Downsides of face masks and possible mitigation strategies: a systematic review and meta-analysis

Please wear a mask: a systematic case for mask wearing mandates

This paper combines considerations from ethics, medicine and public health policy to articulate and defend a systematic case for mask wearing mandates (MWM). The paper argues for two main claims of general interest in favour of MWM. First, MWM provide a more effective, just and fair way to tackle the ongoing COVID-19 pandemic than policy alternatives such as laissez-faire approaches, mask wearing recommendations and physical distancing measures. And second, the proffered objections against MWM may justify some exemptions for specific categories of individuals, but do not cast doubt on the justifiability of these mandates. Hence, unless some novel decisive objections are put forward against MWM, governments should adopt MWM.

Masks and respirators for prevention of respiratory infections: a state of the science review

SUMMARYThis narrative review and meta-analysis summarizes a broad evidence base on the benefits-and also the practicalities, disbenefits, harms and personal, sociocultural and environmental impacts-of masks and masking. Our synthesis of evidence from over 100 published reviews and selected primary studies, including re-analyzing contested meta-analyses of key clinical trials, produced seven key findings. First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community transmission of respiratory pathogens. Fifth, masks are important sociocultural symbols; non-adherence to masking is sometimes linked to political and ideological beliefs and to widely circulated mis- or disinformation. Sixth, while there is much evidence that masks are not generally harmful to the general population, masking may be relatively contraindicated in individuals with certain medical conditions, who may require exemption. Furthermore, certain groups (notably D/deaf people) are disadvantaged when others are masked. Finally, there are risks to the environment from single-use masks and respirators. We propose an agenda for future research, including improved characterization of the situations in which masking should be recommended or mandated; attention to comfort and acceptability; generalized and disability-focused communication support in settings where masks are worn; and development and testing of novel materials and designs for improved filtration, breathability, and environmental impact.

Children's experiences of mask-wearing: a systemic review and narrative synthesis

RATIONALE

Masks have been widely used as a preventative tool during the COVID-19 pandemic. However, the use of masks by children has been controversial, with international guidelines recommending a risk-based approach to national policymakers.

AIMS AND OBJECTIVES

We aimed to conduct a systematic review that explores children's experiences of mask-wearing, drawing on an evidence base that describes mask-wearing in different contexts including air pollution, and to prevent the spread of infectious disease.

METHODS

We searched MEDLINE, Embase and PsycINFO in June 2021, with repeat searches in August 2022 and January 2024, for primary research studies exploring children's experiences of masks. Included studies reported on participants between 4 and 14 years (inclusive), with no restrictions on language where an English translation was available. Two reviewers independently screened titles and abstracts and reviewed full texts, with discrepancies resolved by a third reviewer. We used the Mixed Methods Appraisal Tool for quality appraisal and narrative synthesis to identify key findings. We also conducted stakeholder consultation (Patient and Public Involvement (PPI)) with nine children, where they submitted annotated drawings of their preferred masks to complement our review findings.

RESULTS

We screened 982 titles and abstracts and reviewed 94 full texts. 45 studies were included in the synthesis. Children's experiences of mask-wearing were influenced by their perceived necessity, social norms around their use and parental attitudes. Challenges related to mask-wearing were described, including difficulty reading facial expressions and physical discomfort. Children found it easier to wear masks when sitting and in cooler environments, and they benefited from unmasking during outdoor break time at school. As part of the PPI consultation, children highlighted the importance of mask design and the environmental impact of masks.

CONCLUSION

Children's experiences of mask-wearing were varied and context-dependent, with several mask-design challenges raised. Future policy on mask-wearing needs to consider the context in which mask-wearing would be most beneficial, and how local adaptations to policy can respond to children's needs.

Effect of face masks on dyspnea perception, cardiopulmonary parameters, and facial temperature in healthy adults

Respiratory droplets, naturally produced during expiration, can transmit pathogens from infected individuals. Wearing a face mask is crucial to prevent such transmission, yet the perception of dyspnea and uncomfortable breathing remains a common concern, particularly during epidemics. The aim of this study was to investigate the impact of face mask use on the perception of dyspnea, cardiopulmonary parameters, and facial temperature during physical activity. A randomized crossover study was conducted on healthy adults at a physiology laboratory located in the Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia, in November 2022. Participants underwent five stages of physical exercise tests based on the Bruce Protocol under three conditions: without any face mask (control), wearing a surgical mask, and an N95 mask, forming the study's main groups. Dyspnea perception (measured by the Modified Borg Dyspnea Scale), cardiopulmonary parameters (heart rate, oxygen saturation, respiratory rate, blood pressure, and mean arterial pressure) and facial temperature were measured before the exercise test (pre-workout), at the end of stage 1, 2, 3, 4, 5, and after the whole exercise test (post-workout). A two-way repeated measures ANOVA was conducted, considering two factors: the type of mask (control, surgical mask, N95 mask) and the various stages of the exercise test. A total of 36 healthy adults were included in the study. We found that dyspnea perception was much worse in the N95 mask group, particularly during vigorous exercise. There was no significant difference between groups in cardiopulmonary parameters. However, participants wearing N95 had a greater supralabial temperature than those wearing surgical masks or no mask at all. It is recommended to undertake a more in-depth evaluation of cardiopulmonary physiological measures.

Effectiveness of cloth face masks to prevent viral spread: a meta-analysis

BACKGROUND

The effectiveness of cloth face masks to prevent viral spread has not yet been conclusively established. In this meta-analysis, we evaluate their effectiveness in comparison to standard medical/surgical and N95-typed masks against viral spread.

METHODS

We identified literature through a systematic search in three databases and meta-analytically synthesized relevant studies by means of random-effects as well as multilevel modelling.

RESULTS

Twelve studies comprising k = 28 effect sizes (N = 338) were included. Medical/surgical and N95-typed masks outperformed cloth masks, yielding a large effect (g = 1.40). This effect remained robust when data were grouped according to comparisons with medical/surgical masks (g = 1.25) and N95-typed masks (g = 1.29). However, effects were differentiated according to mask fit, indicating reversals of signs when cloth mask effects were compared with ill-fitting medical/surgical and N95-typed masks (gs = -12.50 and - 10.90, respectively).

CONCLUSIONS

Cloth face masks were found to have significantly poorer filtering performance than medical/surgical masks and N95 masks, but only if non-cloth masks were properly fitted. Our results illustrate the necessity of using well-fitting medical/surgical or N95-typed masks to prevent viral spread, although some allowance should be made in circumstances where higher compliance with cloth mask mandates are expected.

Child mask mandates for COVID-19: a systematic review

BACKGROUND

Mask mandates for children during the COVID-19 pandemic varied in different locations. A risk-benefit analysis of this intervention has not yet been performed. In this study, we performed a systematic review to assess research on the effectiveness of mask wearing in children.

METHODS

We performed database searches up to February 2023. The studies were screened by title and abstract, and included studies were further screened as full-text references. A risk-of-bias analysis was performed by two independent reviewers and adjudicated by a third reviewer.

RESULTS

We screened 597 studies and included 22 in the final analysis. There were no randomised controlled trials in children assessing the benefits of mask wearing to reduce SARS-CoV-2 infection or transmission. The six observational studies reporting an association between child masking and lower infection rate or antibody seropositivity had critical (n=5) or serious (n=1) risk of bias; all six were potentially confounded by important differences between masked and unmasked groups and two were shown to have non-significant results when reanalysed. Sixteen other observational studies found no association between mask wearing and infection or transmission.

CONCLUSIONS

Real-world effectiveness of child mask mandates against SARS-CoV-2 transmission or infection has not been demonstrated with high-quality evidence. The current body of scientific data does not support masking children for protection against COVID-19.

Assessing the impact of diverse mask types on COPD patients: a randomised controlled trial study protocol

INTRODUCTION

Wearing masks has proven beneficial in preventing respiratory pathogen infections in individuals with chronic obstructive pulmonary disease (COPD). However, the impact of different mask types on physiological indicators and daily physical activity in COPD patients remains uncertain. This study aims to assess the immediate effects of various mask types on cardiopulmonary function indicators, subjective perceptions and the 6-minute walking distance (6MWD) in individuals with COPD.

METHODS AND ANALYSIS

This randomised controlled trial will enrol 129 stable COPD patients. Participants will be randomly divided into three groups: control, N95 mask and surgical mask groups. Each group will undergo both a 6-minute seated test and a 6-minute walk test (6MWT), without or with their respective masks. A 10-minute interval will be provided between the two phases. The primary indicators of the study include the 6MWD and blood oxygen saturation. Secondary outcomes encompass blood pressure, pulse rate, Borg score, Rate of Perceived Exertion (RPE) score and subjective perception score. Oxygen saturation, pulse rate and blood pressure will be recorded four times during the trial, while Borg and RPE scores will be compared before and after the 6MWT. Additionally, subjective perception scores will be collected after each mask-wearing stage.

ETHICS AND DISSEMINATION

This study has received approval from the Ethics Committee of the Affiliated Hospital of Gansu University of Chinese Medicine (approval number: 202335). We plan to disseminate research results through publication in a peer-reviewed journal or presentation at a conference.

TRIAL REGISTRATION NUMBER

ChiCTR2300074554.

The Usability of Face Coverings Used to Prevent the Spread of COVID-19

OBJECTIVE

To describe the perceived usability and usability problems associated with face coverings used to prevent the spread of COVID-19.

BACKGROUND

Since public health experts have now identified the appropriate use of facemasks as one of the critical elements in an effective COVID mitigation strategy, understanding how people use and care for them has become important.

METHOD

Data were collected via a survey that was shared on social media to which 2148 people responded. Participants were asked to identify the category class of the face covering they most often wear, rate its usability, answer demographic information, and questions about their mask use and hygiene, and identify issues they may suffer in relation to face cover use.

RESULTS

Overall, users appear to perceive their face coverings favorably from a usability and satisfaction standpoint, even though almost two-thirds of users indicated that they experienced discomfort and problems with glasses fogging with the most popular mask types. When considering demographic information, users' political party affiliation appears related to how they perceive the usability of their face covering.

CONCLUSION

Designers should work to improve the fit and comfort properties of protective masks; evidence suggests the System Usability Scale may be a useful tool in those efforts.

APPLICATION

Understanding mask design and behavioral issues related to their use can help in the development of masks and will maximize their acceptance and effectiveness in the field.

Health effects of filtering facepiece respirators: Research and clinical implications of comfort, thermal, skin, psychologic, and workplace effects

Filtering facepiece respirators (FFR's) such as N95s have become widely used in appropriate settings for personal respiratory protection and are increasingly used beyond workplace settings. Concerns about possible adverse effects have appeared in many publications, particularly since the COVID-19 pandemic led to much more widespread use. This paper synthesizes known effects based upon review of publications in PubMed since 1995, addressing effects other than pulmonary and cardiovascular (reviewed elsewhere). Findings: (1) Subjective discomfort is very frequently reported; this includes general discomfort or organ-system-specific complaints such as respiratory, headache, dermatologic, and heat. Research methods are widely divergent, and we propose a taxonomy to classify such studies by methodology, study population (subjects, experimental vs. observational methodology, comparator, specificity, and timeframe) to facilitate synthesis. (2) Objective measures of increased heat and humidity within the mask are well documented. (3) Frequency and characteristics of dermatologic effects have been insufficiently evaluated. (4) Physical mask designs are varied, making generalizations challenging. (5) More studies of impact on work performance and communication are needed. (6) Studies of effect of FFR design and accompanying training materials on ease and consistency of use are needed.

One year of COVID-19 in dental health services in Norway: psychological impact, risk perceptions and vaccination status

BACKGROUND

Increased psychological pressure on oral healthcare professionals (OHP) due to COVID-19 has been shown, yet little is known about the long-term psychological impacts. We aimed to study the psychological impact of COVID-19 and associated factors including perceived risk and preparedness and vaccination status among OHP in the first year after the lockdown period in Norway.

METHODS

A structured questionnaire sent electronically to dentists, dental hygienists and dental assistants inquired experiences and perceptions during the second year following the outbreak in Norway. The questionnaire comprised a COVID-19 fear scale and questions about risk perception, preparedness and vaccination status. Exploratory factor analysis (EFA) and Structural Equation Modeling (SEM) were used to assess psychological impact, perception of risk and preparedness according to vaccination status of the respondents.

RESULTS

The majority of the 708 respondents were female (92.8%), had ten or more years of work experience (67.1%), and worked in public dental clinics (95.9%). Fears and concerns related to COVID-19 were common, 72.6% feared getting infected and 85.4% feared infecting others. Of the 642 respondents who agreed that their workplaces handled the situation well, 55.6% were fully vaccinated. Three factors were retrieved from EFA: Insecurity, Instability and Infection. SEM showed that females were more concerned with Infection, and respondents with long clinical experience were less likely to express fear about Instability. Fully vaccinated individuals felt more insecure about becoming infected, and those agreeing that their workplaces handled the current situation well were concerned with Insecurity.

CONCLUSIONS

Despite widespread perception of adequate preparedness and high vaccine coverage, a considerable psychological impact and high levels of fear of COVID-19 were observed among the majority of OHP. Fully vaccinated individuals had a larger psychological burden than not fully vaccinated and those with unknown vaccination status. These findings can inform means and interventions to reduce negative impacts of fear in populations with a high psychological burden.

Psychological and psychosocial determinants of COVID Health Related Behaviours (COHeRe): An evidence and gap map

Background

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has resulted in illness, deaths and societal disruption on a global scale. Societies have implemented various control measures to reduce transmission of the virus and mitigate its impact. Individual behavioural changes are crucial to the successful implementation of these measures. Common recommended measures to limit risk of infection include frequent handwashing, reducing the frequency of social interactions and the use of face coverings. It is important to identify those factors that can predict the uptake and maintenance of these protective behaviours.

Objectives

We aimed to identify and map the existing evidence (published and unpublished) on psychological and psychosocial factors that determine uptake and adherence to behaviours aimed at reducing the risk of infection or transmission of COVID-19.

Search Methods

Our extensive search included electronic databases (n = 12), web searches, conference proceedings, government reports, other repositories including both published peer reviewed, pre-prints and grey literature. The search strategy was built around three concepts of interest including (1) context (terms relating to COVID-19), (2) behaviours of interest and (3) terms related to psychological and psychosocial determinants of COVID Health-Related Behaviours and adherence or compliance with recommended behaviours, to capture both malleable and non-malleable determinants (i.e. determinants that could be changed and those that could not).

Selection Criteria

This Evidence and Gap Map (EGM) includes all types of studies examining determinants of common recommended behaviours aimed at mitigating human-to-human spread of COVID-19. All potential malleable and non-malleable determinants of one or more behaviours are included in the map. As part of the mapping process, categories are used to group determinants. The mapping categories were based on a previous rapid review by Hanratty 2021. These include: 'behaviour', 'cognition', 'demographics', 'disease', 'emotions', 'health status', 'information', 'intervention', and 'knowledge'. Those not suitable for categorisation in any of these groups are included in the map as 'other' determinants.

Data Collection and Analysis

Results were imported to a bibliographic reference manager where duplications of identical studies gathered from multiple sources were removed. Data extraction procedures were managed in EPPI-Reviewer software. Information on study type, population, behaviours measured and determinants measured were extracted. We appraised the methodological quality of systematic reviews with AMSTAR-2. We did not appraise the quality of primary studies in this map.

Main Results

As of 1 June 2022 the EGM includes 1034 records reporting on 860 cross-sectional, 68 longitudinal, 78 qualitative, 25 reviews, 62 interventional, and 39 other studies (e.g., mixed-methods approaches). The map includes studies that measured social distancing (n = 487), masks and face coverings (n = 382), handwashing (n = 308), physical distancing (n = 177), isolation/quarantine (n = 157), respiratory hygiene/etiquette (n = 75), cleaning surfaces (n = 59), and avoiding touching the T-zone (n = 48). There were 333 studies that assessed composite measures of two or more behaviours. The largest cluster of determinants was 'demographics' (n = 730 studies), followed by 'cognition' (n = 496 studies) and determinants categorised as 'other' (n = 447). These included factors such as 'beliefs', 'culture' and 'access to resources'. Less evidence is available for some determinants such as 'interventions' (n = 99 studies), 'information' (n = 101 studies), and 'behaviour' (149 studies).

Authors' Conclusions

This EGM provides a valuable resource for researchers, policy-makers and the public to access the available evidence on the determinants of various COVID-19 health-related behaviours. The map can also be used to help guide research commissioning, by evidence synthesis teams and evidence intermediaries to inform policy during the ongoing pandemic and potential future outbreaks of COVID-19 or other respiratory infections. Evidence included in the map will be explored further through a series of systematic reviews examining the strength of the associations between malleable determinants and the uptake and maintenance of individual protective behaviours.

SARS-CoV-2 Papain-like Protease Responsive ZnO/Daclatasvir-Loaded Chitosan/Gelatin Nanofibers as Smart Antimicrobial Medical Textiles: In Silico, In Vitro and Cell Studies

A significant number of deaths are reported annually worldwide due to microbial and viral infections. The development of protective medical textiles for patients and healthcare professionals has attracted many researchers' attention. Therefore, this study aims to develop smart drug-eluting nanofibrous matrices to be used as a basic material for medical textile fabrication. First, chitosan/gelatin nanofibers were selected as the basic material owing to the wide antimicrobial activity of chitosan and the capability of gelatin to be hydrolyzed in the abundance of the papain-like protease (PLpro) enzyme secreted by SARS-CoV-2. Daclatasvir (DAC), an NS5A inhibitor, was selected as the model drug based on in silico studies where it showed high anti-SARS-CoV-2 potential compared to FDA-approved references. Due to their reported antimicrobial and antiviral activities, ZnO NPs were successfully prepared and incorporated with daclatasvir in chitosan/gelatin nanofibrous matrices through electrospinning. Afterward, an in vitro release study in a simulated buffer revealed the controlled release of DAC over 21 days from the nanofibers compared to only 6 h for free DAC. On the other hand, the abundance of PLpro induced the complete release of DAC from the nanofibers in only 4-8 h. Finally, the nanofibers demonstrated a wide antimicrobial activity against S. aureus, E. coli, and C. albicans.

Masking strategy to protect healthcare workers from COVID-19: An umbrella meta-analysis

BACKGROUND

The burden of severe disease and death due to SARS-CoV-2 (COVID-19) pandemic among healthcare workers (HCWs) worldwide has been substantial. Masking is a critical control measure to effectively protect HCWs from respiratory infectious diseases, yet for COVID-19, masking policies have varied considerably across jurisdictions. As Omicron variants began to be predominant, the value of switching from a permissive approach based on a point of care risk assessment (PCRA) to a rigid masking policy needed to be assessed.

METHODS

A literature search was conducted in MEDLINE (Ovid platform), Cochrane Library, Web of Science (Ovid platform), and PubMed to June 2022. An umbrella review of meta-analyses investigating protective effects of N95 or equivalent respirators and medical masks was then conducted. Data extraction, evidence synthesis and appraisal were duplicated.

RESULTS

While the results of Forest plots slightly favoured N95 or equivalent respirators over medical masks, eight of the ten meta-analyses included in the umbrella review were appraised as having very low certainty and the other two as having low certainty.

CONCLUSION

The literature appraisal, in conjunction with risk assessment of the Omicron variant, side-effects and acceptability to HCWs, along with the precautionary principle, supported maintaining the current policy guided by PCRA rather than adopting a more rigid approach. Well-designed prospective multi-centre trials, with systematic attention to the diversity of healthcare settings, risk levels and equity concerns are needed to support future masking policies.

Understanding a constellation of eight COVID-19 disease prevention behaviours using the COM-B model and the theoretical domains framework: a qualitative study using the behaviour change wheel

Background

The use of behavioural science and behaviour change within local authorities and public health has supported healthful change; as evidenced by its importance and contribution to reducing harm during the COVID-19 pandemic. It can provide valuable information to enable the creation of evidence-based intervention strategies, co-created with the people they are aimed at, in an effective and efficient manner.

Aim

This study aimed to use the COM-B model to understand the Capability, Opportunity and Motivation of performing a constellation of eight COVID-19 disease prevention behaviours related to the slogans of 'Hands, Face, Space, Fresh Air'; 'Find, Isolate, Test, (FIT), and Vaccinate' in those employed in workplaces identified as high risk for transmission of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) to support intervention development.

Methods

This qualitative study recruited twenty-three participants (16 female, 7 male), who were interviewed from three environments (schools, care homes, warehouses) across three local authorities. Semi-structured interviews were analysed using thematic analysis.

Findings

Ten core themes were identified inductively; (1) knowledge and skills, (2) regulating the behaviour, (3) willingness to act, (4) necessity and concerns, (5) emotional impact, (6) conducive environment, (7) societal influence, (8) no longer united against COVID-19, (9) credible leadership, and (10) inconsistent adherence to COVID-19 prevention behaviours. Themes were then deductively mapped to the COM-B model of behaviour change and the theoretical domains framework and a logic model using the behaviour change wheel (BCW) was produced to inform intervention design.

Conclusion

This study offers a novel approach to analysis that has included eight behaviours within a single thematic analysis and COM-B diagnosis. This will enable local authorities to direct limited resources to overarching priorities. Of key importance, was the need for supportive and credible leadership, alongside developing interventions collaboratively with the target audience. COVID-19 has had an emotional toll on those interviewed, however, promoting the value of disease prevention behaviours, over and above their costs, can facilitate behaviour. Developing knowledge and skills, through education, training, marketing and modelling can further facilitate behaviour. This supports guidance produced by the British Psychological Society COVID-19 behavioural science and disease prevention taskforce.

Face masks influence emotion judgments of facial expressions: a drift-diffusion model

Face masks slow the spread of SARS-CoV-2, but it has been unknown how masks might reshape social interaction. One important possibility is that masks may influence how individuals communicate emotion through facial expressions. Here, we clarify to what extent-and how-masks influence facial emotion communication, through drift-diffusion modeling (DDM). Over two independent pre-registered studies, conducted three and 6 months into the COVID-19 pandemic, online participants judged expressions of 6 emotions (anger, disgust, fear, happiness, sadness, surprise) with the lower or upper face "masked" or unmasked. Participants in Study 1 (N = 228) correctly identified expressions above chance with lower face masks. However, they were less likely-and slower-to correctly identify these expressions relative to without masks, and they accumulated evidence for emotion more slowly-via decreased drift rate in DDM. This pattern replicated and intensified 3 months later in Study 2 (N = 264). These findings highlight how effectively individuals still communicate with masks, but also explain why they can experience difficulties communicating when masked. By revealing evidence accumulation as the underlying mechanism, this work suggests that time-sensitive situations may risk miscommunication with masks. This research could inform critical interventions to promote continued mask wearing as needed.

The Enduring Effects of COVID for Cancer Care: Learning from Real-Life Clinical Practice

For three years, COVID-19 has circulated among our communities and around the world, fundamentally changing social interactions, health care systems, and service delivery. For people living with (and receiving treatment for) cancer, pandemic conditions presented significant additional hurdles in an already unstable and shifting environment, including disrupted personal contact with care providers, interrupted access to clinical trials, distanced therapeutic encounters, multiple immune vulnerabilities, and new forms of financial precarity. In a 2020 perspective in this journal, we examined how COVID-19 was reshaping cancer care in the early stages of the pandemic and how these changes might endure into the future. Three years later, and in light of a series of interviews with patients and their caregivers from the United States and Australia conducted during the pandemic, we return to consider the potential legacy effects of the pandemic on cancer care. While some challenges to care provision and survivorship were unforeseen, others accentuated and amplified existing problems experienced by patients, caregivers, and health care providers. Both are likely to have enduring effects in the "post-pandemic" world, raising the importance of focusing on lessons that can be learned for the future.

The impacts and implications of the community face mask use during the Covid-19 pandemic: A qualitative narrative interview study

INTRODUCTION

A range of nonpharmaceutical public health interventions has been introduced in many countries following the rapid spread of Covid-19 since 2020, including recommendations or mandates for the use of face masks or coverings in the community. While the effectiveness of face masks in reducing Covid-19 transmission has been extensively discussed, scant attention has been paid to the lived experience of those wearing face masks.

METHOD

Drawing on 40 narrative interviews with a purposive sample of people in the United Kingdom, with a particular focus on marginalised and minoritized groups, our paper explores experiences of face mask use during the pandemic.

RESULTS

We find that face masks have a range of societal, health and safety impacts, and prompted positive and negative emotional responses for users. We map our findings onto Lorenc and Oliver's framework for intervention risks. We suggest that qualitative data offer particular insights into the experiences of public health interventions, allowing the potential downsides and risks of interventions to be more fully considered and informing public health policies that might avoid inadvertent harm, particularly towards marginalised groups.

PATIENT OR PUBLIC CONTRIBUTION

The study primarily involved members of the public in the conduct of the research, namely through participation in interviews (email and telephone). The conception for the study involved extensive discussions on social media with a range of people, and we received input and ideas from presentations we delivered on the preliminary analysis.

Reduction of in-hospital non-COVID-19 pneumonia in stroke patients during the COVID-19 pandemic

BACKGROUND

Measures adopted to contain the spread of SARS-CoV-2 could have led to a reduction in the rate of non-COVID-19 infections. We assessed whether a similar reduction was present in patients with stroke.

METHODS

We performed a hospital-based study nested in a prospective population-based registry. We compared prevalence of infections and in-hospital mortality in subjects admitted for acute stroke between the first pandemic year (study period, from March 2020 to February 2021) and the pre-pandemic year (control period, from March 2019 to February 2020). Infections were reported as pneumonia (PNA), urinary tract infections (UTI), and any infection (INF).

RESULTS

From the control (n = 677) to the study period (n = 520), the prevalence of INF decreased from 11.5 to 4.6% (p < 0.001) and that of PNA decreased from 6.9 to 2.5% (p = 0.001). No changes in in-hospital mortality and length of hospital stay were observed between the two periods.

CONCLUSIONS

The observed reduction of in-hospital pneumonias in patients with stroke was likely attributable to the use of protective measures and limitation of hospital visits. Maintaining some of those measures in the long term may contribute to control infections in hospitalized patients with stroke.

Can mask mandates boost nature-based tourism? The role of escapism and travel anxiety

Tourism in a post-pandemic era will likely be oriented toward nature because contact with nature has restorative health benefits. The purpose of this study was to analyze the antecedents of tourists' intentions to visit nature-based resorts during a pandemic. A nationally representative sample of the Spanish population (n = 500) was recruited by an online commercial panel to test and empirically validate the proposed conceptual framework. The findings confirmed a direct relationship between negative perceptions of wearing face masks during the COVID-19 pandemic and tourists' intentions to visit nature-based resorts. The relationship between the perceived negative effects of wearing face masks and the intention to visit nature-based resorts was positively mediated by the need for escapism. This impact was less pronounced for anxious travelers, as shown by results corroborating the moderating effect of travel anxiety. The findings of this study contribute to research on tourism crises and provide future insights into the recovery of the industry during COVID-19.

Development and evaluation of a fluidic facemask for airborne transmission mitigation

Recently, a fluidic facemask concept was proposed to mitigate the transmission of virus-laden aerosol and droplet infections, such as SARS-CoV-2 (COVID-19). This paper describes an experimental investigation of the first practical fluidic facemask prototype, or "Air-Screen". It employs a small, high-aspect-ratio, crossflow fan mounted on the visor of a filter-covered cap to produce a rectangular air jet, or screen, in front of the wearer's face. The entire assembly weighs less than 200 g. Qualitative flow visualization experiments using a mannequin clearly illustrated the Air-Screen's ability to effectively block airborne droplets (∼10⁰ µm) from the wearer's face. Quantitative experiments to simulate droplets produced during sneezing or a wet cough (∼10² µm) were propelled (via a transmitter) at an average velocity of 50 m/s at 1 m from the mannequin or a target. The Air-Screen blocked 62% of all droplets with a diameter of less than 150 µm. With an Air-Screen active on the transmitter, 99% of all droplets were blocked. When both mannequin and transmitter Air-Screens were active, 99.8% of all droplets were blocked. A mathematical model, based on a weakly-advected jet in a crossflow, was employed to gain greater insight into the experimental results. This investigation highlighted the remarkable blocking effect of the Air-Screen and serves as a basis for a more detailed and comprehensive experimental evaluation.

Designing better cloth masks: The effect of fabric and attachment-style on discomfort

Cloth masks are a tool for controlling community transmission during pandemics, as well as during other outbreak situations. However, cloth masks vary in their designs, and the consequences of this variability for their effectiveness as source control have received little attention, particularly in terms of user discomfort and problematic mask-wearing behaviors. In the present studies, common design parameters of cloth masks were systematically varied to ascertain their effect(s) on the subjective discomfort and frequency of problematic mask-wearing behaviors, which detract from the effectiveness of cloth masks as source control. The type of fabric comprising a mask (flannel or twill made of 100% cotton) and the attachment-style of a mask (i.e., ear loops or fabric ties) were varied in adults (18 to 65 years) and children (ages 6 to 11 years). For adults, ear loops were less comfortable than ties (p = .035) and were associated with greater face- (p = .005) and mask-touching (p = .001). Children, however, found flannel masks to be more breathable than twill masks (p = .007) but touched their masks more frequently when wearing a mask made of flannel than twill (p = .033). Common design parameters of cloth masks not only affect user discomfort and behavior but do so differently in adults and children. To improve the effectiveness of cloth masks as source control, the present studies highlight the importance of measuring the effect(s) of design decisions on user discomfort and behavior in different populations.

Development of a customized mask retainer for improving the fit performance of surgical masks

This study introduces a customized mask retainer to improve the fit performance of surgical masks using various advanced digital techniques. The participant's 3D face scans with and without a surgical mask were taken by using a smartphone. The mask retainer was designed using the 3D face scan data based on the facial anthropometric landmarks. The fitting was inspected and adjusted using the masked face scan data. The retainer was fabricated using a 3D printer. The effectiveness of the retainer on the augmentation of the fit of the surgical mask was tested according to the Chinese Standard (GB 19083-2010). A questionnaire was used to assess the effect of wearing surgical masks with and without retainers and N95 respirators on subjective perception of discomfort. The effectiveness test of the retainer on the augmentation of the fit performance showed a better than 25-fold increase in the overall fit factor, meeting the fit requirement for KN95 respirators in China. The subjective perception of discomfort of wearing N95 was significantly greater than surgical mask with and without retainers. The fit factor results indicated that by using the retainer, the overall fit factors and that of each exercise significantly increased compared to that of the group with the surgical mask alone. And compared with N95, the surgical mask with the retainer significant improved comfort. The surgical mask with the retainer can provide an alternative of personal protective equipment for healthcare workers.

Decreased Speech Comprehension and Increased Vocal Efforts Among Healthcare Providers Using N95 Mask

Aim: N95 masks are recommended for the healthcare providers (HCPs) taking care of patients with coronavirus disease 2019. However, the use of these masks hampers communication. We aimed to evaluate the effect of N95 masks on speech comprehension among listeners and vocal efforts (VEs) of the HCPs.

Materials and Methods: This prospective study involved 50 HCPs. We used a single observer with normal hearing to assess the difficulty in comprehension, while VE was estimated in HCPs. The speech reception threshold (SRT), speech discrimination score (SDS), and VEs were evaluated initially without using N95 mask and then repeated with HCPs wearing N95 mask.

Results: The use of masks resulted in a statistically significant increase in mean SRT [4.25 (1.65) dB] and VE [2.6 (0.69)], with simultaneous decrease in mean SDS [19.2 (8.77)] (all p-values < 0.0001). Moreover, demographic parameters including age, sex, and profession were not associated with change in SRT, SDS, and VE (all p-values > 0.05).

Conclusion: Though use of N95 masks protects the HCPs against the viral infection, it results in decreased speech comprehension and increased VEs. Moreover, these issues are universal among the HCPs and are applicable to the general public as well.

Individual costs and community benefits: Collectivism and individuals' compliance with public health interventions

Differences in national responses to COVID-19 have been associated with the cultural value of collectivism. The present research builds on these findings by examining the relationship between collectivism at the individual level and adherence to public health recommendations to combat COVID-19 during the pre-vaccination stage of the pandemic, and examines different characteristics of collectivism (i.e., concern for community, trust in institutions, perceived social norms) as potential psychological mechanisms that could explain greater compliance. A study with a cross-section of American participants (N = 530) examined the relationship between collectivism and opting-in to digital contact tracing (DCT) and wearing face coverings in the general population. More collectivistic individuals were more likely to comply with public health interventions than less collectivistic individuals. While collectivism was positively associated with the three potential psychological mechanisms, only perceived social norms about the proportion of people performing the public health interventions explained the relationship between collectivism and compliance with both public health interventions. This research identifies specific pathways by which collectivism can lead to compliance with community-benefiting public health behaviors to combat contagious diseases and highlights the role of cultural orientation in shaping individuals' decisions that involve a tension between individual cost and community benefit.

Experiences of face mask use during the COVID-19 pandemic: A qualitative study

The use of face masks and coverings has been a central component of efforts to mitigate the impact of the COVID-19 pandemic and has been legally mandated in some countries. Most academic studies to date, however, have focussed primarily on its effectiveness in reducing SARS-CoV-2 transmission, largely neglecting the social dimensions of mask mandates. In this narrative interview-based study, we consider experiences of face masks, with a particular focus on groups considered to be at a potential disadvantage from compulsory masking. Drawing on 40 telephone, video-call and e-mail interviews, we highlight the impact of inconsistent communication and the notion of mask wearing as an act of altruism on participants' experiences. In particular, we show how intolerance towards individuals who did not wear masks could result in stigma and exclusion, regardless of the legitimacy of their reasons. We suggest that more is needed to mitigate the 'dark side' of discourses of collective effort and altruism at a time of societal stress and fracture, and to account for the needs and interests of groups for whom compulsory masking may result in further marginalisation.

Nanotechnology Transition Roadmap toward Multifunctional Stimuli-Responsive Face Masks

In recent times, the use of personal protective equipment, such as face masks or respirators, is becoming more and more critically important because of common pollution; furthermore, face masks have become a necessary element in the global fight against the COVID-19 pandemic. For this reason, the main mission of scientists has become the development of face masks with exceptional properties that will enhance their performance. The versatility of electrospun polymer nanofibers has determined their suitability as a material for constructing "smart" filter media. This paper provides an overview of the research carried out on nanofibrous filters obtained by electrospinning. The progressive development of the next generation of face masks whose unique properties can be activated in response to a specific external stimulus is highlighted. Thanks to additional components incorporated into the fiber structure, filters can, for example, acquire antibacterial or antiviral properties, self-sterilize the structure, and store the energy generated by users. Despite the discovery of several fascinating possibilities, some of them remain unexplored. Stimuli-responsive filters have the potential to become products of large-scale availability and great importance to society as a whole.

Effect of Face Masks on Physiological and Perceptual Responses during 30 Minutes of Self-Paced Exercise in Older Community Dwelling Adults

This study examined the effects of different types of masks (no mask, surgical mask (SM), and N95-mask) on physiological and perceptual responses during 30-min of self-paced cycle ergometer exercise. This study was a prospective randomly assigned experimental design. Outcomes included workload (Watts), oxygen saturation (SpO₂), end-tidal carbon dioxide (PetCO₂), heart rate (HR), respiratory rate (RR), rating of perceived exertion (RPE), and rating of perceived dyspnea (RPD). Volunteers (54-83 years (n = 19)) completed two familiarization sessions and three testing sessions on an air braked cycle ergometer. No significant difference was found for condition x time for any of the dependent variables. RPE, RPD, and PetCO₂ were significantly higher with an N95-mask vs. no mask (NM) ((p = 0.012), (p = 0.002), (p < 0.001)). HR was significantly higher with the SM compared to the NM condition (p = 0.027) (NM 107.18 ± 9.96) (SM 112.34 ± 10.28), but no significant difference was found when comparing the SM to the N95 condition or when comparing the N95condition to the NM condition. Watts increased across time in each condition (p = 0.003). Initially RR increased during the first 3 min of exercise (p < 0.001) with an overall gradual increase noted across time regardless of mask condition (p < 0.001). SpO₂ significantly decreased across time but remained within normal limits (>95%). No significant difference was found in Watts, RR, or SpO₂ regardless of mask condition. Overall, the N95mask was associated with increased RPE, RPD, and PetCO₂ levels. This suggests trapping of CO₂ inside the mask leading to increased RPE and RPD.

Perspectives, benefits and challenges of a live OSCE during the COVID-19 pandemic in a cross-sectional study

OBJECTIVES

Restrictions due to the COVID-19 pandemic mandated fundamental changes to student evaluations, including the administration of the observed structured clinical examination (OSCE). This study aims to conduct an in-person OSCE to verify students' practical skills under necessary infection control practices and the impact of face masks on student-patient interactions.

DESIGN

Cross-sectional design.

SETTING

The OSCE at Medical School of Tuebingen takes place in October 2020.

PARTICIPANTS

A total of 149 students (third year of study) completed the survey (RR=80.1%). It was their first OSCE.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measure was how this type of OSCE was evaluated by participating students in regard to preparation, content and difficulty as well as in real life. Secondary outcome measures were how the implemented hygiene actions influenced the OSCE, including the interaction and communication between students and standardised patients (SPs). Items were rated on a 6-point Likert scale (1=completely to 6=not at all). Means, SDs, frequencies and percentages were calculated.

RESULTS

149 students, 32 SPs and 59 examiners participated. The students rated the OSCE with 2.37 (±0.52) for preparation and 2.07 (±0.32) for content. They perceived the interaction to be significantly disrupted by the use of face masks (3.03±1.54) (p<0.001) compared with the SPs (3.84±1.44) and the examiners (4.14±1.55). In general, the three groups considered the use of face masking the OSCE to be helpful (1.60±1.15).

CONCLUSIONS

An in-person OSCE, even in the midst of a global pandemic, is feasible and acceptable to both students and faculty. When compared the students' results to previous students' results who completed the OSCE before the pandemic, the results indicated that students felt less prepared than under non-pandemic circumstances; however, their performances on this OSCE were not lower.

Medical masks' and respirators' pattern of use, adverse effects and errors among Portuguese health care professionals during the COVID-19 pandemic: A cross-sectional study

Background

During COVID-19 pandemic, a shortage of surgical masks (Mask) and respirators (Resp) was experienced worldwide. We aimed to assess its pattern of use, adverse effects and user errors by Portuguese health care professionals (HCP).

Methods

A cross-sectional study was conducted through snowball convenience sample, collected by email/ social media to health care organizations. Participants answered an online anonymous survey in March 2021.

Results

Mean age of 3052 respondents was 42.1 years old, 83.6% were female and 77.8% provided direct health care to COVID-19 patients. Mean time of use per shift was 6-8 hours in 40.8% of the participants. 28.0% reported never changing it during their shift. Resp use (vs Mask) was more associated with discomfort (58.2% vs 26.8%), affecting task performance (41.5 vs 18.9%) and communication (55.0 vs 40.9%), dyspnea (36.0 vs 14.4%), skin rash (37.5 vs 19.4%) and headache (37.5 vs 19.4%). Frequent user errors included touching the front while in use (70.1% Mask vs 66.3% Resp) and omitting hand hygiene before (61.8% Mask vs 55.0% Resp) or after use (61.3% Mask vs 57.0% Resp). Average number of errors was higher for Mask (4.3), than for Resp (3.2) (all: P < .001).

Conclusions

Most HCP admitted an extended use of Mask/ Resp. Resp were more prone to adverse effects and Mask more prone to errors. Strategies to reinforce good practices should be considered.

Bayesian network meta-analysis of face masks' impact on human physiology

Several concerns regarding the safety of face masks use have been propounded in public opinion. The objective of this review is to examine if these concerns find support in the literature by providing a comprehensive overview of physiological responses to the use of face masks. We have performed a systematic review, pairwise and network meta-analyses to investigate physiological responses to the use of face masks. The study has been registered with PROSPERO (C RD42020224791). Obtained results were screened using our exclusion and inclusion criteria. Meta-analyses were performed using the GeMTC and meta R packages. We have identified 26 studies meeting our inclusion and exclusion criteria, encompassing 751 participants. The use of face masks was not associated with significant changes in pulsoxymetrically measured oxygen saturation, even during maximal-effort exercises. The only significant physiological responses to the use of face masks during low-intensity activities were a slight increase in heart rate, mildly elevated partial pressure of carbon dioxide (not meeting criteria for hypercarbia), increased temperature of facial skin covered by the mask, and subsequent increase of the score in the rating of heat perception, with N95 filtering facepiece respirators having a greater effect than surgical masks. In high-intensity conditions, the use of face masks was associated with decreased oxygen uptake, ventilation, and RR. Face masks are safe to use and do not cause significant alterations in human physiology. The increase in heart rate stems most likely from increased respiratory work required to overcome breathing resistance. The increase in carbon dioxide is too small to be clinically relevant. An increased rating of heat perception when using face masks results from higher temperature of facial skin covered by the mask.

Assessing Car Seat Posture through Comfort and User Experience

The vehicular market is undergoing a profound transformation that includes a trend toward fully automated driving. When travelling in automated systems, the main task is no longer driving. Therefore, the interior design of automated vehicles requires a renovation to adapt to new use cases. With this motivation, the use case of sleeping while travelling was chosen for this user study, in which different seat configuration conditions were evaluated. The three preselected seat positions for this research included the upright, reclined and flat seat positions. To the best of our knowledge, this study is the first to examine the comfort of different seat angles in meeting the need to sleep in a moving vehicle. Since the physical experience of the occupants with a high-fidelity seat prototype is essential to evaluate the new interior concept of the vehicle of the future, in this study, the experimental participants were asked about their perception of comfort and overall user experience while travelling by car under close-to-real test conditions. Therefore, the primary objective of this evaluation was to explore different seat configurations and find the most suitable seat position for the use case of sleeping in a car while moving. Our findings suggest that users prefer reclining and flat seats in short-/medium- and long-term use cases, respectively.

Face mask mandates and risk compensation: an analysis of mobility data during the COVID-19 pandemic in Bangladesh

Introduction

Concerns have been raised about the potential for risk compensation in the context of mask mandates for mitigating the spread of COVID-19. However, the debate about the presence or absence of risk compensation for universal mandatory mask-wearing rules—especially in the context of COVID-19—is not settled yet.

Methods

Mobility is used as a proxy for risky behaviour before and after the mask mandates. Two sets of regressions are estimated to decipher (any) risk-compensating effect of mask mandate in Bangladesh. These include: (1) intervention regression analysis of daily activities at six types of locations, using pre-mask-mandate and post-mandate data; and (2) multiple regression analysis of daily new COVID-19 cases on daily mobility (lagged) to establish mobility as a valid proxy.

Results

(1) Statistically, mobility increased at all five non-residential locations, while home stays decreased after the mask mandate was issued; (2) daily mobility had a statistically significant association on daily new cases (with around 10 days of lag). Both significances were calculated at 95% confidence level.

Conclusion

Community mobility had increased (and stay at home decreased) after the mandatory mask-wearing rule, and given mobility is associated with increases in new COVID-19 cases, there is evidence of risk compensation effect of the mask mandate—at least partially—in Bangladesh.

Machine learning empowered COVID-19 patient monitoring using non-contact sensing: An extensive review

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which caused the coronavirus disease 2019 (COVID-19) pandemic, has affected more than 400 million people worldwide. With the recent rise of new Delta and Omicron variants, the efficacy of the vaccines has become an important question. The goal of various studies has been to limit the spread of the virus by utilizing wireless sensing technologies to prevent human-to-human interactions, particularly for healthcare workers. In this paper, we discuss the current literature on invasive/contact and non-invasive/non-contact technologies (including Wi-Fi, radar, and software-defined radio) that have been effectively used to detect, diagnose, and monitor human activities and COVID-19 related symptoms, such as irregular respiration. In addition, we focused on cutting-edge machine learning algorithms (such as generative adversarial networks, random forest, multilayer perceptron, support vector machine, extremely randomized trees, and k-nearest neighbors) and their essential role in intelligent healthcare systems. Furthermore, this study highlights the limitations related to non-invasive techniques and prospective research directions.

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This article describes cutting-edge technology (invasive/non-invasive) and its role in the recognition of COVID-19 symptoms.

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This article summarizes state-of-art machine-learning algorithms and their roles in modern healthcare systems.

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This article presents the challenges associated with wireless sensing techniques and potential future research directions.

Development and validation of the discomfort of cloth Masks-12 (DCM-12) scale

During the COVID-19 pandemic, the use of face masks by the public has helped to slow the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the community. Cloth masks have been recommended because of their effectiveness, availability, and reusability. Like other types of face masks, however, user discomfort while wearing cloth masks is thought to engender behaviors that limit the effectiveness of cloth masks as source control (e.g., adjusting or removing one's mask temporarily while in public). To design cloth masks that are more tolerable, a measurement instrument for assessing subjective user discomfort is needed. Across two studies, we identified and confirmed a two-dimensional factor structure underlying the discomfort of cloth masks - discomfort related to the breathability and discomfort related to the tightness of the mask against the face and head. Additionally, we provide replicable evidence that both factor-subscales predict the self-reported frequencies of problematic mask-wearing behaviors.

Telehealth and food insecurity screenings: challenges and lessons learned

Food insecurity remains a persistent problem in the United States and affected 35.2 million Americans in 2019. In the wake of COVID-19, food insecurity has increased in many communities. Given that food insecurity exacerbates poor health or health conditions, screening of food insecurity within medical settings is frequently identified within the literature as an important first step in effectively addressing this social concern and improving the health outcomes of patients. However, health care providers often do not screen for food insecurity for a variety of reasons. In this article review, we discuss the challenges associated with incorporating food insecurity screenings within the medical model and how the COVID-19 pandemic has exacerbated these challenges. Specifically, the COVID-19 pandemic has substantially increased the delivery of health care services via telehealth, making screening for food insecurity even more difficult via remote videoconferencing. We examine the strengths and weaknesses of telehealth and their implications for food insecurity screenings. We discuss how these implications might inform future research regarding the use of telehealth as a means of screening patients for social determinants of health in the COVID-19 era. Given that the use of telehealth is not expected to back to pre-pandemic levels, it is important to understand how to best screen for social determinants of health via videoconferencing.

Personal Interventions to Reduce Exposure to Outdoor Air Pollution

Unhealthy levels of air pollution are breathed by billions of people worldwide, and air pollution is the leading environmental cause of death and disability globally. Efforts to reduce air pollution at its many sources have had limited success, and in many areas of the world, poor air quality continues to worsen. Personal interventions to reduce exposure to air pollution include avoiding sources, staying indoors, filtering indoor air, using face masks, and limiting physical activity when and where air pollution levels are elevated. The effectiveness of these interventions varies widely with circumstances and conditions of use. Compared with upstream reduction or control of emissions, personal interventions place burdens and risk of adverse unintended consequences on individuals. We review evidence regarding the balance of benefits and potential harms of personal interventions for reducing exposure to outdoor air pollution, which merit careful consideration before making public health recommendations with regard to who should use personal interventions and where, when, and how they should be used. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Face masks increase compliance with physical distancing recommendations during the COVID-19 pandemic

Governments across the world have implemented restrictive policies to slow the spread of COVID-19. Recommended face mask use has been a controversially discussed policy, among others, due to potential adverse effects on physical distancing. Using a randomized field experiment (N = 300), we show that individuals kept a significantly larger distance from someone wearing a face mask than from an unmasked person during the early days of the pandemic. According to an additional survey experiment (N = 456) conducted at the time, masked individuals were not perceived as being more infectious than unmasked ones, but they were believed to prefer more distancing. This result suggests that wearing a mask served as a social signal that led others to increase the distance they kept. Our findings provide evidence against the claim that mask use creates a false sense of security that would negatively affect physical distancing. Furthermore, our results suggest that behavior has informational content that may be affected by policies.

Face mask use and physical distancing before and after mandatory masking: No evidence on risk compensation in public waiting lines

During the COVID-19 pandemic, the introduction of mandatory face mask usage triggered a heated debate. A major point of controversy is whether community use of masks creates a false sense of security that would diminish physical distancing, counteracting any potential direct benefit from masking. We conducted a randomized field experiment in Berlin, Germany, to investigate how masks affect distancing and whether the mask effect interacts with the introduction of an indoor mask mandate. Joining waiting lines in front of stores, we measured distances kept from the experimenter in two treatment conditions - the experimenter wore a mask in one and no face covering in the other - in two time spans - before and after mask use becoming mandatory in stores. We find no evidence that mandatory masking has a negative effect on distance kept toward a masked person. To the contrary, masks significantly increase distancing and the effect does not differ between the two periods. However, we show that after the mandate distances are shorter in locations where more non-essential stores, which were closed before the mandate, had reopened. We argue that the relaxations in general restrictions that coincided with the mask mandate led individuals to reduce other precautions, like keeping a safe distance.

Universal use of surgical masks is tolerated and prevents respiratory viral infection in stem cell transplant recipients

Prevention of respiratory viral infection in stem cell transplant patients is important due to its high risk of adverse outcome. This single-centre, mixed methods study, conducted before the severe acute respiratory syndrome coronavirus-2 pandemic, explored the barriers and facilitators to a policy of universal mask use by visitors and healthcare workers, and examined the impact of the first year of introduction of the policy on respiratory viral infection rates compared with preceding years, adjusted for overall incidence. Education around universal mask use was highlighted as being particularly important in policy implementation. A significant decrease in respiratory viral infection was observed following introduction.

Efficacy of face masks against respiratory infectious diseases: a systematic review and network analysis of randomized-controlled trials

During the ongoing COVID-19 pandemic, face masks are among the most common and practical control measures used globally in reducing the risk of infection and disease transmission. Although several studies have investigated the efficacy of various face masks and respirators in preventing infection, the results have been inconsistent. Therefore, we performed a systematic review and network meta-analysis (NMA) of the randomized-controlled trials (RCTs) to assess the actual efficacy of face masks in preventing respiratory infections. We searched nine electronic databases up to July 2020 to find potential articles. We accepted trials reporting the protective efficacy of face masks against respiratory infections, of which the primary endpoint was the presence of respiratory infections. We used the ROB-2 Cochrane tool to grade the trial quality. We initially registered the protocol for this study in PROSPERO (CRD42020178516). Sixteen RCTs involving 17 048 individuals were included for NMA. Overall, evidence was weak, lacking statistical power due to the small number of participants, and there was substantial inconsistency in our findings. In comparison to those without face masks, participants with fit-tested N95 respirators were likely to have lesser infection risk (RR 0.67, 95% CI 0.38-1.19,P-score 0.80), followed by those with non-fit-tested N95 and non-fit-tested FFP2 respirators that shared the similar risk, (RR 0.73, 95% CI 0.12-4.36,P-score 0.63) and (RR 0.80, 95% CI 0.38-1.71,P-score 0.63), respectively. Next, participants who donned face masks with and without hand hygiene practices showed modest risk improvement alike (RR 0.89, 95% CI 0.67-1.17,P-score 0.55) and (RR 0.92, 95% CI 0.70-1.22,P-score 0.51). Otherwise, participants donning double-layered cloth masks were prone to infection (RR 4.80, 95% CI 1.42-16.27,P-score 0.01). Eleven out of 16 RCTs that underwent a pairwise meta-analysis revealed a substantially lower infection risk in those donning medical face masks (MFMs) than those without face masks (RR 0.83 95% CI 0.71-0.96). Given the body of evidence through a systematic review and meta-analyses, our findings supported the protective benefits of MFMs in reducing respiratory transmissions, and the universal mask-wearing should be applied-especially during the COVID-19 pandemic. More clinical data is required to conclude the efficiency of cloth masks; in the short term, users should not use cloth face masks in the outbreak hot spots and places where social distancing is impossible.

Maintaining mask momentum in transplant recipients

The widespread use of facemasks has been a crucial element in the control of the SARS‐CoV‐2 pandemic.  With mounting evidence for mask efficacy against respiratory infectious diseases and greater acceptability of this intervention, it is proposed that masking should continue after the pandemic has abated to protect some of our most vulnerable patients, recipients of stem cell and solid organ transplants. This may involve not only masking these high‐risk patients, but possibly their close contacts and the healthcare workers involved in their care. We review the evidence for mask efficacy in prevention of respiratory viruses other than SARS‐CoV‐2 and address the burden of disease in transplant recipients.  Although we acknowledge that there are limited data on masking to prevent infection in transplant recipients, we propose a framework for the study and implementation of routine masking as a part of infection prevention interventions after transplantation.

COVID-19 false dichotomies and a comprehensive review of the evidence regarding public health, COVID-19 symptomatology, SARS-CoV-2 transmission, mask wearing, and reinfection

Scientists across disciplines, policymakers, and journalists have voiced frustration at the unprecedented polarization and misinformation around coronavirus disease 2019 (COVID-19) pandemic. Several false dichotomies have been used to polarize debates while oversimplifying complex issues. In this comprehensive narrative review, we deconstruct six common COVID-19 false dichotomies, address the evidence on these topics, identify insights relevant to effective pandemic responses, and highlight knowledge gaps and uncertainties. The topics of this review are: 1) Health and lives vs. economy and livelihoods, 2) Indefinite lockdown vs. unlimited reopening, 3) Symptomatic vs. asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 4) Droplet vs. aerosol transmission of SARS-CoV-2, 5) Masks for all vs. no masking, and 6) SARS-CoV-2 reinfection vs. no reinfection. We discuss the importance of multidisciplinary integration (health, social, and physical sciences), multilayered approaches to reducing risk ("Emmentaler cheese model"), harm reduction, smart masking, relaxation of interventions, and context-sensitive policymaking for COVID-19 response plans. We also address the challenges in understanding the broad clinical presentation of COVID-19, SARS-CoV-2 transmission, and SARS-CoV-2 reinfection. These key issues of science and public health policy have been presented as false dichotomies during the pandemic. However, they are hardly binary, simple, or uniform, and therefore should not be framed as polar extremes. We urge a nuanced understanding of the science and caution against black-or-white messaging, all-or-nothing guidance, and one-size-fits-all approaches. There is a need for meaningful public health communication and science-informed policies that recognize shades of gray, uncertainties, local context, and social determinants of health.

Anxiety Sensitivity Mediates Relations Between Mental Distress Symptoms and Medical Care Utilization During COVID-19 Pandemic

Anxiety and uncertainty are common during pandemics. The present study extended previous pandemic research by investigating the role of two transdiagnostic risk factors — anxiety sensitivity (AS: fear of physiological anxiety or “fear of fear”; Reiss & McNally, 1985) and intolerance of uncertainty (IU; Buhr & Dugas, 2009) — in explaining relations between mental distress symptoms and behavioural responding during the COVID-19 pandemic. Student and community-based participants (N=457; 87.6% female) were recruited between May and July 2020 to complete measures of anxiety (health, panic, general), depression, and stress. Anxiety and related symptoms were found to be higher than in previous studies. Parallel mediation analyses showed that clinically meaningful levels of mental distress symptoms directly influenced safety behaviours and medical care utilization but also indirectly influenced the latter (vs. former) through AS-physical concerns (vs. IU). CBT interventions, targeting AS-physical concerns, may reduce mental distress symptoms during pandemic and prevent overuse of healthcare.

Transmissibility and transmission of respiratory viruses

Human respiratory virus infections lead to a spectrum of respiratory symptoms and disease severity, contributing to substantial morbidity, mortality and economic losses worldwide, as seen in the COVID-19 pandemic. Belonging to diverse families, respiratory viruses differ in how easy they spread (transmissibility) and the mechanism (modes) of transmission. Transmissibility as estimated by the basic reproduction number (R₀) or secondary attack rate is heterogeneous for the same virus. Respiratory viruses can be transmitted via four major modes of transmission: direct (physical) contact, indirect contact (fomite), (large) droplets and (fine) aerosols. We know little about the relative contribution of each mode to the transmission of a particular virus in different settings, and how its variation affects transmissibility and transmission dynamics. Discussion on the particle size threshold between droplets and aerosols and the importance of aerosol transmission for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza virus is ongoing. Mechanistic evidence supports the efficacies of non-pharmaceutical interventions with regard to virus reduction; however, more data are needed on their effectiveness in reducing transmission. Understanding the relative contribution of different modes to transmission is crucial to inform the effectiveness of non-pharmaceutical interventions in the population. Intervening against multiple modes of transmission should be more effective than acting on a single mode.