To Mask or Not to Mask?

As of April 3, 2020, the CDC recommends all individuals excluding children under the age of 2 cover their faces with a cloth mask in public where social distancing measures are hard to follow (grocery stores, pharmacies).

The CDC now recommends the idea of universal masking in public. Translation: masks for everyone, everywhere, except children under 2.

Taking your dog out? Wear a mask. Going to the grocery store? Wear a mask. Heading out with your family for some fresh air? Wear a mask.

Why the change? Below we will help you understand the rationale behind this recommendation, the urgency behind this recommendation, and how you can put universal masking into practice for yourself and your family.

What’s the recommendation?

As of April 3, 2020, the CDC recommends all individuals excluding children under the age of 2 cover their faces with a cloth mask in public where social distancing measures are hard to follow (grocery stores, pharmacies). This means a non-medical cloth that can be made from a scarf or a light towel at home. Specific localities are also implementing specific rules.

What’s the idea behind everyone wearing masks?

There is widespread evidence, particularly from countries who have effectively curbed the COVID-19 pandemic like China, Japan, South Korea, and Taiwan, that universal masking can prevent community-based transmission. In fact, in 2003 during the SARS epidemic, universal masking was advised, and the data suggests that it helped.

This idea is supported by numerous studies of other infections that spread by droplet (coughing, sneezing, saliva going from one person and entering another person’s mouth or nose), such as the flu. In one study looking at homes where someone had the flu, masking in combination with hand hygiene reduced the risk of transmission within a household by two-thirds.

Increasingly, we are finding that COVID-19 can spread from those who are not yet feeling sick, with the latest estimates being that 25% of those who are carrying COVID-19 are asymptomatic. Furthermore, while we believe that a 6-foot radius is currently sufficient to prevent exposure to those who are coughing and sneezing, reenactments of sneezes demonstrate that droplets containing the virus could transmit as far as 23-27 feet.

Even though they are not perfect, many experts believe that some kind of mask is better than none at all.

Why did the CDC change its recommendation one month into the COVID-19 pandemic?

Due to a shortage of personal protective equipment, specifically masks, for healthcare workers who are truly exposed to COVID-19 every day, there has been an abundance of caution around recommending masks for everyone in the general public. If every average citizen is using a mask — not just one mask, but potentially going through many masks — there may not be sufficient masks for those who critically need them.

That being said, experts at the CDC spent time weighing this against the risk of further transmission, illness, healthcare resources used to treat the sick, and fatalities from the virus. Because the recommendation is explicitly to use cloth non-medical masks, the idea is that this won’t be additional stresses on existing resource constraints related to healthcare masks. In addition, other industries began to fill the gaps, with apparel manufacturers turning to producing masks.

We are learning more about the spread of COVID-19 every day, and are finding that it may be more contagious than we originally thought. Thus, anything we can do to prevent the spread is being considered a worthwhile solution.

What about the claims that wearing a mask can increase your risk of getting COVID-19?

Some healthcare officials have claimed that universal masking will actually increase an individual’s risk of getting COVID-19, unless you are a healthcare worker. If you are not used to wearing a mask, you may be more likely to fiddle and fuss with it, which means touching your eyes, nose, mouth, and face more often — precisely the behaviors that spread the infection.

Nevertheless, data from countries where masking is more of a cultural norm (due to smog, risk of infection in crowded conditions, and other issues), find that this is not actually the case, and that the benefits of masking in light of COVID-19 outweigh these risks.

What kind of mask is appropriate?

The CDC explicitly recommends non-medical cloth masks that can be made at home. This is thought to be sufficient to prevent asymptomatic spread and also protect everyone against large droplets from those who are symptomatic and coughing or sneezing. But would it just be wiser for all of us to wear the most protective kind of mask? Here is an overview and why this isn’t necessary.

N95s: N95s best protect against COVID-19 due to the fact that they filter and trap 95% of particles that measure 3 microns or larger (coronaviruses travel in droplets that are far larger than this). However, when putting universal masking into practice, walking around the block does not require an N95 mask. N95 masks must be fitted to your face to be effective and should be reserved for healthcare workers who are being exposed repetitively to patients up close.

Surgical mask: For the purpose of the day to day, a surgical mask works just fine to prevent you from being exposed to that stray droplet. You can use the same mask again and again as long as it doesn’t get dirty or wet. In China, surgical masks were recommended for people at moderate risk for infection (working in high-density areas such as grocery stores or train stations, security or police force, or if you live with someone who is being isolated with COVID-19 infection).

Cloth masks: This is what the CDC recommends universally except for children under the age of 2. This is in accordance with recommendations made in China for those who were low or very low risk. They’re appropriate for making a trip to the grocery store or doctor’s office, for outdoor activities, and among children above the age of 2. Studies have shown that a cloth mask (t-shirt material, cotton bandana, towel, or any non-medical cloth mask) is more effective than not masking in preventing transmission of infections similar to COVID-19.

How do I mask my children?

A homemade cloth mask for children above the age of 2 is perfectly fine. This could be a small bandana with two rubber bands for earloops. Keep in mind that children are at more risk of contaminating their masks due to touching them, moving them, and not having them on correctly. Given that children are overall at low risk for both acquiring and getting very sick from COVID-19, it may be ok to be more liberal about not masking children, especially those finicky ones.

How do I talk to my child about masks?

Because masks can seem scary to children, it is important to have a conversation with your kids about what they might see among people around them, what the masks mean, and why they are important.

Although this guidance is slightly out of date (“You wear a mask when you are sick and when you get better, you don’t have to wear a mask”), we like the overall tone and types of questions in this conversation guide from Zero to Three outlines.

In addition, normalizing mask-wearing (parents wearing masks in front of their kids) can help children feel comfortable and learn good mask etiquette, including for kids as young as toddler age.

Is there a proper way to wear a mask?

Believe it or not, there is a proper way to put on and remove a mask.

  1. Wash your hands or clean with an alcohol-based hand sanitizer before handling your mask.
  2. Pick up the mask attachments (the sides or strings) and cover your mouth and nose with the mask.
  3. Avoid touching the mask especially over your nose or mouth, or use clean hands if you do.
  4. Remove the mask by grabbing the strings again avoiding touching the part that goes over your nose and mouth. Then clean your hands once again.

Here is a short clip demonstrating proper masking and unmasking. Although this clip is of a surgical mask, the same steps apply when using a cloth mask.

How long should I expect to use a mask versus discarding it?

For surgical masks, frontline healthcare workers are being asked to discard them after 1 week of use as long as they are not dirty or wet. For the general public, it seems reasonable to keep reusing a surgical mask indefinitely so long as it continues to be fitted to your face when you put it on and is not dirty, wet, or wearing thin.

Cloth masks can be reused as long as they are not obviously soiled, but launder them as frequently as you feel comfortable.

Chitra Akileswaran, MD, MBA is a physician and entrepreneur. She is the Co-founder of Cleo and serves as Chief medical Officer. Dr. Akileswaran is a Board Certified Obstetrician Gynecologist and is currently a Strategy and Operations Lead at Highland Hospital within Alameda Health System, a Level 1 Trauma Center in Oakland, California. She holds a Lecturer appointment at Harvard Medical School. She previously worked Kyruus, Inc. and McKinsey & Company. She received her undergraduate degree from Brown University, an MD from Harvard Medical School, and an MBA from Harvard Business School. She lives in San Francisco with her husband and son.

Cleo aims to give the most accurate information about COVID-19, but details and recommendations about this pandemic may have changed since this story was published. For the latest information, please check out resources from the WHO, CDC, and local public health departments.