Facemasks in the COVID-19 era: A health hypothesis on inefficacy of facemasks

The physical properties of medical and non-medical facemasks suggest that facemasks are ineffective to block viral particles due to their difference in scales. According to the current knowledge, the virus SARS-CoV-2 has a diameter of 60 nm to 140 nm [nanometers (billionth of a meter)], while medical and non-medical facemasks’ thread diameter ranges from 55 µm to 440 µm [micrometers (one millionth of a meter), which is more than 1000 times larger. Due to the difference in sizes between SARS-CoV-2 diameter and facemasks thread diameter (the virus is 1000 times smaller), SARS-CoV-2 can easily pass through any facemask. In addition, the efficiency filtration rate of facemasks is poor, ranging from 0.7% in non-surgical, cotton-gauze woven mask to 26% in cotton sweeter material. With respect to surgical and N95 medical facemasks, the efficiency filtration rate falls to 15% and 58%, respectively when even small gap between the mask and the face exists.

Clinical scientific evidence challenges further the efficacy of facemasks to block human-to-human transmission or infectivity. A randomized controlled trial (RCT) of 246 participants [123 (50%) symptomatic)] who were allocated to either wearing or not wearing surgical facemask, assessing viruses transmission including coronavirus. The results of this study showed that among symptomatic individuals (those with fever, cough, sore throat, runny nose ect…) there was no difference between wearing and not wearing facemask for coronavirus droplets transmission of particles of >5 µm. Among asymptomatic individuals, there was no droplets or aerosols coronavirus detected from any participant with or without the mask, suggesting that asymptomatic individuals do not transmit or infect other people. This was further supported by a study on infectivity where 445 asymptomatic individuals were exposed to asymptomatic SARS-CoV-2 carrier (been positive for SARS-CoV-2) using close contact (shared quarantine space) for a median of 4 to 5 days. The study found that none of the 445 individuals was infected with SARS-CoV-2 confirmed by real-time reverse transcription polymerase.

A meta-analysis among health care workers found that compared to no masks, surgical mask and N95 respirators were not effective against transmission of viral infections or influenza-like illness based on six RCTs. Using separate analysis of 23 observational studies, this meta-analysis found no protective effect of medical mask or N95 respirators against SARS virus. A recent systematic review of 39 studies including 33,867 participants in community settings (self-report illness), found no difference between N95 respirators versus surgical masks and surgical mask versus no masks in the risk for developing influenza or influenza-like illness, suggesting their ineffectiveness of blocking viral transmissions in community settings.

Another meta-analysis of 44 non-RCT studies (n = 25,697 participants) examining the potential risk reduction of facemasks against SARS, middle east respiratory syndrome (MERS) and COVID-19 transmissions. The meta-analysis included four specific studies on COVID-19 transmission (5,929 participants, primarily health-care workers used N95 masks). Although the overall findings showed reduced risk of virus transmission with facemasks, the analysis had severe limitations to draw conclusions. One of the four COVID-19 studies had zero infected cases in both arms, and was excluded from meta-analytic calculation. Other two COVID-19 studies had unadjusted models, and were also excluded from the overall analysis. The meta-analytic results were based on only one COVID-19, one MERS and 8 SARS studies, resulting in high selection bias of the studies and contamination of the results between different viruses. Based on four COVID-19 studies, the meta-analysis failed to demonstrate risk reduction of facemasks for COVID-19 transmission, where the authors reported that the results of meta-analysis have low certainty and are inconclusive.

In early publication the WHO stated that “facemasks are not required, as no evidence is available on its usefulness to protect non-sick persons”. In the same publication, the WHO declared that “cloth (e.g. cotton or gauze) masks are not recommended under any circumstance”. Conversely, in later publication the WHO stated that the usage of fabric-made facemasks (Polypropylene, Cotton, Polyester, Cellulose, Gauze and Silk) is a general community practice for “preventing the infected wearer transmitting the virus to others and/or to offer protection to the healthy wearer against infection (prevention)”. The same publication further conflicted itself by stating that due to the lower filtration, breathability and overall performance of fabric facemasks, the usage of woven fabric mask such as cloth, and/or non-woven fabrics, should only be considered for infected persons and not for prevention practice in asymptomatic individuals. The Central for Disease Control and Prevention (CDC) made similar recommendation, stating that only symptomatic persons should consider wearing facemask, while for asymptomatic individuals this practice is not recommended. Consistent with the CDC, clinical scientists from Departments of Infectious Diseases and Microbiology in Australia counsel against facemasks usage for health-care workers, arguing that there is no justification for such practice while normal caring relationship between patients and medical staff could be compromised. Moreover, the WHO repeatedly announced that “at present, there is no direct evidence (from studies on COVID-19) on the effectiveness face masking of healthy people in the community to prevent infection of respiratory viruses, including COVID-19”. Despite these controversies, the potential harms and risks of wearing facemasks were clearly acknowledged. These including self-contamination due to hand practice or non-replaced when the mask is wet, soiled or damaged, development of facial skin lesions, irritant dermatitis or worsening acne and psychological discomfort. Vulnerable populations such as people with mental health disorders, developmental disabilities, hearing problems, those living in hot and humid environments, children and patients with respiratory conditions are at significant health risk for complications and harm.

"EFFICACY" OF FACEMASKS