The best way to make masks work against Covid-19

Editor’s Note: Rear Admiral Susan Blumenthal, MD, MPA (ret) served as US Assistant Surgeon General, Deputy Assistant Secretary for Health, and a White House Health Advisor. She is the Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research, senior fellow in health policy at New America, clinical professor at Tufts and Georgetown University Schools of Medicine and a visiting professor at the MIT Media Lab. Emily Stark is a research associate in health policy at New America. The views expressed in this commentary are their own. Read more opinion articles on CNN.

What over eight months of navigating the novel coronavirus pandemic has taught us is that a mask is one of the most valuable tools currently available to mitigate the spread of the virus.

Susan Blumenthal, MD

Emily Stark

A recent report produced by the Institute for Health Metrics and Evaluation at the University of Washington found that if 95% of Americans wore masks, we could save nearly 70,000 lives that would otherwise be lost to Covid-19 by March 1. Additional research has shown that wearing face masks reduces the spread of Covid-19. But while infection rates are rising in all 50 states, only 34 states and the District of Columbia require face covering in public. In cities and counties with masking mandates, Covid-19 cases have tended to decline compared to municipalities without such rules. Indeed, according to the US Centers for Disease Control and Prevention, seven studies have confirmed significant declines in coronavirus infections in communities after universal masking orders were implemented.

Yet, more than 30% of the US population does not use them on a daily basis, according to the Institute for Health Metrics and Evaluation.

As the United States faces a tsunami of Covid-19 infections, with 2,200 daily deaths projected by mid-January, a national masking mandate is long overdue as part of a federal strategy to prevent further spread of the virus.

President-elect Joe Biden has made implementing this critical public health intervention a top priority. He will call on governors to enact masking orders in their states and ask local authorities to buttress these actions by making them mandatory in their municipalities.

The U.S. Capitol is seen in the morning hours of November 4, 2020 in Washington, DC. The nation awaits the results of a historic presidential election between President Donald Trump and his Democratic challenger, former Vice President Joe Biden with swing states still too close to call. (Photo by Alex Wong/Getty Images)

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This is a key beginning, because policymakers’ mixed messaging about whether or not to wear masks has been extremely confusing to the public. Additionally, growing Covid-19 pandemic fatigue may be making mask-wearing less likely.

We also urgently need a national mask certification and labeling program to provide people with information that could help them choose which face coverings to wear.

The myriad of face coverings available in the marketplace –from cloth masks to neck gaiters to N95s– has left many people mystified about which to use and what kind of protection it provides. Any mask is better than no mask, but researchers at the N95DECON collaborative have found the level of protection to vary widely among fabric type as well as brands that appear to look similar.

When the CDC recently updated its guidance to underscore that wearing masks provides the dual benefit of protecting both the user and others, it also highlighted the need for more research on which materials best block and filter the virus.

CDC guidance that masks include two or more layers of washable, breathable fabric that cover the nose and mouth completely, secured under the chin and fit snugly around the face is helpful, but for the general public we must raise the bar.

We would never dream of sending our country’s soldiers into combat without state-of-the-art helmets, armor and weapons. In this battle against Covid-19, all Americans need the best personal protection possible to fight back.

Consumers need an easy to use rating system: just as the US requires package content and labeling for tobacco and food products, masks should be rated for the percent of viral particles filtered by the mask.

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The Lincoln Laboratory at the Massachusetts Institute of Technology (MIT) has already conducted tests to determine the percentage of viral particles for N95 and KN95 masks that are uncertified by US agencies or manufactured in foreign countries. More research is needed to evaluate the effectiveness of different materials for consumer masks using a standard methodology so that results can be compared across studies. In addition to labeling, package warnings should be included about use of unregulated materials found in some mask inserts that might shed particles, posing respiratory hazards.

Science should guide a national certification process, with accredited laboratories verifying masks’ filtration of respiratory particles, airflow resistance, and safety of materials used, in addition to establishing a rating system for effectiveness. Manufacturers and the appropriate government agency should work together to develop standards for designs, labeling, and user instructions to reflect the most up-to-date public health recommendations. Such a system would allow consumers to purchase masks based on a scientific evaluation of their performance, giving Americans greater confidence that they have a tool that works when they return to workplaces, schools, and social gatherings.

Government agencies or industry groups customarily grade the safety and quality of a variety of products. Currently, respirators (masks) used in the workplace fall under the purview of the CDC’s National Institute for Occupational Safety and Health, whereas the Food and Drug Administration (FDA) reviews masks used in medical settings. The responsibility to develop and enforce mask standards for the general public should be included in the jurisdiction of an appropriate government agency.

In the meantime, the personal protective equipment (PPE) industry is in the process of setting uniform standards for masks with guidance for the general public. For example, ASTM International, formerly known as the American Society for Testing and Materials, which develops voluntary standards for manufacturers on a variety of products is developing mask design and performance guidance. Their specifications would cover the construction, filtration efficiency, and breathability of masks as well as their size, fit, durability, and cleaning. A Consumer Reports type system would also be very helpful.

This May 4, 2020, file photo provided by the University of Maryland School of Medicine, shows the first patient enrolled in Pfizer's COVID-19 coronavirus vaccine clinical trial at the University of Maryland School of Medicine in Baltimore.

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With a new administration in January 2021 an executive order by the President or guidance from the White House Coronavirus Task Force requiring masks to be worn on federal property could be issued as well as examining other governmental authorities for requiring face coverings to be used in public settings across states.

In addition to issuing clearer guidance on the use face masks, the US Department of Health and Human Services (HHS) should significantly expand and fund a major public education campaign explaining the benefits of wearing masks and how to use them properly. Celebrities, athletes, and local influencers could be recruited to deliver public service announcements demonstrating the importance of wearing masks, serving as role models.

While there may be difficulties in enforcing a universal mask mandate, even small steps toward uniform adoption can help move our country from peril to progress in stemming the tide of viral transmission.

An economic analysis from Goldman Sachs Research found that increasing universal masking by 15% could prevent the need for lockdowns and reduce associated losses of up to $1 trillion or about 5% of the US gross domestic product. As Americans, wearing a mask can become a collective action to help combat this life-threatening disease, providing a path forward toward economic recovery as well.

Public health actions in response to other major health concerns, such as requiring seatbelt use to prevent motor vehicle accidents, food labeling, and health warnings on tobacco products, as well as regulations regarding smoking in public places, have been mandated before and are now accepted social norms. Wearing masks should follow these examples. If non-compliance is an issue, fines or other penalties can be considered as enforcement mechanisms. However, equity considerations must be at the forefront with high-quality masks available for everyone.

Until safe and effective vaccines and therapeutics are developed and widely available, with the Covid-19 pandemic significantly worsening in the United States, mask wearing, combined with social distancing and proper hygiene, must be woven into the fabric of our daily lives. Developing a national certification and labeling system for mask effectiveness, educating about their power for preventing infection, and mandating their use are essential components of protecting individuals and communities from viral spread in America’s battle against this pandemic.