Data regarding the “real-world” effectiveness of community masking are limited to observational and epidemiological studies.
- An investigation of a high-exposure event, in which 2 symptomatically ill hair stylists interacted for an average of 15 minutes with each of 139 clients during an 8-day period, found that none of the 67 clients who subsequently consented to an interview and testing developed infection. The stylists and all clients universally wore masks in the salon as required by local ordinance and company policy at the time.32
- In a study of 124 Beijing households with > 1 laboratory-confirmed case of SARS-CoV-2 infection, mask use by the index patient and family contacts before the index patient developed symptoms reduced secondary transmission within the households by 79%.33
- A retrospective case-control study from Thailand documented that, among more than 1,000 persons interviewed as part of contact tracing investigations, those who reported having always worn a mask during high-risk exposures experienced a greater than 70% reduced risk of acquiring infection compared with persons who did not wear masks under these circumstances.34
- A study of an outbreak aboard the USS Theodore Roosevelt, an environment notable for congregate living quarters and close working environments, found that use of face coverings on-board was associated with a 70% reduced risk.35
- Investigations involving infected passengers aboard flights longer than 10 hours strongly suggest that masking prevented in-flight transmissions, as demonstrated by the absence of infection developing in other passengers and crew in the 14 days following exposure.36,37
Seven studies have confirmed the benefit of universal masking in community level analyses: in a unified hospital system,38 a German city,39 a U.S. state,40 a panel of 15 U.S. states and Washington, D.C.,41,42 as well as both Canada43 and the U.S.44 nationally. Each analysis demonstrated that, following directives from organizational and political leadership for universal masking, new infections fell significantly. Two of these studies42,44 and an additional analysis of data from 200 countries that included the U.S.45 also demonstrated reductions in mortality. An economic analysis using U.S. data found that, given these effects, increasing universal masking by 15% could prevent the need for lockdowns and reduce associated losses of up to $1 trillion or about 5% of gross domestic product.42
Conclusions
Experimental and epidemiological data support community masking to reduce the spread of SARS-CoV-2. The prevention benefit of masking is derived from the combination of source control and personal protection for the mask wearer. The relationship between source control and personal protection is likely complementary and possibly synergistic14, so that individual benefit increases with increasing community mask use. Further research is needed to expand the evidence base for the protective effect of cloth masks and in particular to identify the combinations of materials that maximize both their blocking and filtering effectiveness, as well as fit, comfort, durability, and consumer appeal. Adopting universal masking policies can help avert future lockdowns, especially if combined with other non-pharmaceutical interventions such as social distancing, hand hygiene, and adequate ventilation.
