidance on what should trigger different levels of public health restrictions.</p>
<h2>The lockdown was a safety net</h2>
<p>So far, all cases in Melbourne’s latest outbreak are associated with one of the following: the initial exposures at the Holiday Inn (authorities believe this occurred on February 3 or 4); a worker’s spouse; or a private dinner held on February 6. This represents two generations of spread from the original returned traveller (whose partner and child were also infected and included in health department counts).</p>
<p>All transmission to current known cases therefore happened before the lockdown. All of the highest-risk close contacts of these cases, who have since tested negative, were in quarantine before the lockdown too. </p>
<p>The ring of negative cases tells us the risk of infection in more casual contacts is extremely low.</p>
<p>Like the recent local lockdowns in Queensland and WA, Victoria’s lockdown does not seem to have contributed to containment. As it turned out, the outbreak was effectively controlled by rapid case detection, testing, tracing and isolation by the time lockdown came into effect. </p>
<p>This is great news and a credit to public health teams and the public who came forward for testing and quarantine. But what if the epidemiology had played out differently? We should aim to deepen our understanding, to learn more about whether, and when, we need circuit-breakers in the future. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/perth-is-the-latest-city-to-suffer-a-covid-quarantine-breach-why-does-this-keep-happening-154375">Perth is the latest city to suffer a COVID quarantine breach. Why does this keep happening?</a>
</strong>
</em>
</p>
<hr>
<h2>We can’t conclude lockdown was a success… yet</h2>
<p>We can analyse the impacts the current, and other, lockdowns would have had under higher-transmission situations by overlaying actual contact tracing data with different contact infection scenarios. Victoria provides the richest data for this as the second ring of contacts of cases are quarantined routinely, which means we can treat more of the primary contacts as if they had become actual cases and then upgrade transmission risk among their own contacts. </p>
<p>We can also use this opportunity to investigate the actual change in the number of close contacts that lockdown brings. In the current outbreak, Victoria broadened the definition of “close contact” to anyone in contact with a case, or a venue where the case had been. Pre-lockdown, this took us from 59 close contacts, not quite 10 per original Holiday Inn case, to 3,400 including Terminal 4 at Melbourne Airport. </p>
<p>Using broad definitions of a close contact is a very cautious approach, and pushes us towards lockdowns faster to keep tracing manageable. So this element of our response also needs to be reviewed to identify a safe but proportionate level of contact to deem “close contact”. </p>
<p>Circuit-breaker lockdowns act as <a href="https://theconversation.com/brisbanes-covid-lockdown-has-a-crucial-difference-it-aims-to-squash-an-outbreak-before-it-even-starts-152892">safety nets</a>. It’s innately difficult to evaluate whether they’re really necessary. In Victoria, contact tracing stood up to the test. And thankfully, cases were either not very infectious, or by chance didn’t mix with others in a way that led to widespread transmission before our public health response was wrapped around it.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/brisbanes-covid-lockdown-has-a-crucial-difference-it-aims-to-squash-an-outbreak-before-it-even-starts-152892">Brisbane's COVID lockdown has a crucial difference: it aims to squash an outbreak before it even starts</a>
</strong>
</em>
</p>
<hr>
<p>But we can create scenarios that offer a sterner test of our contact-tracing capacity to determine whether the safety nets might be required, what they should look like, and when they would need to be initiated to be effective.</p>
<p>Our circuit-breakers have progressively become more expansive — Queensland’s lasted three days and only covered Greater Brisbane, whereas Victoria’s was five days and statewide. There’s a danger this trend will continue on the presumption that lockdown makes a crucial difference to the outcome.</p>
<p>The truth is that our success in containing these outbreaks, and the luck in not having higher levels of infection, still leaves us with work to do to evaluate the place of circuit-breakers in Australia.</p><img src="https://counter.theconversation.com/content/155450/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Bennett receives funding from Medical Research Future Fund and the National Health and Medical Research Council</span></em></p>We need to rigorously analyse data from recent lockdowns, so we can respond better to future outbreaks.Catherine Bennett, Chair in Epidemiology, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1553552021-02-16T01:03:33Z2021-02-16T01:03:33ZGlobal weekly COVID cases are falling, WHO says — but ‘if we stop fighting it on any front, it will come roaring back’<p>The number of reported <a href="https://news.un.org/en/story/2021/02/1084742">global weekly COVID cases is falling</a> and has dropped nearly 50% this year, the World Health Organization (WHO) said overnight. This incredibly encouraging news shows the power of public health measures — but we must remain vigilant. Letting our guard down now, when new variants are emerging, could easily reverse the trend.</p>
<p>According to a WHO <a href="https://news.un.org/en/story/2021/02/1084742">press release</a>: </p>
<blockquote>
<p>“Last week saw the lowest number of reported weekly cases since October”, Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) told journalists at a regular press briefing in Geneva. </p>
<p>Noting a nearly 50% drop this year, he stressed that “how we respond to this trend” is what matters now. </p>
<p>While acknowledging that there is more reason for hope of bringing the pandemic under control, the WHO chief warned, “the fire is not out, but we have reduced its size”. </p>
<p>“If we stop fighting it on any front, it will come roaring back”. </p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/are-vaccines-already-helping-contain-covid-early-signs-say-yes-but-mutations-will-be-challenging-154479">Are vaccines already helping contain COVID? Early signs say yes, but mutations will be challenging</a>
</strong>
</em>
</p>
<hr>
<p>This welcome news shows that when governments respond rapidly by putting in place public health measures, we reap the benefits even before widespread vaccine rollouts. That’s a really important message now, and for when the next pandemic hits (and another one eventually will).</p>
<p>As good as this news is, though, we are still seeing infections in fairly large numbers worldwide. And, as we have regrettably seen in the past, subsequent waves of infection can easily emerge.</p>
<p>We also now have a series of variants to contend with. Even as begin to understand how the variants now circulating will affect the effectiveness of current vaccines, it’s possible we could see yet another new variant emerge that would reverse the downward trend. This remains a real risk when there are still so many new infections worldwide and when so few countries have been able to start vaccinating.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/384356/original/file-20210216-23-pwpn7r.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://ourworldindata.org">Our World in Data</a></span>
</figcaption>
</figure>
<h2>It’s too early to see vaccine effect</h2>
<p>Some countries, such as Israel and the United Kingdom, have already vaccinated huge swathes of their population. That’s a tremendous achievement and we will start to see the benefits in the coming months. But fundamentally, it’s too early to see the effect of the vaccine rollout in widespread reduction of infection. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/384357/original/file-20210216-24-4kojyj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption"></span>
<span class="attribution"><a class="source" href="https://ourworldindata.org/covid-vaccinations">Our World in Data</a></span>
</figcaption>
</figure>
<p>On the other hand, we have recently seen a much greater focus on public health measures in places such as Europe, the Middle East and the United States. These places have been significantly affected by COVID outbreaks and are dealing with <a href="https://time.com/5929246/uk-coronavirus-third-wave/">third waves</a>, as some are preparing for <a href="https://www.reuters.com/article/us-health-coronavirus-iran-idINKBN2AD0KQ">their fourth</a>.</p>
<p>It’s likely these public health measures — such as lockdowns, physical distancing, mask-wearing and increased hygiene measures — are what’s driving the global downward trend. That shows the benefit when leaders do engage and bring their populations with them.</p>
<p>To keep that trend going in the right direction, we need high levels of public compliance with those public health measures and more equitable access to vaccines globally.</p>
<h2>Unequal global access to vaccines is a major risk</h2>
<p>Very few low-income countries have started a widespread vaccine rollout, and many are struggling to secure doses. Having unequal access globally to vaccines is obviously <a href="https://www.ft.com/content/797e3d7b-0091-4bfd-8cae-c0b5be380772">morally wrong and dangerous</a> — but it also represents a great economic risk to high income countries like Australia. </p>
<p>Having high-income countries buying up all the stock of vaccines and leaving poorer nations with little recourse will <a href="https://www.foreignaffairs.com/articles/world/2020-12-29/vaccine-nationalism-will-prolong-pandemic">prolong the pandemic</a>. And that’s bad news for the global economy, with estimates suggesting the pandemic will cost <a href="https://jamanetwork.com/journals/jama/fullarticle/2771764">US$16 trillion dollars</a>.</p>
<p>Even if Australia were able to maintain its success so far, having the pandemic run out of control in other countries means no travel, will continue to make it hard for Australians to return home, and could lead to shortages of products and materials from other countries. As the global financial crisis showed, economic strife in other parts of the world can have profound impact locally, even when Australia is doing relatively OK.</p>
<p>The risk this poses to lives and to the global economy is one reason the WHO has <a href="https://news.un.org/en/story/2021/02/1084372">called for</a> vaccine rollouts to begin in all countries in the first 100 days of 2021, and for health-care workers in lower- and middle-income countries to be protected first. </p>
<p>The WHO has issued a <a href="https://www.who.int/campaigns/annual-theme/year-of-health-and-care-workers-2021/vaccine-equity-declaration">vaccine equity declaration</a> calling for, among other things, world leaders to increase contributions to the UN-led vaccine equity initiative, COVAX, and to share doses with COVAX even as they roll out their own national campaigns. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/5opR6x6NMpQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>We also clearly need to upscale <a href="https://cepi.net/news_cepi/preparing-for-the-next-disease-x/">vaccine research and manufacturing capacity</a> around the world, which would also help us respond to the next pandemic, too.</p>
<p>There’s still <a href="https://www.wsj.com/articles/will-we-be-ready-for-the-next-pandemic-11613145677">a lot of work</a> to be done.</p>
<h2>Relaxing too soon can undo our progress</h2>
<p>As the WHO’s Director-General said overnight, the fire is not out and “if we stop fighting it on any front, it will come roaring back”. </p>
<p>That’s why sticking to the fundamentals of infection control is so important. That means keeping up with the hand-washing and physical distancing. It means wearing a mask if you can’t physically distance and complying with lockdowns and other public health orders. Yes, it’s hard to maintain a high level of commitment, but the alternative is far worse.</p>
<p>When people start to hear that global case numbers are improving, there’s a tendency to relax — and that’s risky. Now is the time we need to work together to see this contained, and ideally suppressed. </p>
<p>We may never completely eradicate this virus. But if we stick with the public health measures, and vaccinate as many people as possible worldwide, we can keep the trend going in the right direction.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/uk-south-african-brazilian-a-virologist-explains-each-covid-variant-and-what-they-mean-for-the-pandemic-154547">UK, South African, Brazilian: a virologist explains each COVID variant and what they mean for the pandemic</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/155355/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Kamradt-Scott is an Associate Professor in the Centre for International Security Studies, University of Sydney, and a Non-Resident Fellow of the United States Studies Centre. He receives funding from the Australian Research Council and the Canadian Institute for Health Research. Adam is also a director of the Global Health Security Network.</span></em></p>When people start to hear that global case numbers are improving, there’s a tendency to relax — and that’s risky.Adam Kamradt-Scott, Associate professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1545642021-02-11T15:06:47Z2021-02-11T15:06:47ZAre two cloth masks better than one for preventing the spread of COVID-19?<figure><img src="https://images.theconversation.com/files/383123/original/file-20210208-21-vgaszv.jpg?ixlib=rb-1.1.0&rect=389%2C71%2C3579%2C2789&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Layering face masks has been suggested as a way to increase protection against COVID-19 variants that may be more transmissible.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Double masking has emerged as a crowd-sourced method for adding extra layers to our masks, using the masks that we have — a response to concerns about the overall direction of the pandemic and the <a href="https://theconversation.com/why-new-covid-19-variants-are-on-the-rise-and-spreading-around-the-world-153530">transmissibility of new COVID-19 variants</a>. </p>
<p>When our group <a href="https://doi.org/10.7326/M20-2567">recommended cloth masks</a> as a worthwhile additional effort to reduce transmission of COVID-19, some of the masks that we had identified in the literature were <a href="https://doi.org/10.1128/jb.83.3.663-667.1962">three-</a> and <a href="https://doi.org/10.1002/bjs.1800621203">four-layer masks</a>: in an experimental setting, they were very effective at blocking particles exhaled by the wearer. </p>
<p>We are a group of epidemiologists and engineers who have been working <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">to summarize what is known</a> about the filtration properties of textiles, to maintain a plain-language website <a href="https://www.clothmasks.ca/">clothmasks.ca</a>, and to create new knowledge about the best textiles to use and the best mask designs.</p>
<p>On the basis of our research review, <a href="https://theconversation.com/covid-19-masks-faqs-how-can-cloth-stop-a-tiny-virus-whats-the-best-fabric-do-they-protect-the-wearer-146822">we recommended two- to four-layer masks</a>, and provided <a href="https://www.clothmasks.ca/how-to-make-a-cloth-mask">a pattern for making a four-layer mask</a>. Four layers is a challenge, though, in terms of design, particularly for the home or artisanal sewer, and few commercial masks have four layers. To sew a four-layer mask, stitching may have to go through eight layers of material after turning seams, multiplied by three for darts or pleats. </p>
<p>The simple action of wearing two multi-layer masks together gets around this problem. It seems to have arisen, like many good ideas, in a number of places at the same time.</p>
<h2>Filtration efficiency</h2>
<figure class="align-right ">
<img alt="Man wearing two cloth face masks" src="https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=720&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=720&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=720&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=904&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=904&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383640/original/file-20210210-21-e1reug.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=904&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wearing two fabric face masks together improves filtration efficiency.</span>
<span class="attribution"><span class="source">(Catherine Clase)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We summarize the protective function of a mask or mask material in terms of the percentage of small particles that it filters out — the <a href="https://doi.org/10.1016/j.mayocp.2020.07.020">filtration efficiency</a>. Every extra layer worn increases the overall filtration efficiency of the mask, though not in a simple way. This was first <a href="https://www.jstor.org/stable/30082047">shown in a laboratory setting in 1919</a> and confirmed in <a href="https://doi.org/10.1021/acsnano.0c04897">studies conducted in aerosol labs</a> in Chicago and from the <a href="https://doi.org/10.1021/acsnano.0c05025">U.S. National Institute of Standards and Technology</a> during the current pandemic. </p>
<p>Nurses working in the 1919 influenza pandemic double masked, wearing two three-layer gauze masks. During the first SARS outbreak in 2003, health-care workers in China made twelve- to sixteen-layer masks when they ran out of certified personal protective equipment. Studies that included people wearing these masks suggested that <a href="https://doi.org/10.1016/S0140-6736(20)31142-9">they did provide protection for the wearer</a>.</p>
<p>Increasing the filtration efficiency is our goal whether we are trying to achieve source control (my mask protects you, your mask protects me) or protection of the wearer (my mask protects me). <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/prevention-risks/about-non-medical-masks-face-coverings.html">Health Canada recommends</a> a middle layer of non-woven polypropylene in masks to improve filtration efficiency. </p>
<p>We think that this non-woven material, which can be sewn and washed like a textile, is <a href="https://theconversation.com/polypropylene-the-material-now-recommended-for-covid-19-mask-filters-what-it-is-where-to-get-it-149613">likely to be a useful addition</a>. Probably the best way to improve the filtration efficiency of masks is to <a href="https://www.clothmasks.ca/polypropylene">add a layer of polypropylene</a>, either when the mask is made or as a washable filter insert into a pocket masks.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=527&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=527&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=527&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=662&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=662&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382632/original/file-20210204-20-m7ee9x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=662&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pocket mask with an insert of washable spunbond industry-grade polypropylene.</span>
<span class="attribution"><span class="source">(Jonathan Clase)</span></span>
</figcaption>
</figure>
<p>Wearing two such masks together, or one mask with polypropylene with another that you are less sure about, is likely to be a good way to further improve filtration. You can even layer two masks without polypropylene and place a rectangle of polypropylene between masks. The tension of the outer mask will keep it in place. </p>
<p>The non-standardized community masks that we have bought, made or been given, imperfect and varied though they are, are proving effective at reducing transmission in the pandemic. Studies of mask mandates in <a href="https://doi.org/10.1377/hlthaff.2020.00818">the United States</a>, <a href="https://doi.org/10.3386/w27891">Canada</a> and <a href="https://doi.org/10.1073/pnas.2015954117">Germany</a>, and <a href="https://doi.org/10.4269/ajtmh.20-1015">between-country comparisons</a>, all consistently show associated reductions in transmission when masks are worn. </p>
<p>Improving filtration further is also likely to be a worthwhile goal: modelling studies show that <a href="https://doi.org/10.1016/j.idm.2020.04.001">improving filtration reduces transmission of COVID-19</a>. Adding layers by double masking is a way of using the masks that we already have, possibly to better effect. And we need all the leverage we can find at this point.</p>
<h2>Breathability</h2>
<p>There is an important caveat. Every layer added also affects breathability, or how it feels to wear the mask in term of the effort of breathing. This is important for comfort and helps keep the mask safe for the wearer. </p>
<p>If you feel short of breath in a double mask, it may be too many layers for you. If you are <a href="https://theconversation.com/joggers-and-cyclists-should-wear-masks-if-they-cant-maintain-a-physical-distance-from-pedestrians-153110">exercising in a double mask</a>, be alert for the feeling of breathlessness and monitor how it feels; don’t push yourself further than you normally would.</p>
<figure class="align-center ">
<img alt="Red cloth face masks" src="https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383199/original/file-20210209-21-c23gsv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">More layers provide more protection, but it’s difficult to sew masks with more than three layers. Wearing two multi-layer masks together gets around this problem.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>The other problem with the extra layers is that when breathability decreases, it means that the resistance of the mask to the passage of air has increased. This increases the pressure inside the mask and may cause leaking around the edge. Sometimes the double mask, with two sets of head fastenings, will get around this problem because the fit to the face is more snug and held in place by more points. </p>
<p>But there will be diminishing returns if the breathability is so poor that there is significant airflow around the edges of the mask. The aim is to minimize this completely unfiltered air. You can watch out for this when you add the second mask — does the amount of leakage feel less, or more, than when you wore one of the masks alone? And can you breathe comfortably enough for the task you are planning?</p>
<p>At McMaster’s <a href="https://www.eng.mcmaster.ca/centre-excellence-protective-equipment-and-materials-cepem">Centre of Excellence in Protective Equipment and Materials</a>, our group is working with commercial mask manufacturers, textile experts, quilters and other home sewers to create alternative designs for masks and test them in the laboratory. Until such studies are done, double masking is a creative innovation that is worth trying out with the masks that you have.</p><img src="https://counter.theconversation.com/content/154564/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Clase is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article. Catherine has received consultation, advisory board membership or research funding from the Ontario Ministry of Health, Sanofi, Pfizer, Leo Pharma, Astellas, Janssen, Amgen, Boehringer-Ingelheim and Baxter. In 2018 she co-chaired a KDIGO potassium controversies conference sponsored at arm's length by Fresenius Medical Care, AstraZenec, Vifor Fresenius Medical Care, relypsa, Bayer HealthCare and Boehringer Ingelheim.</span></em></p><p class="fine-print"><em><span>Prof. Charles-François de Lannoy is a member of the Cloth Mask Knowledge Exchange, a research and knowledge translation group which includes industry stakeholders. Industry stakeholders contribute to the Cloth Mask Knowledge Exchange by contributing to grant funding, and through in-kind contributions of time and expertise. Industry stakeholders make masks and distribute polypropylene and other fabrics. They may potentially benefit from this article.
Charles has received research funding from the Natural Sciences and Engineering Research Council (NSERC), Canada First Research Excellence Fund (CFREF), Global Water Futures (GWF), Canadian Foundation for Innovation (CFI), Ontario Centres of Excellence (OCE), Southern Ontario Water Consortium (SOWC), MITACS, ECO Canada, the France-Canada Research Fund, McMaster University, and the North American Membrane Society (NAMS). </span></em></p><p class="fine-print"><em><span>Scott Laengert is the recipient of an NSERC scholarship.</span></em></p><p class="fine-print"><em><span>Juan Jesus Carrero and Roberto Pecoits-Filho do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Are two face masks better than one? Adding layers of filtration by double masking is a way of using the masks that we already have, possibly to better effect.Catherine Clase, Physician, epidemiologist, associate professor, McMaster UniversityCharles-Francois de Lannoy, Assistant Professor, Chemical Engineering, McMaster UniversityJuan Jesus Carrero, Professor of Epidemiology, Karolinska InstitutetRoberto Pecoits-Filho, Professor of Medicine, Pontificia Universidade Católica do ParanáScott Laengert, PhD Student, Chemical Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1538392021-02-03T12:37:37Z2021-02-03T12:37:37ZIs your mask effective against COVID-19? Three questions you should ask yourself<figure><img src="https://images.theconversation.com/files/429557/original/file-20211101-13-n478fn.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/stop-covid2019-concept-photo-montage-multiple-1748936021">Roman Samborskyi</a></span></figcaption></figure><p>The emergence of new, potentially more infectious, coronavirus variants has led many people to worry about the effectiveness of their masks in protecting themselves and other people from catching COVID-19. Some experts are recommending people <a href="https://edition.cnn.com/2021/01/28/health/double-masks-covid-19-wellness-trnd/index.html">wear two masks</a> in order to increase the protection. </p>
<p>Masks have been the subject of much debate since the pandemic began. Today, most governments and health bodies recommend we wear them to prevent the transmission of COVID-19. </p>
<p>But not all masks are the same, and not all are widely available. At the start of the pandemic, the global shortage of personal protection equipment, including masks, led to the mass uptake of reusable fabric face coverings. </p>
<p>Soon after, in every shop, place of worship, restaurant, public transport and other common areas, different face coverings appeared, and along with them different problems. Now, every day, we see masks that do not fit properly, masks that slip down the face when talking, masks that fog up our glasses or irritate the skin behind the ears, never mind the eternal question of where we should keep your masks when we take them off. </p>
<p>Part of the problem has been a lack of official guidance on what makes a good mask. But at the end of last year, the World Health Organization published a <a href="https://www.who.int/publications/i/item/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak">guidance document</a>, which addressed three important elements for the factory manufacture of fabric face masks. The guidance sets out minimum thresholds for fit, filtration and breathability. </p>
<p>Here, we explain why these three elements are important and why you should think about what mask you wear and how you wear it. </p>
<h2>Does your mask fit?</h2>
<figure class="align-right ">
<img alt="A mannequin wearing a mask lit by green light revealing cloud of vapour leaking from mask." src="https://images.theconversation.com/files/382205/original/file-20210203-17-1xrn63w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/382205/original/file-20210203-17-1xrn63w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382205/original/file-20210203-17-1xrn63w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382205/original/file-20210203-17-1xrn63w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382205/original/file-20210203-17-1xrn63w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382205/original/file-20210203-17-1xrn63w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382205/original/file-20210203-17-1xrn63w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Leakage is one of the major problems in mask effectiveness.</span>
<span class="attribution"><span class="source">Henriquez, Cousins Burleigh, MacKay</span></span>
</figcaption>
</figure>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/27754781/">Face mask fit is critical</a> in order to prevent gaps between the skin and mask so that, when breathing, the aerosols do not get diverted through the gaps, for example those around our nose. This phenomenon is called “leakage”. Our research has also indicated that leakage is one of the major problems in mask effectiveness.</p>
<p>With a diverse range of facial features and profiles, it is easy to see why – a mask design that fits snugly over one person’s nose will leave big gaps over another’s. The wire embedded around the nose section even when pressed can move and cause gaps when talking and also gaps can form around the cheek and jaw bone. </p>
<p>So one of the most important things to check is how your mask fits your face. Is there a lot of air escaping through the top or sides? If so, consider buying a mask of a different size that fits more snugly over your mouth and nose.</p>
<h2>How does it filter particles?</h2>
<p>The question of leakage goes hand-in-hand with the ability of face masks to filter out the infectious agents in aerosols and droplets while still allowing the user to breathe properly. </p>
<p>To address filtration, we need to determine <a href="https://www.sciencedirect.com/science/article/pii/S2452199X20301481">how aerosols can penetrate</a> through different masks. Masks work by modulating air-flow through the fabric, reducing the number of particles passing through in each direction.</p>
<p>Many different materials are used in masks, including cloth, different types of polymers and nanofibers. Surgical masks are made from layers of polypropylene, which is a plastic material. </p>
<p><a href="https://pubs.acs.org/doi/abs/10.1021/acsnano.0c03252">Different cloths</a> have been tested for filtration efficacy with multiple layers of polyester and cotton proving the most effective. So it’s worth checking what your mask is made of when purchasing it. Also, don’t be too worried about washing your fabric face mask. Preliminary results from our research show that good filtration fabrics actually improve in their filtration ability over time and are effective up to 50 washes. </p>
<h2>Is it comfortable?</h2>
<p>Breathability and comfort are also critical to to encourage people to wear their masks properly.</p>
<p>Reports suggest that users can experience headaches, facial itching and perceived difficulty in breathing due to <a href="https://www.atsjournals.org/doi/10.1513/AnnalsATS.202007-812RL">increased skin and air temperature</a> when wearing masks. </p>
<p>If our masks are uncomfortable, it’s more likely we won’t wear them properly, and that can contribute to the spread of COVID-19. So make sure your mask doesn’t make you so uncomfortable that you have to periodically remove it, which risks undermining all your good work.</p>
<h2>Finding the best face mask</h2>
<p>How do we make sure that we are wearing the best face mask covering to prevent transmission? We have been working with industry groups to address this issue and improve design, assess fabric filtration and raise awareness of the importance of the three key elements. </p>
<p>The good news is that our preliminary data shows that reusable fabric face masks and coverings are capable of achieving excellent filtration of particles that produce good seals to reduce the risk of leaks on different facial profiles. The use of reusable face masks also reduces the amount of single-use surgical face mask waste, which is a growing problem. </p>
<p>Based on the World Health Organization guidance, and our research, we can say that as long as your mask fits you snugly and comfortably, with minimal leakage, you can feel confident in wearing it, even with the rise of new variants of the virus.</p><img src="https://counter.theconversation.com/content/153839/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fiona Henriquez has worked with tensARC Ltd on the Project “Novel face mask design for source control of viruses as a low-tech tool to enhance social distancing” funded by Innovate UK and Scottish Funding Council. She has also received funding from Scottish Funding Council to research filtration efficacy of face masks with Foxglide. </span></em></p><p class="fine-print"><em><span>Mia Burleigh has worked with tensARC Ltd on the Project “Novel face mask design for source control of viruses as a low-tech tool to enhance social distancing” funded by Innovate UK and Scottish Funding Council. </span></em></p><p class="fine-print"><em><span>William MacKay has worked with tensARC Ltd on the Project “Novel face mask design for source control of viruses as a low-tech tool to enhance social distancing” funded by Innovate UK and Scottish Funding Council. He has also received funding from Scottish Funding Council to research filtration efficacy of face masks with Foxglide.</span></em></p>Everything you need to know about fit, filtration and breathability.Fiona Henriquez, Professor of Parasitology, University of the West of ScotlandMia Cousins Burleigh, Senior Technician, University of the West of ScotlandWilliam MacKay, Reader in Healthcare-Acquired Infections, University of the West of ScotlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1525172021-01-25T13:32:06Z2021-01-25T13:32:06ZYes, customers do like it when waiters and hairdressers wear a mask – especially if it’s black<figure><img src="https://images.theconversation.com/files/379559/original/file-20210119-13-sp5y0v.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C3000%2C1994&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The authors didn't examine diners' perceptions of polka-dot masks specifically. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakCalifornia/a31f7dcd4bb34e858c9ff38ef0d0b3fd/photo?hpSectionId=879083fa405d449fa332cbf742e7d609&st=hpsection&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=340&Query=restaurant%20AND%20mask&currentItemNo=16">AP Photo/Ringo H.W. Chiu</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Customers perceive a better quality of service, feel less anxious and exhibit more trust in businesses when waiters and other service workers wear a mask, according to a new study we just submitted for peer review. And we found this to be especially true when the mask was black.</p>
<p>We surveyed about 4,500 Americans through <a href="https://www.mturk.com">Amazon’s Mechanical Turk</a>, showing each of them a random picture of a service employee, with or without a mask, in either a grocery store, bank, hair salon, hotel or restaurant. We included photos of men and women who were either Black, white or Asian. Further, the masks were in one of five color schemes: white, black, blue, multi-colored or clear.</p>
<p>We then asked participants to record their impressions of the service workers and subsequent perceptions, emotions and behavior. </p>
<p>We found that customers consistently expected higher quality of service from workers who wore masks compared to employees who weren’t wearing face coverings. We also found that participants tended to become less anxious when they saw a service person with a mask. </p>
<p>Interestingly, we found that the color of the mask worn made a difference. People who wore black masks got the highest ratings, followed by white, multi-colored and blue. The clear mask – even though it allows customers to actually see facial expressions – was rated the lowest by respondents.</p>
<p>While we didn’t ask participants about their political leanings, we did learn where they reside. And we found that those based in the West had the most positive reaction to mask-wearing, followed, in order, by people in the Southwest, Northeast, Southeast and Midwest.</p>
<p>We found no meaningful differences in terms of the respondents’ age, race or educational level. </p>
<figure class="align-center ">
<img alt="Six different images show various people wearing masks of varying colors, including one without a mask." src="https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=335&fit=crop&dpr=1 600w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=335&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=335&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=421&fit=crop&dpr=1 754w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=421&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/376825/original/file-20201230-15-1ehuvr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=421&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">These are six of the pictures that participants in the survey randomly saw.</span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Why it matters</h2>
<p>President Joe Biden’s <a href="https://www.wsj.com/articles/bidens-first-day-orders-will-include-mask-mandate-blocking-keystone-pipeline-11611136804">first acts as president</a> included requiring masks be worn on all federal property and on <a href="https://www.nytimes.com/live/2021/01/21/world/covid-19-coronavirus?type=styln-live-updates&label=coronavirus%20updates&index=0&action=click&module=Spotlight&pgtype=Homepage#biden-rolls-out-full-scale-wartime-coronavirus-strategy-including-requiring-masks-on-some-planes-trains-and-buses">planes and trains</a>, and <a href="https://www.aarp.org/health/healthy-living/info-2020/retailers-require-face-masks-coronavirus.html">most businesses already expect their employees</a> to wear face coverings while working. While the primary reason for this is to <a href="https://theconversation.com/masks-help-stop-the-spread-of-coronavirus-the-science-is-simple-and-im-one-of-100-experts-urging-governors-to-require-public-mask-wearing-138507">mitigate the spread of the coronavirus</a> and protect workers, little is known about how mask-wearing can affect customer perceptions of service quality. </p>
<p><a href="https://www.theatlantic.com/politics/archive/2020/04/america-asia-face-mask-coronavirus/609283/">Wearing a mask in Asian cultures</a> has been a socially accepted practice for years. In the United States, however, wearing a mask became common only last year as the pandemic worsened in the spring. The practice <a href="https://theconversation.com/masks-and-mandates-how-individual-rights-and-government-regulation-are-both-necessary-for-a-free-society-150819">remains controversial</a> among some people who claim it violates their civil liberties or isn’t actually effective, though health officials have consistently endorsed their use.</p>
<p>Although there have been many reports of <a href="https://www.nytimes.com/2020/06/30/style/mask-america-freedom-coronavirus.html">altercations</a> when workers asked a customer to wear a mask, our research shows most people appreciate it when waiters and hairdressers cover their own faces. </p>
<h2>What’s next</h2>
<p>We plan to also study other effects of wearing masks. For example, are the perceptions of service staff members affected when customers and fellow employees wear a mask or not? What’s the impact on a customer if a mask carries a logo of a company or branding message? Do servers who wear masks receive higher tips?</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/152517/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The positive reaction to service workers wearing masks varied by region, with those in the West on the high end and people in the Midwest at the low end.Cihan Cobanoglu, Professor of Hospitality and Tourism, University of South FloridaFaizan Ali, Assistant Professor of Hospitality and Tourism, University of South FloridaKhuraman Shahtakhtinskaya, Financial Analyst and Researcher, University of South FloridaLuana Nanu, Ph.D. Student in Hospitality Management, Auburn UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1498002020-11-12T17:24:46Z2020-11-12T17:24:46ZVaccine roll-out is still months away – how can we avoid more lockdowns in the meantime?<figure><img src="https://images.theconversation.com/files/368869/original/file-20201111-13-poejmn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/group-students-library-studying-during-period-1850476216">MadariaPix/Shutterstock</a></span></figcaption></figure><p>The news of a <a href="https://theconversation.com/90-efficacy-for-pfizers-covid-19-mrna-vaccine-is-striking-but-we-need-to-wait-for-the-full-data-149818">potentially viable vaccine</a> for COVID-19 is exciting, but even once we start administering an effective jab it will take a long time to halt the spread of the virus. Many countries are still trying to contain dangerous epidemics, and several have had to implement further economically damaging lockdowns. But why is the virus still spreading after months of the basic public health message of hand washing, mask wearing and social distancing?</p>
<p>The main way the virus is thought to spread is through <a href="https://www.bmj.com/content/371/bmj.m3862.full">respiratory droplets and fomites</a> (contaminated objects or materials such as clothes, furniture and door handles). With this mode of spread, most infections take place through close contact, for example, between people positioned face to face, less than 2m apart. </p>
<p>This is why there has been such a focus on face masks and social distancing, as well as thorough cleaning. And yet it’s still very common to see people not wearing masks properly (if at all) or staying 2m apart, even as they repeatedly sanitise their hands.</p>
<p>Unsurprisingly, spread is common within households, social gatherings, dining together or travelling on public transport. In an <a href="https://www.publichealthontario.ca/-/media/documents/ncov/wwksf-routes-transmission-mar-06-2020.pdf?la=en">analysis of 75,465 COVID-19 cases in China</a>, 78%-85% of clusters occurred within households, suggesting that transmission occurs during close and prolonged contact. </p>
<p>In <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6944e1.htm?s_cid=mm6944e1_w">another study</a> from the US, infected people passed the virus on to an average of 53% of the people they lived with. However, this does not explain all of the disease transmission, and other factors probably also account for the ongoing spread.</p>
<h2>Airborne spread</h2>
<p>In the early months of the pandemic, there was <a href="https://www.nature.com/articles/d41586-020-02058-1">considerable debate</a> over whether smaller aerosol particles in the air played a significant role in disease transmission. In reality, this debate was artificial as droplets and aerosolised virus lie on a spectrum of particle size, and transmission is possible through both routes. </p>
<p>While the <a href="https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions">available evidence</a> still points to droplets as the main route of transmission, there is now <a href="https://jamanetwork.com/journals/jama/article-abstract/2768396">greater recognition of the role played by aerosol (airborne) spread</a>. Aerosolised virus travels further, spread out more and can stay suspended in the air for hours, while most droplets will probably land no more than a few feet away from the source. </p>
<p>Imagine aerosolised viral particles as cigarette smoke: if you stood close to a smoker you are more likely to inhale a great deal of smoke. Some activities such as talking, and especially <a href="https://www.tandfonline.com/doi/full/10.1080/02786826.2020.1812502">singing</a> and shouting, increase aerosol and droplet exhalation.</p>
<figure class="align-center ">
<img alt="Cartoon of group of people wearing face masks surrounded by a cloud." src="https://images.theconversation.com/files/368878/original/file-20201111-17-1qwpgu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368878/original/file-20201111-17-1qwpgu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=530&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368878/original/file-20201111-17-1qwpgu8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=530&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368878/original/file-20201111-17-1qwpgu8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=530&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368878/original/file-20201111-17-1qwpgu8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=666&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368878/original/file-20201111-17-1qwpgu8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=666&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368878/original/file-20201111-17-1qwpgu8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=666&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">COVID can still spread between people wearing masks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/crowd-people-wearing-protective-medical-masks-1629876031">Zubada/Shutterstock</a></span>
</figcaption>
</figure>
<p>This highlights why wearing a mask doesn’t mean you don’t also need to social distance. Barrier methods (such as face masks and visors) can certainly protect against droplets, but are less protective against airborne spread, especially if prolonged contact takes place indoors. Transmission can occur even if people aren’t facing each other, or are more than 2m apart – even if face masks are worn. </p>
<h2>Ventilation</h2>
<p>This is where ventilation is important. In a poorly ventilated room, the concentration of viral particles is likely to build up and could increase the risk of infection. But good ventilation will dilute the concentration of viral particles in the air.</p>
<p>It’s not yet clear what proportion of infections occur through airborne transmission. But if it turns out to be higher than previously thought, people in high-risk jobs, such as health workers, will need a higher grade of personal protective equipment (PPE). </p>
<p>Likewise, settings where people are likely to spend a long time indoors, such as workplaces and classrooms, will need solutions to improve ventilation or avoid indoor crowding. Public messaging may also need to put more emphasis on the importance of ventilation and the avoidance of indoor crowding, in addition to advice on handwashing, face masks and social distancing.</p>
<h2>Super-spreading</h2>
<p>The other phenomenon increasingly recognised for <a href="https://gijn.org/2020/10/26/tracking-the-superspreader-events-driving-the-covid-19-pandemic/">driving infections is the role of super-spreading events</a>. Super-spreading occurs when one person infects a much higher number of other people than average. Some <a href="https://wellcomeopenresearch.org/articles/5-67">research suggests</a> less than 20% of infected people produce over 80% of infections. </p>
<p>Super-spreading events <a href="https://wwwnc.cdc.gov/eid/article/26/6/20-0495_article">often occur when</a> people are gathered close together in crowded areas and insufficiently ventilated indoor spaces. Examples include workplaces such as factories, <a href="http://tbs.seoul.kr/eFm/newsView.do?typ_800=N&idx_800=3388071&seq_800=">bars and nightclubs</a>, house parties, gyms, <a href="https://www.cbc.ca/news/canada/calgary/calgary-church-outbreak-covid-1.5707121">places of worship</a> and <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e6.htm">choirs</a>. Super-spreading events can also take place in <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3692807">hospitals and care homes</a> where infection control measures are usually more stringent and PPE are used.</p>
<p>Notably, these events almost all occur <a href="https://wellcomeopenresearch.org/articles/5-83/v2">in indoor locations</a>. The likelihood of getting infected in a closed indoor space is <a href="https://www.medrxiv.org/content/10.1101/2020.02.28.20029272v2">18.7 times higher</a> than outdoors. Unfortunately, in the winter, people spend more time indoors and this may <a href="https://theconversation.com/how-to-prevent-covid-19-superspreader-events-indoors-this-winter-147439">heighten the risks of transmission</a>, hence the need to minimise mixing between households.</p>
<h2>Not self-isolating</h2>
<p>UK surveys have found <a href="https://www.sciencedirect.com/science/article/pii/S003335062030319X">less than 25% of infected people</a> properly self-isolate when asked to and only 12% of their contacts reportedly comply with quarantine requests. This is probably making a big contribution to the spread of the virus. </p>
<p>But <a href="https://journals.sagepub.com/doi/full/10.1177/0141076820956824">isolation can be unpleasant, distressing and have significant social and economic costs</a>. So more needs to be done to motivate and normalise self-isolation as soon as people start experiencing COVID symptoms or are asked to quarantine. And more help needs to be given to <a href="https://theconversation.com/paying-people-to-self-isolate-saves-lives-and-money-149260">overcome the practical barriers</a> that stop people doing so.</p>
<h2>Asymptomatic spread</h2>
<p>Around <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003346">20% of people who catch COVID are thought to display no symptoms</a>, and many more will only develop mild symptoms or show symptoms later in the course of their illness despite being infectious. As a result, these people are unlikely to be self-isolating and may be unwittingly spreading infections. </p>
<p>This could be made worse by the fact that mass testing programmes will inevitably produce a significant number of <a href="https://www.nejm.org/doi/full/10.1056/NEJMp2015897">false-negative results</a>, that tell people they aren’t infected when in fact they are, because of the limitations of the test. Asymptomatic people who receive a false negative test may wrongly think there’s less need for them to take protective measures.</p>
<p>In October, there were <a href="https://www.medrxiv.org/content/10.1101/2020.10.30.20223123v1.full.pdf">close to 1 million infected people in the UK</a>. Numbers this high simply makes it much easier for the virus to keep spreading. If we really want to reduce the spread of COVID-19 while we wait for a vaccine without a constant cycle of lockdowns, the best advice to the public remains to act as though you might already be infected.</p><img src="https://counter.theconversation.com/content/149800/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lee has previously received research funding from the National Institute for Health Research. He is a member of the UK Faculty of Public Health and the Royal Society for Public Health.</span></em></p>Why the virus just keeps spreading – and what to do about it.Andrew Lee, Reader in Global Public Health, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.