Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) April 8, 2020 Kelvin Droegemeier, Ph.D. Office of Science and Technology Policy Executive Office of the President Eisenhower Executive Office Building 1650 Pennsylvania Avenue, NW Washington, DC 20504 Dear Dr. Droegemeier: Attached please find a rapid expert consultation that was prepared by Rich Besser and Baruch Fischhoff, members of the National Academies of Sciences, Engineering, and Medicineâs Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats, with input from Sundaresan Jayaraman and Michael Osterholm. Details on the authors and reviewers of this rapid expert consultation can be found in the Appendix. The aim of this rapid expert consultation is to respond to your request concerning the effectiveness of homemade fabric masks worn by the general public to protect others, as distinct from protecting the wearer. The request stems from an interest in reducing transmission within the community by individuals who are infected, potentially contagious, but asymptomatic. Overall, the available evidence is inconclusive about the degree to which homemade fabric masks may suppress the spread of infection from the wearer to others. For as long as homemade fabric masks are in use by the public, the investigations outlined at the end of the rapid expert consultation could reduce uncertainty about the effectiveness of these masks. My colleagues and I hope this input is helpful to you as you continue to guide the nationâs response in this ongoing public health crisis. Respectfully, Harvey V. Fineberg, M.D., Ph.D. Chair Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats This rapid expert consultation responds to your request concerning the effectiveness of homemade fabric masks worn by the general public to protect others, as distinct from protecting 1 Copyright National Academy of Sciences. All rights reserved.
Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) the wearer. The request stems from an interest in reducing transmission within the community by individuals who are infected, potentially contagious, but asymptomatic or presymptomatic. As discussed below, the answer depends on both the masks themselves and how infected individuals use them. The following analysis is restricted to the effectiveness of homemade fabric masks, of the sort illustrated in recommendations 1 directed at the general public, in terms of their ability to reduce viral spread during the asymptomatic or presymptomatic period. It does not apply to either N95 respirators or medical masks. In considering the evidence about the potential effectiveness of homemade fabric masks, it is important to bear in mind how a respiratory virus such as SARS-CoV-2 spreads from person to person. Current research supports the possibility that, in addition to being spread by respiratory droplets that one can see and feel, SARS-CoV-2 can also be spread by invisible droplets, as small as 5 microns (or micrometers), and by even smaller bioaerosol particles. 2 Such tiny bioaerosol particles may be found in an infected personâs normal exhalation. 3 The relative contribution of each particle size in disease transmission is unknown. There is limited research on the efficacy of fabric masks for influenza and specifically for SARS- CoV-2. As we describe below, the few available experimental studies have important limitations in their relevance and methods. Any type of mask will have its own capacity to arrest particles of different sizes. Even if the filtering capacity of a mask were well understood, however, the degree to which it could in practice reduce disease spread depends on the unknown role of each particle size in transmission. Asymptomatic but infected individuals are of special concern, and the particles they would emit from breathing are predominantly bioaerosols. To complicate matters further, different individuals vary in the extent to which they emit bioaerosols while breathing. Because of the concern with spread from asymptomatic individuals, who, unlike symptomatic persons, may be out and about, this rapid expert consultation includes the effects of fabric masks on bioaerosol transmission. 1 Centers for Disease Control and Prevention (CDC) Recommendation Regarding the Use of Cloth Face Coverings, Especially in Areas of Significant Community-Based Transmission in response to COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover.html. 2 Gralton et al. (2011) noted the following in regard to particulate size and the importance of airborne precautions whenever there is a risk of both droplet and aerosol transmission: âRegardless of the complexities and limitations of sizing particles and the contention of size cut-offs, it remains that particles have been observed to occupy a size range between 0.05 and 500 microns. Even using the conservative cut-off of 10 microns, rather than the 5 micron to define between airborne and droplet transmission, this size range indicates that particles do not exclusively disperse by airborne transmission or via droplet transmission but rather avail of both methods simultaneously. This suggestion is further supported by the simultaneous detection of both large and small particles. In line with these observations and logic, current dichotomous infection control precautions should be updated to include measures to contain both modes of aerosolised transmission. This may require airborne precautions to be used when at risk of any aerosolized infection, as airborne precautions are considered as a step-up from droplet precautions.â Gralton et al. 2011. The role of particle size in aerosolised pathogen transmission: A review. Journal of Infection 62(1):1-13. DOI: 10.1016/j.jinf.2010.11.010. 3 National Academies of Sciences, Engineering, and Medicine. 2020. Rapid Expert Consultation on the Possibility of Bioaerosol Spread of SARS-CoV-2 for the COVID-19 Pandemic (April 1, 2020). Washington, DC: The National Academies Press. https://doi.org/10.17226/25769. 2 Copyright National Academy of Sciences. All rights reserved.
Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) IMPACT OF MASK DESIGN AND FABRICATION ON PERFORMANCE Any effects of fabric masks will depend on how and how well they are made. In an unpublished study whose raw data are not currently available, Jayaraman et al. 4 examined a range of fabric- based filtration systems, in terms of how well they stopped particles (filtration efficiency) and how much they impeded breathing (differential pressure, Delta-P, the measured pressure drop across the material, which determines the resistance of the material to air flow). 5 The study varied fabric type (woven, woven brushed, knitted, knitted brushed, knitted pile), material type (cotton, polyester, polypropylene, silk), fabric parameters (fabric areal density, yarn linear density, fabric weight), and construction type (number of layers, orientation of the layers). The study found wide variation in filtration efficiency. A mask made from a four-layer woven handkerchief fabric, of a sort that might be found in many homes, had 0.7% filtration efficiency for 0.3 micron size particles and a Delta-P of 0.1â. Much higher filtration efficiency was observed with filters created specifically for the research from a five-layer woven brushed fabric (35.3% of the particles were trapped) and from four layers of polyester knitted cut-pile fabric (50% of the particles were trapped with a Delta-P of 0.2â). The greater a maskâs breathing resistance, which is reflected in a higher Delta-P, the more difficult it is for users to wear it consistently, and the more likely they are to experience breathing difficulties when they do. 6 Although Jayaraman et al. did not measure breathing resistance directly, almost all of the masks they tested would be expected to have breathing resistance within the range of commercial N95 respirators. One mask that used 16 layers of the handkerchief fabric, in order to increase filtration efficiency (63% efficiency with a Delta-P of 0.425â), had breathing resistance greater than that of commercial N95 respirators, which would cause great discomfort to many wearers and cause some to pass out. An additional consideration in the effectiveness of any mask is how well it fits the user. 7 Even with the best material, if a mask does not fit, virus-containing particles can escape through creases and gaps between the mask and face. Leakage can also occur if the holding mechanism (e.g., straps, VelcroÂ®) is weak. We found no studies of non-expert individualsâ ability to produce properly fitting masks. Nor did we find any studies of the effectiveness of masks produced by professionals, when following instructions available to the general public (e.g., online). Given the current Centers for Disease Control and Prevention (CDC) recommendation to wear cloth face coverings in public settings in areas of significant community-based transmission, additional research should examine the ability of the general public to produce properly fitted fabric masks when following communications and instructions. 4 Jayaraman et al. Pandemic FluâTextile Solutions Pilot: Design and Development of Innovative Medical Masks, Final Technical Report, Georgia Institute of Technology, Atlanta, Georgia, submitted to CDC, February 14, 2012. 5 The tests were conducted according to ASTM F2299-3 test method using poly-dispersed sodium chloride aerosol particles with an airflow rate of 30L/min and airflow velocity of 11 cm/s. Aerosol sizes measured: 0.1, 0.2, 0.3, 0.4, 0.5, 0.7, 1, and 2 microns. 6 3Mâ¢ Health Care Particulate Respirator and Surgical Masks, Healthcare Respirator Brochure, 3M Company, Minnesota. 7 Davies et al. (2013) noted that, âAlthough any material may provide a physical barrier to an infection, if as a mask it does not fit well around the nose and mouth, or the material freely allows infectious aerosols to pass through it, then it will be of no benefit.â Davies et al. 2013. Testing the efficacy of homemade masks: Would they protect in an influenza pandemic? Disaster Medicine and Public Health Preparedness 7(4):413-418. DOI: 10.1017/dmp.2013.43. 3 Copyright National Academy of Sciences. All rights reserved.
Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) ROLE OF THE WEARER The effectiveness of homemade fabric masks will also depend on the wearerâs behavior. Even if a mask could fit well, its effectiveness still depends on how well the wearer puts it on and keeps it in place. As mentioned, breathing difficulty can impede effective use (e.g., pulling a mask down), as can moisture from the wearerâs breath. Moisture saturation is inevitable with fabrics available in most homes. Moreover, moisture can trap the virus and become a potential contamination source for others after a mask is removed. EFFECTIVENESS OF HOMEMADE FABRIC MASKS IN PROTECTING OTHERS Several experimental studies have examined the effects of fabric masks on the transmission of droplets of various sizes. Anfinrud et al. 8 shared via email that they used sensitive laser light-scattering procedures to detect droplet emission while people were speaking. The authors found that âa damp homemade cloth facemaskâ reduced droplet emission to background levels (when users said âStay Healthyâ three times). However, when a fabric is dampened, the yarns can swell over time, potentially altering its filtering performance. That swelling will depend on the fabric: cotton swells readily, synthetics less so. In an unpublished follow-up experiment, Anfinrud et al. repeated their study with a variety of dry (not moistened) cloths, including a standard workers dust mask (not certified N95) and a mask rigged from an airline eye covering. They found that all of these masks reduced droplet emission generated by speech to background level. 9 Bae et al. (2020) evaluated the effectiveness of surgical and cotton masks in filtering SARS- CoV-2. 10 They found that neither kind of mask reduced the dissemination of SARS-CoV-2 from the coughs of four symptomatic patients with COVID-19 to the environment and external mask surface. The study used disposable surgical masks (180 mm Ã 90 mm, 3 layers [inner surface mixed with polypropylene and polyethylene, polypropylene filter, and polypropylene outer surface], pleated, bulk packaged in cardboard; KM Dental Mask, KM Healthcare Corp) and reusable 100% cotton masks (160 mm Ã 135 mm, 2 layers, individually packaged in plastic; Seoulsa). The median viral loads of nasopharyngeal and saliva samples from the four participants were 5.66 log copies/mL and 4.00 log copies/mL, respectively. The median viral loads after coughs without a mask, with a surgical mask, and with a cotton mask were similar: 2.56 log copies/mL, 2.42 log copies/mL, and 1.85 log copies/mL, respectively. All swabs from the outer mask surfaces of the masks were positive for SARS-CoV-2, whereas swabs from three out of the four symptomatic patients from the inner mask surfaces were negative. Note that this study focused on symptomatic patients who coughed. 8 Anfinrud et al. In Press. Could SARS-CoV-2 be transmitted via speech droplets? New England Journal of Medicine. https://doi.org/10.1101/2020.04.02.20051177. 9 Personal communication, Adriaan Bax, National Institutes of Health, April 4, 2020. 10 Bae et al. 2020. Effectiveness of surgical and cotton masks in blocking SARS-CoV-2: A controlled comparison in 4 patients. Annals of Internal Medicine. DOI: 10.7326/M20-1342. 4 Copyright National Academy of Sciences. All rights reserved.
Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) Rengasamy et al. (2010) 11 tested the filtration performance of five common household fabric materials: sweatshirts, T-shirts, towels, scarves, and cloth masks (of unknown material) in a laboratory setting. These fabric materials were tested for sprays having both similar and diverse particle sizes (monodisperse and polydisperse). The range of sizes used in the study (0.02-1 micron) includes that of potential virus-containing droplets. 12 The study projected the particles at face velocities, typical of breathing at rest and during exertion (5.5 and 16.5 cm/s). The test also examined N95 respirator filter media. At the lower velocity, 0.12% of particles penetrated the N95 respirator material; at the higher velocity, penetration was less than 5%. For the five common household fabric materials, across the tests, penetration ranged from about 40-90%, indicating a 10-60% reduction. The authors concluded that common fabric materials may provide a low level of protection against nanoparticles, including those in the size ranges of virus-containing particles in exhaled breath (0.02-1 micron). However, Gralton et al. (2011) found particles generated from respiratory activities range from 0.01 up to 500 microns, with a particle size range of 0.05 to 500 microns associated with infection. They stress the need for airborne precautions to be used when at risk of any aerosolized infection, as airborne precautions are considered as a step-up from droplet precautions. Davies et al. (2013) 13 had 21 healthy volunteers make their own face masks from fresh, unworn cotton t-shirts. This is the only study we found with user-made masks. Participants then coughed into a box, when wearing their own mask, a surgical mask, or no mask. They received no help or guidance from the researcher in making or fitting their masks. The researchers took samples of particles settling onto agar plates and a Casella slit sampler in the box. Under the baseline conditions of no mask, only a small number of colony-forming units (indicative of bacteria) were detected, limiting the opportunity to demonstrate reductions. Still, the investigators reported that both homemade and surgical masks reduced the number of large-sized microorganisms expelled by volunteers, with the surgical mask being more effective. van der Sande et al. (2008) 14 examined the extent to which respirator masks, surgical masks, and tea-cloth masks made by the researchers would reduce tiny (0.02-1 micron) particle counts on one side of the mask compared to the other. They used burning candles in a test room to generate particles. Two of the studyâs three experiments examined the protection afforded the wearer (reduced particle counts inside the masks compared to outside). Although not directly germane to the question of protecting others, the study found a modest degree of protection for the wearer from cloth masks, an intermediate degree from surgical masks, and a marked degree with the equivalent of N95 masks. For example, among adults, N95 masks provided 25 times the protection of surgical masks and 50 times the protection of cloth masks. The studyâs third 11 Rengasamy et al. 2010. Simple respiratory protectionâevaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles. Annals of Occupational Hygiene 54(7):789-798. https://doi.org/10.1093/annhyg/meq044. 12 According to Gralton et al. (2011), particles generated from respiratory activities range from 0.01 up to 500 microns, with a particle size range of 0.05 to 500 microns associated with infection. Gralton et al. 2011. The role of particle size in aerosolised pathogen transmission: A review. Journal of Infection 62:1-13. DOI: 10.1016/j.jinf.2010.11.010. 13 Davies et al. 2013. Testing the efficacy of homemade masks: Would they protect in an influenza pandemic? Disaster Medicine and Public Health Preparedness 7(4):413-418. DOI: 10.1017/dmp.2013.43. 14 van der Sande et al. 2008. Professional and home-made face masks reduce exposure to respiratory infections among the general population. PLOS ONE 3(7):e2618. DOI: 10.1371/journal.pone.0002618. 5 Copyright National Academy of Sciences. All rights reserved.
Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) experiment tested the effectiveness of the three masks at reducing emissions from a simulation dummy head that produced uniform âexhalations.â It found that cloth masks reduced emitted particles (leakage) by one-fifth, surgical masks reduced it by one-half, and N95-equivalent masks reduced it by two-thirds. MacIntyre et al. (2015) 15 conducted a randomized controlled trial comparing infection rates of 1,607 hospital health care workers wearing cloth (two layers, made of cotton) or medical masks (three layers, made of non-woven material) while performing their normal tasks. Workers who used cloth masks experienced much higher rates of influenza-like illness (relative risk = 13.00, 95% confidence interval 1.59 to 100.07). This study measured the protective effect for the wearer, rather than the protection of others from the wearer, and did not include a condition with individuals wearing no masks. EFFECT ON USERSâ RISK BEHAVIOR In our rapid review, we found no studies of the effects of wearing masks on usersâ behavior. Speculatively, for some users, masks could provide a constant reminder of the importance of social distancing, as well as signal its importance to others, strengthening the social norm of social distancing. Conversely, for some users, masks might âcrowd outâ other precautionary behaviors, giving them a feeling that they have done enough to protect themselves and others. Prior research, conducted in less intense settings, could support either speculation. Focused research could help determine when precautionary behaviors reinforce or displace one another. It is critically important that any discussion of homemade fabric masks reinforce the central importance of physical distancing and personal hygiene (frequent handwashing) in reducing spread of infection. CONCLUSIONS There are no studies of individuals wearing homemade fabric masks in the course of their typical activities. Therefore, we have only limited, indirect evidence regarding the effectiveness of such masks for protecting others, when made and worn by the general public on a regular basis. That evidence comes primarily from laboratory studies testing the effectiveness of different materials at capturing particles of different sizes. The evidence from these laboratory filtration studies suggests that such fabric masks may reduce the transmission of larger respiratory droplets. There is little evidence regarding the transmission of small aerosolized particulates of the size potentially exhaled by asymptomatic or presymptomatic individuals with COVID-19. The extent of any protection will depend on how the masks are made and used. It will also depend on how mask use affects usersâ other precautionary behaviors, including their use of better masks, when those become widely available. Those behavioral effects may undermine or enhance homemade fabric masksâ overall effect on public health. The current level of benefit, if any, is not possible to assess. MacIntyre et al. 2015. A cluster randomised trial of cloth masks compared with medical masks in healthcare 15 workers. BMJ Open 5(4):e006577. DOI: 10.1136/bmjopen-2014-006577. 6 Copyright National Academy of Sciences. All rights reserved.
Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic (April 8, 2020) Research could provide firmer answers by assessing the effectiveness of such fabric masks, as made and used by the general public. That research would have the goals of providing the public with (1) usable instructions on how to make, fit, use, and clean homemade fabric masks; (2) estimates of the protection that such masks afford users and others in different environments (e.g., where the likelihood of contact is higher, like grocery stores, compared to wearing masks all of the time); and (3) effective reinforcement of other precautionary behaviors. That research could provide policy makers with estimates of the net effect of encouraging the use of homemade fabric masks on public health, with realistic estimates of how such masks will be made and used, as well as how they will affect other precautionary behaviors of users and others who observe and interact with them. My colleagues and I hope this input is helpful to you as you continue to guide the nationâs response in this ongoing public health crisis. Respectfully, Richard Besser, M.D. Member Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats Baruch Fischhoff, Ph.D. Member Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats APPENDIX Authors and Reviewers of This Rapid Expert Consultation This rapid expert consultation was prepared by staff of the National Academies of Sciences, Engineering, and Medicine, and members of the National Academiesâ Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats: Richard Besser, Robert Wood Johnson Foundation, and Baruch Fischhoff, Carnegie Mellon University. The following subject- matter experts also provided input: Sundaresan Jayaraman, Georgia Tech, and Michael Osterholm, University of Minnesota. Harvey Fineberg, chair of the Standing Committee, approved this document. The following individuals served as reviewers: Ned Calonge, The Colorado Trust; Robert Hornik, University of Pennsylvania; Thomas Inglesby, Johns Hopkins Bloomberg School of Public Health Center for Health Security; and Grace Lee, Stanford University. Bobbie A. Berkowitz, Columbia University School of Nursing; Ellen Wright Clayton, Vanderbilt University Medical Center; and Susan Curry, University of Iowa, served as arbiters of this review on behalf of the National Academiesâ Report Review Committee and their Health and Medicine Division. 7 Copyright National Academy of Sciences. All rights reserved.