Does mask-wearing really offer infection protection for adults and children?

Vaccines and increased immunity went a long way to reduce the morbidity and mortality of the SARS-CoV-2 pandemic in 2019, but as the world moves toward another winter—and another cold and flu season—researchers are investigating what non-pharmaceutical, physical measures can best protect us from infection.

Viral pandemics and acute respiratory epidemics are not new health challenges since the COVID-19 pandemic. Although COVID-19 was a particularly large and impactful pandemic, similar infections have come before and will come again, according to experts.

Using data collected from prior epidemics like the H1N1 influenza cases in 2009 and another SARS variety in 2003, researchers are trying to answer the question of what physical interventions might offer the best protections from infectious organisms going forward.

Masking during the COVID-19 pandemic was embraced by some, but was also a source of contention.

In response to strong debates over the efficacy and appropriateness of mandatory mask wearing, researchers from numerous public and private institutions reviewed academic, national, and international databases that investigated the use of physical interventions as a method of infection prevention control. The team considered masking, as well as other physical barriers like:

• Screening at entry ports
• Isolation and quarantine policies
• Physical distancing
• Masks and other personal protective equipment
• Hand hygiene

Nearly 80 randomized control trials were included in the final review—most of which were conducted prior to the COVID-19 pandemic during noninfluenza outbreaks. Several studies did include flu season infection control measures, particularly in the setting of the H1N1 influenza pandemic in 2009 and general influenza seasons from 2016 and earlier.

Efficacy of physical barriers were judged based on their ability to reduce circulation and transmission of lower respiratory viruses circulating at the time of the study compared to during COVID-19.

Low compliance with effective and consistent mask-wearing may have skewed the results of many of the trials, according to the study team, but they also concluded that the overall the benefit of wearing masks as an infection control and prevention measure during respiratory pandemics is questionable.

There was low certainty evidence from 12 trials that reviewed the use of standard surgical masks during influenza-like pandemics, with masking making little to no difference in infection rates or outcomes, the study revealed.

The research team also compared the use of standard surgical masks to the use of N95’s and other respirator products. Four studies in the healthcare setting and one in home setting were evaluated, and the study team again found a lack of solid evidence that one mask offered any more protection against influenza-like infections than the other. The study team also noted that the biggest constant in early studies was the lack of good outcomes reporting and frequent complaints about the discomfort of respirator masks. Studies focused on N95 versus standard surgical mask use during the COVID pandemic are still underway.

Data from controlled studies were unavailable or severely limited for other physical barrier methods like screenings, quarantine, and even isolation or physical distancing, the report adds. What did show at least some benefit was good hand hygiene.

According to the study, hand hygiene was found to help reduce acute respiratory infection rates by about 14%, and influenza-like illness by about 11% in places like schools, homes, and offices.

There are more questions to be answered specific to the use of physical barriers during the COVID-19 pandemic, but the researchers suggest masking offers questionable protection against the transmission of respiratory infections at best, and that hand hygiene might be a more effective strategy.

Jessica L. Peck, DNP, APRN, CPNP-PC,CNE,CNL,FAANP,FAAN, past president of the National Association of Pediatric Nurse Practitioners, clinical professor of nursing at Baylor University, and a published speaker and author on pediatric health topics, says the study really is a confirmation of what health care professionals have known for a long time.

“This study affirms time-tested health promotion guidance handed down by nurses for more than a century, that the most effective way to prevent cold and flu illnesses is good old-fashioned hand washing,” Peck says.

This isn’t to say that other measures don’t offer some benefit, she adds, but explains that the results of this report suggest that masking and other physical measures should be considered on an individual basis weighing mental, social, and physical well-being.

Donna Hallas, PhD, RN, PPCNP-BC, CPNP, PMHS, FAANP, FAAN, a clinical professor and nurse practitioner who has held leadership roles in a number of nursing organizations, says since the report is a systematic review of many studies, it offers some of the highest-level evidence that can be applied to clinical practice. Although the end result was a call for more research on COVID-19-specific outcomes for mask-wearing, Hallas says a big take-away from the report was the suggestion that outcomes may best be improved with the development of structured and coordinated public health programs that include education and instruction on a variety of infection control measures.

“Evaluating these findings in relation to COVID-19 may be a game changer for future pandemics, as the number of deaths during the COVID-19 pandemic in the US could have been reduced if individuals, families, and communities committed to following the expert advice of the CDC health care experts rather than opposing health care initiatives based on misinformation, and failure to follow the guidance,” Hallas says.

Reference
Jefferson T, Dooley L, Ferroni E, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database Syst. Rev. January 2023;1(CD006207). doi:10.1002/14651858.CD006207.pub6