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The mask debate has reared its head again — but this time it’s about what type to wear.
Several countries are mandating medical-grade masks in community settings as more infectious coronavirus variants spread across Europe, relegating homemade cloth masks to the outdated health recommendations of 2020. But many others, as well as the World Health Organization, are standing behind their support of fabric face coverings.
Experts calling for widespread use of more protective masks say it comes down to a fundamental disagreement about what kind of science is “good enough” to support their policy recommendations. This dispute over the evidence on masks — along with concerns over costs, supply and the accessibility of more protective coverings — is holding back most countries from upgrading their mask recommendations.
It’s been a tumultuous ride. In March 2020, the World Health Organization’s line was that masks weren’t needed for healthy people. Then, in April, it significantly softened its stance, and its subsequent mask guidance iterations became increasingly more accepting of the value of masks in the community. European governments followed suit and became the unlikely source of “how-to” guides for making cloth masks.
Since then, apart from the occasional protest against lockdown restrictions and mask mandates, the debate has mostly died down in Europe — in contrast to some other countries, such as the United States.
But as more infectious virus variants began spreading across Europe, some countries, including Germany, Austria and France, have tightened rules, in some cases making FFP2 masks (often known as N95 masks in the U.S. and KN95 in Asia) compulsory in more densely populated settings.
The German state of Bavaria mandated FFP2 protective masks in January, which was quickly followed by a country-wide obligation to wear a medical-grade mask inside shops or on public transport. On January 25, Austria jumped on the bandwagon, specifically requiring FFP2 masks in these situations. France, meanwhile, has recommended against wearing some homemade masks that don’t meet certain standards.
“Whereas fabric masks, or blue and white surgical masks, stop you breathing out infectious virus onto other people, FFP2 masks are also designed to protect the wearer from breathing in infectious virus shed in aerosols from infected individuals,” explained Lawrence Young, professor of molecular oncology at the Warwick Medical School, of the science behind the new recommendations.
But many other European countries, as well as the WHO, are sticking to their current advice. Maria Van Kerkhove, the WHO’s technical lead for COVID-19, says there’s no evidence yet of a change in the mode of transmission — and she emphasized the WHO isn’t planning on changing its advice. The “limited and inconsistent scientific evidence” on masks in community settings is grounds for not recommending higher-grade masks, she says.
The issue is a debate over what exactly evidence-based medicine is, explained Thomas Czypionka, head of the Institute for Advanced Studies’ Health Economics and Health Policy Unit in Austria. Many researchers believe the only type of evidence that’s good enough is the “gold standard” of randomized controlled trials — and everything else should be shunned in systematic reviews.
“If you have this understanding of evidence-based medicine, and you say there’s no evidence for the effectiveness of masks, [the conclusion is] don’t recommend masks,” he said.
The catch: Clinical trials on mask wearing aren’t possible during a pandemic. It wouldn’t be ethical to make one group wear face masks and the other go without if there’s a potential of increasing the transmission of a deadly virus.
Instead of randomized controlled trials, then, some policymakers rely on observational studies based on lab evidence. But this approach doesn’t go down very well with the group of scientists who see randomized controlled trials as the only benchmark of good science, said Julian Tang, consultant virologist at the Leicester Royal Infirmary and honorary associate professor at the University of Leicester’s Department of Respiratory Sciences.
“They don’t believe that laboratory evidence is truly evidence,” he said.
These lab studies show potentially dramatic reductions in particulates being inhaled, with the effectiveness increasing significantly for higher-grade masks, he noted. The order of protectiveness goes from cloth mask, to surgical mask, to FFP1, then FFP2 and finally FFP3 masks, he explained.
A recent lab study from the U.S. Centers for Disease Control and Prevention found that so-called double masking — by wearing a cloth mask over surgical mask — also significantly helps reduce exposure to coronavirus.
As for the handful of randomized clinical trials that do exist on masks, the findings have been mostly inconclusive over the years, he said.
“If you want an incremental benefit, wearing a better mask when you go out and mix with people will give you more protection if you can tolerate wearing it. And that’s really the bottom line,” said Tang.
The Association of Schools of Public Health in the European Region (ASPHER) is of a different mind, not placing much weight on the body of lab work. It believes that new mask directives aren’t based on evidence, pointing out lab studies haven’t specifically focused on the risk of infection. This makes it “impossible to formulate a safe idea beyond whether there are gains or not in this latest proposed approach.”
Then there are those, like virologist Steven Van Gucht, who call for a broader understanding of risk and protection rather than fixating on masks. In his view, ditching cloth masks or double masking isn’t the answer — the places where people are masked aren’t the places where infections occur, he told POLITICO’s EU Confidential. Rather, it’s restricting close contact and physical distancing that really matters. “We need to focus on the real risks,” said Van Gucht.
The other conundrum for policymakers is shortages. At the start of the pandemic, masks were in short supply — something that complicated the push for formal recommendations early on, as many experts feared that mandates would make matters worse and would be impossible to implement, Czypionka says.
While supply issues have mostly been solved, they could become a problem again if millions of people need to purchase new higher-grade masks overnight, ASPHER notes.
The other major obstacle for widespread use of FFP2 masks is their cost. For example, a five-pack of FFP2 masks at British pharmacy chain Boots costs £9.99, whereas a five-pack of surgical masks costs £4.50. Neither are washable, and according to the fine print, they are not reusable either (although some argue FFP2s can be re-used). By comparison, a pack of two washable and reusable masks from the same pharmacy costs £10.
In many parts of the world, it’s hard enough to mandate cloth masks — let alone more expensive higher-grade masks, said Claudia Pagliari, director of global health at the University of Edinburgh.
“If the WHO started to say, ‘Well, this is the only thing that works,’ they’re … recommending something that only rich people can do,” she said. “As for the rest of you, [the message is] you’re going to have to just make do.”
“The optics of that are very bad, aren’t they?” she added.
For now, places like Bavaria are continuing to implement the FFP2 mandate, even though fresh complications are popping up. Most recently, its beard aficionados are facing another conundrum — whether FFP2 masks are effective when significant facial hair impedes a tight fit.
But there’s one point that all sides of the debate can get behind — masks are just one tool of many in the arsenal that can help prevent transmission.
They are just one aspect of control, said the WHO’s Van Kerkhove: “They can’t be used alone.”
Sarah Wheaton contributed reporting.
This story has been updated with news of the CDC report on double masking.
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