COVID-19 — Facemasks and Psychologists

During the course of the current COVID-19 pandemic, facemask wearing has become a point of massive contention with many authorities insisting on their use by people in public places and even issuing fines for people caught not doing so. In some cases this has led to ugly and often unnecessarily violent confrontations between members of the public and sometimes with police.

Meanwhile, the science on the issue has seemed to shift so that at one time people in positions of authority were saying they were unnecessary and even inappropriate for general public to use and then the same authorities shifting to recommending them and even making them mandatory by all.

In this connection, a section of recent ABC News article dated 9 September entitled “Majority of Australians support mandatory face masks in public places, survey reveals” caught my eye: 

Masks ‘not yet ingrained’

Dominika Kwasnicka, a behavioural psychologist at the University of Melbourne, said mask-wearing is not yet a “social norm” in Australia.

“It’s definitely not yet ingrained in our culture,” she said.

“It’s very difficult to break [social norms], but we are very successful with changing and breaking them.”

But with time, she added, a change in attitudes may come.

“We can see in our history, for instance when we started encouraging people to wear seatbelts,” Dr Kwasnicka said.

“People didn’t consider them necessary, didn’t consider them as something that would save their lives. But with time we made them compulsory.

“I’m very confident that we can also change social norms when it comes to wearing a mask, but it’s going to take time.”

This raises some concerns about the role of a psychology professional in the support of facemask wearing practices being promoted by many authorities as the “new normal”. In particular, the apparently enthusiastic and uncritical acceptance of the very doubtful proposition that facemasks are an effective and appropriate infection control measure for an airborne influenza like virus (such as we are currently informed is the case with the COVID-19 pandemic). This is compounded by the implication of use of the interviewee’s professional and academic capabilities to support population behaviour modification activities that promote what many critics of the measure perceive to be a scientifically unsupported and physiologically and psychologically damaging practice i.e. the normalised and habitual facemask wearing by the healthy general public.

A. Lack of supporting evidence for facemask wearing as an appropriate infection control measure

Although the use of facemasks has been likened to being akin to using car seatbelts, this position is sadly not supported by the body of scientific research pointing to the doubtful efficacy of facemasks (especially medical and cloth masks)—for protecting either the wearer or those around them—that has been built up over the past 20 years. This facemask research stands in contrast to seatbelt research that has consistently demonstrated that independent of the other factors contributing to lower road accident and injury rates—such as modern car body design, better road design, speed restrictions and the presence of devices such as airbags—seatbelts do indeed limit the damage caused to people involved in car accidents. Proof of this efficacy is testified in their unfailing use by rally, speedway and Formula 1 drivers who stake their lives on them every time they go out.

Sadly, the same cannot be said about the efficacy of facemasks as devices to limit either the contamination of wounds during surgery or the spread of influenza like viruses. In support of this position, I refer readers to the following article which provides the US Center for Disease Control’s (CDC’s) findings on facemasks as at 5 May 2020:

May 2020, Nonpharmaceutical Measures for Pandemic Influenza in Nonhealthcare Settings—Personal Protective and Environmental Measures https://wwwnc.cdc.gov/eid/article/26/5/19-0994_article
In our systematic review, we identified 10 RCTs that reported estimates of the effectiveness of face masks in reducing laboratory-confirmed influenza virus infections in the community from literature published during 1946–July 27, 2018. In pooled analysis, we found no significant reduction in influenza transmission with the use of face masks (RR 0.78, 95% CI 0.51–1.20; I2 = 30%, p = 0.25) (Figure 2). One study evaluated the use of masks among pilgrims from Australia during the Hajj pilgrimage and reported no major difference in the risk for laboratory-confirmed influenza virus infection in the control or mask group (33). Two studies in university settings assessed the effectiveness of face masks for primary protection by monitoring the incidence of laboratory-confirmed influenza among student hall residents for 5 months (9,10). The overall reduction in ILI or laboratory-confirmed influenza cases in the face mask group was not significant in either studies (9,10). Study designs in the 7 household studies were slightly different: 1 study provided face masks and P2 respirators for household contacts only (34), another study evaluated face mask use as a source control for infected persons only (35), and the remaining studies provided masks for the infected persons as well as their close contacts (11–13,15,17). None of the household studies reported a significant reduction in secondary laboratory-confirmed influenza virus infections in the face mask group (11–13,15,17,34,35). Most studies were underpowered because of limited sample size, and some studies also reported suboptimal adherence in the face mask group.
Disposable medical masks (also known as surgical masks) are loose-fitting devices that were designed to be worn by medical personnel to protect accidental contamination of patient wounds, and to protect the wearer against splashes or sprays of bodily fluids (36). There is limited evidence for their effectiveness in preventing influenza virus transmission either when worn by the infected person for source control or when worn by uninfected persons to reduce exposure. Our systematic review found no significant effect of face masks on transmission of laboratory-confirmed influenza. (Xiao et al. 2020)

In addition to the above, a survey of research papers (see Attachment 1) dating back over 20 years provides context to the debate about the use of medical masks in surgery and as a measure to limit the spread of airborne diseases such as colds and influenza like illnesses. The consistent findings of the research saw many surgeons and dental practitioners eschewing mask wearing due to lack of any proven reduction in either wound infections or spread of bacterial or viral diseases through their use.

Despite this extensive body of research showing that the evidence for facemask efficacy is weak at best and that they may actually be counter-productive (especially cloth masks), recent moves to make mandate facemask wearing in the context of the COVID-19 pandemic responses has seen a confusing flip-flopping of advice from health authorities.

Symptomatic of this confusing advice to the public was Dr. Anthony Fauci’s response early in the pandemic where he advised that masks were un-necessary and then, later, he reversed his position to advise the opposite. But, the latter advice was not on the basis of any purported efficacy of facemasks in preventing infections, rather on the basis of their symbolic role of showing that everybody should wear one in public, that he does as a “symbol” of right action, and that it shows “respect for another person.” (Selwyn Duke 2020).

This symbolic function of facemask wearing has long been recognised in the medical profession and despite the evidence of inefficacy so that in spite of conjecturing that masks might provide some benefit a recent article in The New England Journal of Medicine finished off with the following:

“It is also clear that masks serve symbolic roles. Masks are not only tools, they are also talismans that may help increase health care workers’ perceived sense of safety, well-being, and trust in their hospitals. Although such reactions may not be strictly logical, we are all subject to fear and anxiety, especially during times of crisis. One might argue that fear and anxiety are better countered with data and education than with a marginally beneficial mask, particularly in light of the worldwide mask shortage, but it is difficult to get clinicians to hear this message in the heat of the current crisis. Expanded masking protocols’ greatest contribution may be to reduce the transmission of anxiety, over and above whatever role they may play in reducing transmission of Covid-19. The potential value of universal masking in giving health care workers the confidence to absorb and implement the more foundational infection-prevention practices described above may be its greatest contribution.” (Klompas et al. 2020)

Notwithstanding the body of research referred to above, it is evident that the current politicisation of facemask wearing has seen a re-evaluation and re-interpretation of past research in an effort to score political points. For instance, President Donald Trump’s initial resistance to mask wearing was seized upon by Democrats, so that even papers that found the evidence for facemask wearing was weak at best (if not just statistically insignificant) but which stated they may be worth using were used as evidence that they were effective in an attempt to discredit his position and damage him electorally in the forthcoming presidential elections. Additionally, some recent correlational and observational research (surely, just one step up from anecdotal) has sought to show that masks are effective by demonstrating that since masks have been mandated in certain places the death or ‘case’ rates have declined; however, as with all such correlational and observational studies, these can be criticised for methodological or confounding factors and none negate the very real findings of the previous 20 plus years of randomised controlled tests (RCT’s) that have consistently found no statistically significant effect—as is explained in the CDC article of 5 May 2020 quoted above.

In March 2020, the US Surgeon General Dr. Jerome Adams is reported as warning people to “stop buying facemasks to prevent the novel coronavirus’ and that “you actually might increase your risk of infection if facemasks are not worn properly” (Howard 2020).

The latest WHO advice to government (dated 5 June 2020) concerning general use of masks by the public are documented state advise governments to “encourage the general public to wear masks in specific situations and settings as part of a comprehensive approach” i.e. no mention of mandating their use as a blanket rule in all public situations. (World Health Organization 2020b) [Emphasis added]

At the start of August, lack of evidence and concern that facemask wearing may also make the situation worse was reported as being behind the decision by the Dutch authorities to not mandate their use, a position which referenced the WHO’s stated position on the subject:

“The World Health Organisation has also been sceptical, warning that ‘widespread use of masks by healthy people in the community setting is not yet supported by high-quality or direct scientific evidence’. Although changing its advice in June to back the encouragement of mask wearing in some settings, the WHO lists 11 ‘potential harms’ that range from discomfort through to self-contamination and lower compliance with more critical preventative measures.”(Birrell 2020)

Notably, as at writing the WHO’s website for advice to the public includes no reference to facemask wearing (World Health Organization 2020a) – [Archived at https://archive.vn/s3CkJ]

Finally, simple physics will tell you that a cough or sneeze will produce an airflow under pressure. Like any fluid, air under pressure naturally takes the path of least resistance and that will not be through the pores of a medical or cloth mask, but rather out the sides. This means that while a face mask may stop large particulate matter (which tends to fall quite quickly by force of gravity anyway), they are demonstrably infective in preventing emission of aerosol sized particles—especially when ejected by an infected person exhibiting symptoms of coughing and sneezing (noting that asymptomatic transmission has been largely ruled out (Ducharme 2020)). Also, if medical or cloth facemasks are so effective, then one has to wonder at all of the money spent on PPE for asbestos workers, pesticide workers and others over the years. 

Figure 1: Exhalation of cigarette smoke (0.01 to 1 microns) with medical facemask
Figure 2: Dry wall particles (average 3 microns) with a medical facemask

Interestingly, at least one ‘fact check site’ (AFP Fact Check, which is funded by the French government) has supposedly debunked this drywall dust evidence of facemask ineffectiveness, citing ‘experts’ who claim recent evidence and inapplicability but failing to provide references to underlying research studies to support the position (Dunlop 2020). The fact remains that if cigarette smoke and dry wall dust can pass through or around a medical mask then exhaled or inhaled aerosols containing influenza-like viruses most certainly can too and that is doubly so for cloth masks.

B. Damaging physiological and psychological effects of facemask wearing

Quite a lot of the criticism of people raising their voices against facemask wearing has dismissed their objections as being a result of the ‘inconvenience’ or they have been personally attacked and psychologised, such as in terms of sociopathy, oppositional personality disorders or having politically libertarian tendencies that militate against a community-good orientation in favour of narcissistic self-interest.

Physiological risks

Despite these lazy and often politically or ideologically motivated attacks, the research into the effects of facemask wearing provides ample evidence of the potential for very real physical harms to accrue from regular and prolonged use of facemasks—especially for those with respiratory or cardiovascular conditions or cancer, and for people engaged in exercise or other strenuous activities. It is of concern that these harms have frequently been downplayed or refuted by certain sections of the media so that the public has been bombarded by conflicting and often erroneous messages to the potential detriment of their health and wellbeing. At the extreme of these deleterious effects two Chinese school boys died this year as a result of wearing masks during exercising (Digon 2020).

The ability for facemasks of all types to collect and retain bacterial, fungal and viral contaminants through normal use and recycle these onto the face and into the airway (as well as to hands as masks are adjusted and fiddled with) is obvious and a good part of the reason that in medical contexts anti-bacterial single use disposal masks are provided. The health dangers from facemask contamination can only be acerbated through mandates that dictate use throughout the day, as is the case for retail and many service workers such as bus drivers, police and others in frontline public facing roles. According to Gulay Kilic, an infectious disease doctor, despite warnings the N95 masks are used incorrectly; “It is very difficult to use the masks because once they become sweaty, in a short time it can cause infections, Kilic said, and noted only patients with weakness and fatigue should wear masks” (Hamit 2020).

Cloth masks are particularly problematic given their typically absorbent characteristics, being made from layers of cotton or other commonly available fabrics which, as well as being very porous and thus providing little impediment to aerosols and even macro sized particles, are not considered to be adequate PPE for EMTs, paramedics and other healthcare providers due to findings that they increase the chance of viral illness 13x and only protect from only 3% of particles (Pearce 2020). The washing of non-disposable cloth masks at home also risks exposing the home and family to potential viral particles. A 2015 randomised controlled test (RCT) of cloth masks result cautioned against the use of cloth masks citing moisture retention, reuse of cloth masks and poor filtration which may result in increased risk of infection; an analysis by mask use showed influenza-like illness (ILI) and laboratory-confirmed virus were significantly higher in the cloth masks group compared with the medical masks group. Penetration of cloth masks by particles was almost 97% and medical masks 44% (MacIntyre CR et al. 2015).

Over the past few months there has been much debate on whether facemask wearing can result in either hypoxia (insufficient oxygen available in the body) or hypercapnia (excess of CO2 in the bloodstream). Symptoms of hypercapnia include dizziness, drowsiness, excessive fatigue, headaches, feeling disoriented, flushing of the skin and shortness of breath. Symptoms of hypoxia include anxiety, restlessness, confusion, changes in the colour of skin, cough, rapid breathing, shortness of breath and sweating. While many ‘fact check’ sites and authorities have weighed in to assert that masks do not cause these effects, curiously, the basis of their case appears to be that because masks are porous and have gaps around the edges, gas exchange is not a problem—reinforcing the argument that masks cannot fully prevent transfer of aerosolised particles and thus airborne viral transmission. However, the bulk of the studies absolving masks of these effects have also focused on the wearing of masks by surgeons and medical staff in surgical or clinical conditions, which rarely involve prolonged strenuous physical activity, hot conditions (most are in airconditioned theatres or other environmentally controlled hospital settings) or the need to fasten the masks to avoid anything other than the exchange of macro particulate matter such as expelled spit, splattered blood or the spraying of other body fluids—avoidance of which is the main stated purpose of wearing medical masks in clinical and surgical situations.

The other main difference between facemask wearing under clinical conditions and everyday use is that, in contrast to the general public, clinicians are trained and monitored in the proper use of masks, including how to put them on and fit them, not to touch masks while in use, replacing and disposing of masks that have been touched, using masks only once and then disposing of them in a safe manner. The safe and hygienic disposal of masks is especially of concern given that research shows masks and respirators can become contaminated with influenza when used during patient care (Rule et al. 2018) and that surgical masks have been identified as  a source of bacterial contamination during operative procedures (Zhiqing et al. 2018). Given the purportedly extreme dangers of the COVID-19 virus to one and all, it is of concern that more attention has not been paid to the dangers of either touching masks while wearing them nor for the secure sanitary disposal of them once removed. In any event, the fact that the masks themselves have been proven to attract and harbour viral and bacterial contaminants and that these are then available to be inhaled by the wearer (potentially increasing viral load and thus increasing the likelihood of an infection or of an asymptomatic infection progressing to serious illness—also of other bacterial or fungal infections taking hold in the airway) and transmitted to others due to improper handing is a health concern in its own right.

The fact that facemasks do indeed obstruct breathing is evidenced by advice from Asthma UK for people who have asthma or other lung conditions (such as chronic obstructive pulmonary disease or cystic fibrosis) to not wear a face mask if it makes it difficult for them to breathe, with hot air and tight fit being cited as factors that can trigger symptoms (Blanchard 2020). Overall, the example of the two dead Chinese schoolboys is surely sufficient to demonstrate that facemask wearing under everyday non-clinical conditions can give very different outcomes to those encountered by surgeons and medical staff in the course of their normal duties.

In contrast to the assertions of unproblematic safety mentioned above, a 2020 study of health care professionals in New York found that:

“…wearing [N95] masks for a prolonged amount of time causes a host of physiologic and psychologic burdens and can decrease work efficiency. Activity cannot be performed as long or as efficiently while wearing masks as compared to when masks are not worn. Additionally, the timeframe that an activity can be sustained is decreased when wearing masks and PPE. Prolonged use of N95 and surgical masks causes physical adverse effects such as headaches, difficulty breathing, acne, skin breakdown, rashes, and impaired cognition. It also interferes with vision, communication, and thermal equilibrium.” (Rosner 2020)

In addition to this, the following also give cause to question the safety of facemasks:

  • A study of the effects of wearing no mask, a surgical mask and a FFP2/N95 mask in 12 healthy males found that ventilation, cardiopulmonary exercise capacity and comfort are reduced by surgical masks and highly impaired by FFP2/N95 face masks in healthy individuals (Fikenzer et al. 2020). 
  • A 2018 study of 44 healthy subjects who were tested using a six minute walking test (as is regularly used in pulmonology) with or without a surgical mask found that dyspnea (shortness of breath) variation was significantly higher with surgical mask and the difference was clinically relevant (Person et al. 2018).
  • Another study of end-stage renal disease patients in 2004 during the SARS outbreak then found that wearing an N95 mask for 4 hours during hemodialysis significantly reduced partial pressure of oxygen (PaO2) and increased respiratory adverse effects in the patients (Kao et al. 2004).
  • A two-phase controlled clinical study on healthy pregnant women between 27 to 32 weeks gestation examining energy expenditure during nursing tasks and pulmonary function of 20 subjects at rest and exercising found that breathing through N95 mask materials impeded gaseous exchange and imposed an additional metabolic system workload (Tong et al. 2015).
  • A 2008 study with 53 surgeons of surgical mask induced deoxygenation during major surgery revealed a decrease in the oxygen saturation of arterial pulsations (SpO2) and a slight increase in pulse rates after the first hour compared to preoperative values in all surgeon groups; the decrease was more prominent in the surgeons aged over 35 (Beder A et al.).

Given that the habitual and mandated use of facemasks by the general public is a relatively recent practice, it is too early to say what long-term detrimental health effects will transpire as more and more people are subject to these requirements. However, a growing body of research supports the above findings of physiological harm accruing from facemask wearing, as expressed in the following:

“Exercising with facemasks may reduce available Oxygen and increase air trapping preventing substantial carbon dioxide exchange. The hypercapnic hypoxia may potentially increase acidic environment, cardiac overload, anaerobic metabolism and renal overload, which may substantially aggravate the underlying pathology of established chronic diseases. Further contrary to the earlier thought, no evidence exists to claim the facemasks during exercise offer additional protection from the droplet transfer of the virus.” (Chandrasekaran and Fernandes 2020)

It is a concern that research into the effects of low oxygen availability in the metabolic system resulting from long-term and habitual facemask using for extended periods during the day, shows that there may also be possible implications for other serious diseases, such as cancer. Indications of this can be found in the work of William G. Kaelin, Jr., MD, who along with two other researchers earned the 2019 Nobel Prize in Medicine. These researchers found that through their ability to take over the oxygen-sensing system, hypoxic cancer cells acquire the ability to metastasize and resist chemotherapy and radiation treatment (Kaelin 2019).

Having regard to the foregoing, it is especially of concern that facemask mandates have been instituted in a number of jurisdictions apparently without the authorities having undertaken a comprehensive formal risk assessment into the health impacts of facemask wearing in everyday situations, work types and activities. For instance, UK Column News reported that official information requests to the UK health authorities revealed that as at August 2020 no record existed of a formal risk assessment having taken place prior to the UK government mandates concerning the wearing of facemasks in public (Gerrish and Robinson 2020).

Psychological risks

The psychological risks of facemask wearing (especially where this is mandated and enforced by the police through fines and arrests, organisational rules such as by schools or employers, peer-to-peer coercion or public media shaming) need to be examined from the point of view of a) the effects on individuals and b) their psychological effects at a societal level. In the case of individuals, this means examining their effects on self-image, social relationships and inter-personal communications. Societal level impacts need to consider the symbolic nature of facemask wearing mandates in terms of power relations, the impact on relationships between groups and the psychological effects on the relationships individuals have with groups. It is clear that psychological research into the effects is still in its early days as evidenced by a May 2020 research program request for research participants for s study into understand the long term psychological effects of wearing masks in public at the University of Maine (Bennage 2020).

Without doubt, given the atmosphere of heightened fear and social upheaval brought about by the pandemic, its economic and social consequences, there is anecdotal evidence that many people feel that facemasks represent a simple measure that may offer hope of some control they can exert over whether they can avoid the virus or at least participate in some form of normal life outside their own home. Some people believe that facemasks are effective as advertised and that in wearing one they will reduce their own risk of contracting the virus or that they have a should wear one as a matter of civic duty and as a demonstration of personal concern for the welfare of others. Still others feel that wearing a facemask represents a symbol of support for others who are forced to wear one due to the nature of their work as medical personnel or frontline workers in public facing roles.

Regardless of that, research shows that the wearing of a mask is not psychologically neutral for either the wearer or those around them. For instance, mask wearing has been hypothesised to bring about four main psychological effects: disinhibition, transformation, facilitation of the expression of aspects of the wearer’s Self and various psycho-somatic changes (Cooper). This lack of neutrality is also evidenced in reported ‘pushback’ by some sections of the community, which has been explained by some psychologists in terms of the mask evoking “a sense of moral outrage—that they feel that their rights are being trampled upon”. For instance, clinical psychologist at the University of British Columbia, and author of The Psychology of Pandemics, Dr. Steven Taylor, is quoted as saying:

“For some people, when their freedoms are violated, or they perceive their freedoms are violated, they respond with something called psychological reactance,” said Taylor, a clinical psychologist at the University of British Columbia, and author of The Psychology of Pandemics. (Vermes 2020)

Taylor is also quoted as pointing out that seeing someone wearing a mask may signal to a person that the wearer is infected with COVID-19 or that believing mask wearing is a sign of Asian culture, they find that offensive. The same article also quotes Dr. Mustafa Hirji, acting medical officer of health for Ontario’s Niagara Region, who pointed out that ‘pandemic fatigue’—a desire to end restrictions and return to “normal life”—may factor into the pushback.

C. Use of behavioural psychology to promote psychologically and physically damaging facemask wearing among the healthy general public

When viewed from a behavioural modification perspective, the social-conformity based and legal enforcement of facemask wearing is one of several inter-related and complementary behavioural modification and legal mechanisms currently being employed by the authorities, ostensibly to prevent the spread of the COVID-19 virus among the public and thus prevent unnecessary deaths, reduce anticipated overloading of the health system and avoid possible long-term effects of the illness for individuals.

The fact that opposing sections of the community may have real and valid concerns about both the efficacy and safety of facemasks and authoritarian nature of the power dynamic revealed in making facemasks compulsory does not seem to factor. The profession has right on its side and whatever opponents say, they are wrong and must be either persuaded to see the light or be forced by threats of violence (arrest or imprisonment) or extortion (fines) to comply. 

“Taylor believes that officials should have chosen a proactive approach to mask wearing in an effort to normalize the practice. The same, he adds, should be done when it comes to a future vaccine. “Six months ago, I was talking about the need to prepare for vaccination non-adherence — of a massive pushback against the vaccine when we get a vaccine. We need to prepare for that now,” Taylor said. In order to convince skeptics, Taylor believes that the messaging needs to change. Mask wearing, he says, should be presented as a patriotic practice or duty to your fellow citizens. “Just like you get up when you do the seven o’clock cheer for health-care workers, you should be wearing a mask — and a mask is a sign that you’re doing something to help protect your community.“” (Vermes 2020)

The messaging here is that the facemask wearing is in preparation for a future vaccine campaign—in effect training the public to comply to and accept a vaccine without pushback in spite of any concerns—valid or not—that they may have when this is demanded of them. Inevitably, this supports a view of vaccines as an unconditional good, which flies in the face of many instances where vaccines have been found to have been responsible for:

  • Incidences of vaccine interactions—such as the US Defence Department study that found the influenza vaccine increased susceptibility to coronavirus infection by 36% (Wolff GG 2020)
  • Inducting autoimmune disease (Toussirot É and Bereau M)
  • Induced enhancement of viral infections (Huisman et al. 2009)
  • Numerous examples of vaccine induced harms which have resulted in billions of dollars in payouts to the victims (Holland 2018)
  • Starting a polio epidemic in seven countries—currently underway as at Sept 2020 (Cheng 2020).

Taylor’s resort to ‘patriotic duty’ is a telling sign of the weakness of the position. One shudders to think how many millions of young men have died over the centuries through being persuaded to take up arms and go to the killing fields on the strength of this insidious and emotionally blackmailing phrase. In this is only topped by the resort to officially supported virtue signalling expounded in the final sentence.

Interestingly, these same psychological mechanisms can be seen in Biderman’s Chart of Coercion (Cult recovery 101) as it pertains to the psychology of cults. These mechanisms and their applicability to the present situation being as described in the following table:

Table 1: Applicability of Biderman’s Chart of Coercion

MechanismPurpose and implementationEffectsCOVID-19 Lockdown applicability
IsolationDeprives individual of social support, effectively rendering him unable to resistMakes individual dependent upon interrogatorDevelops an intense concern with self.The sense of humiliation makes members feel they deserve the poor treatment they are receiving and may cause them to allow themselves to be subjected to any and all indignities out of gratefulness that one as unworthy as they feel is allowed to participate in the group at all.Quarantine, social distancing, stay-at-home and exercise restrictions and prohibition of crowds and large gatheringsFacemask wearing and visors suppress social recognition and human emotional connectionsRestrictions on movement and social gatherings reduce psychological supports and ability to express and resolve feelings of frustration and powerlessness.
Monopolisation of perceptionFixes attention upon immediate predicament; fosters introspectionEliminates stimuli competing with those controlled by captorFrustrates all actions not consistent with compliance.The members begin to focus on what they can do to meet any and all group demands and how to preserve peace in the short run. Abusive groups may remove children from their parents, control all the money in the group, arrange marriages, destroy personal items of members or hide personal items.Constant media focus on infection ‘case’ rates, deaths and sensationalised side-effects (particularly, for younger victims)Necessity to be fully engaged with media updates due to constantly changing location and time specific rules and restrictionsNeed to provide name and details just to eat or drink in social settings e.g. cafés, bars and restaurants.
Induced debility and exhaustionForced to take on role of servant Forced to clean house or work excessively long hours Interference with sleep patterns, eating, or nutrition.Feelings of being overwhelmed by demands, close to tears, guilty if one says no to a request or goes against a requirement. Being intimidated or pressured into volunteering for duties and subjected to scorn or ridicule when one does not “volunteer”. Being rebuked or reproved when family or work responsibilities intrude on church responsibilities. Daily life and way of being prescribed by lockdown and social distancing laws and regulations—constant state of watchfulness and stressProlonged stress from social isolation and economic effects of loss of work and incomeLack of exercise due to work from home and exercise restrictions e.g. mandated time restrictions, access to gyms, social exercise groups.
Occasional indulgencesProvides motivation for complianceHope that the situation in the church will change or self-doubt (“Maybe I’m just imagining it’s this bad,”) then replace fear or despair and the members decide to stay a while longer.  Other groups practice sporadic demonstrations of compassion or affection right in the middle of desperate conflict or abusive episodes.  This keeps members off guard and doubting their own perceptions of what is happening.Periodic and random loosening and tightening of restrictions which individuals can neither anticipate nor controlPromise of more freedom form complying with facemasks, social distancing and eventual vaccine acceptance as path to freedom and normalcyExpressions of care from politicians and health bureaucrats while simultaneously prescribing harsh punishments for non-compliance.
Devaluing the individualCreates fear of freedom and dependence upon captorsCreates feelings of helplessnessDevelops lack of faith in individual capabilitiesUnwillingness to allow members to use their gifts.  Establishing rigid boot camplike requirements for the sake of proving commitment to the group before gifts may be exercised. No consideration is given to the length of time a new member has been a Christian or to his age or station in life or his unique talents or abilities.  The rules apply to everyone alike. This has the effect of reducing everyone to some kind of lowest common denominator where no one’s gifts or natural abilities are valued or appreciated.Use of threats in the form of fines and gaol sentences for non-complianceUse of extreme police powers, including high visibility violent arrests and suppression of social media attempts to organise resistance, police night-time/evening home ‘investigations’ of resistersFailure to promote information about individual’s ability to protect self by improving own immune system health through measures such as exercise and taking vitamins D & C and Zinc supplementsSuppression of existing proven remedies such as hydroxychloroquine in favour of a vaccine focused solution (Dennis Behreandt 2020)Classifying those who object as sociopathic or otherwise anti-social and antagonistic to health of communityProjection of political and health authorities as only source of release from the situation.

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Digon, Snow (2020): 2 Chinese Boys Wearing Masks During Gym Class Dropped Dead, Reports Say. International Business Times. Available online at https://www.ibtimes.com/2-chinese-boys-wearing-masks-during-gym-class-dropped-dead-reports-say-2971556, updated on 5/9/2020.

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Dunlop, W. G. (2020): Drywall dust penetration does not mean face masks are ineffective against the coronavirus. AFP Fact Check. Available online at https://factcheck.afp.com/drywall-dust-penetration-does-not-mean-face-masks-are-ineffective-against-coronavirus, updated on 9/3/2020, checked on 9/9/2020.

Fikenzer, S.; Uhe, T.; Lavall, D.; et al. (2020): Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity. In Clinical Research in Cardiology. Available online at https://doi.org/10.1007/s00392-020-01704-y, checked on 9/9/2020.

Gerrish, Brian; Robinson, Mike (2020): Mask risk assessments: UK Column viewer writes to Angela Rayner MP. Location 4:22 – 15:30. UK Column News. Video. Available online at https://www.ukcolumn.org/ukcolumn-news/uk-column-news-12th-august-2020, checked on 9/11/2020.

Hamit, Dilara (2020): Improper use of medical masks can cause infections. N95 masks useful only in intensive care when worn by health personnel, infectious diseases physicians say. Anadolu Agency, updated on 3/20/2020, checked on 9/9/2020.

Holland, Mary S. (2018): Liability for Vaccine Injury: The United States, the European Union, and the Developing World. In Emory Law Journal 67 (3), pp. 416–462. Available online at http://law.emory.edu/elj/content/volume-67/issue-3/articles/liability-vaccine-injury-united-european-world.html, checked on 9/11/2020.

Howard, Jacqueline (2020): US Surgeon General Dr. Jerome Adams not only wants people to stop buying facemasks to prevent the novel coronavirus, but warns that you actually might increase your risk of infection if facemasks are not worn properly. CNN, updated on 3/2/2020, checked on 9/9/2020.

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Kaelin, William G. (2019): Cancer and Oxygen: What’s the Connection? Dana-Farber Cancer Institute. Available online at https://blog.dana-farber.org/insight/2019/11/cancer-and-oxygen-whats-the-connection/, updated on 11/22/2019, checked on 9/9/2020.

Kao, Tze-Wah; Huang, Kuo-Chiang; Huang, Yu-Ling; Tsai, Tun-Jun; Hsieh, Bor-Shen; Wu, Ming-Shiou (2004): The physiological impact of wearing an N95 mask during hemodialysis as a precaution against SARS in patients with end-stage renal disease. In Journal of the Formosan Medical Association = Taiwan yi zhi 103 (8), pp. 624–628.

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Attachment 1. Research papers and documents concerning facemask efficacy

The following provides a survey of journal articles and official documents outlining research and official statements regarding facemask  efficacy [colouring and emphasis added].

  • 31 July 2020, Public Health Guidance for Community-Related Exposure  https://www.cdc.gov/coronavirus/2019-ncov/php/public-health-recommendations.htmlWhile research indicates masks may help those who are infected from spreading the infection, there is less information regarding whether masks offer any protection for a contact exposed to a symptomatic or asymptomatic patient. Therefore, the determination of close contact should be made irrespective of whether the person with COVID-19 or the contact was wearing a mask.
  • July 23, 2020, Masking lack of evidence with politics https://www.cebm.net/covid-19/masking-lack-of-evidence-with-politics/  The small number of trials and lateness in the pandemic cycle is unlikely to give us reasonably clear answers and guide decision-makers. This abandonment of the scientific modus operandi and lack of foresight has left the field wide open for the play of opinions, radical views and political influence.
  • July 7, 2020, Cloth face masks offer zero shield against virus, a study shows  http://www.asahi.com/ajw/articles/13523664
    Kazunari Onishi, an associate professor at St. Luke’s International University in Tokyo, found that cloth masks had a 100-percent leakage rate in terms of airborne particles penetrating the fabric and through the gap between masks and faces, substantially raising the risk of infection.
  • 2020 Jul Medical masks vs N95 respirators for preventing COVID-19 in healthcare workers: A systematic review and meta-analysis of randomized trials https://pubmed.ncbi.nlm.nih.gov/32246890/  
    Low certainty evidence suggests that medical masks and N95 respirators offer similar protection against viral respiratory infection including coronavirus in healthcare workers during non-aerosol-generating care. Preservation of N95 respirators for high-risk, aerosol-generating procedures in this pandemic should be considered when in short supply.
  • 2020 Jun 5; 99(23): e20525.  The efficacy of masks for influenza-like illness in the community: A protocol for systematic review and meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306358/ 
    At present, masks are worn in the muzzle to prevent the wearer’s respiratory secretions from contaminating others or the environment.[7] Common masks or surgical masks have limited effectiveness in preventing the lungs from harmful substances entering from the environment. These are the basic parameters of the mask that tell us. More evidence is needed as to whether masks could protect people in the community.[1]
  • 21 May 2020 Universal Masking in Hospitals in the Covid-19 Era https://www.nejm.org/doi/full/10.1056/NEJMp2006372
    We know that wearing a mask outside health care facilities offers little, if any, protection from infection. Public health authorities define a significant exposure to Covid-19 as face-to-face contact within 6 feet with a patient with symptomatic Covid-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching Covid-19 from a passing interaction in a public space is therefore minimal. In many cases, the desire for widespread masking is a reflexive reaction to anxiety over the pandemic.
  • 2020 May Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis  https://pubmed.ncbi.nlm.nih.gov/32167245/The use of N95 respirators compared with surgical masks is not associated with a lower risk of laboratory-confirmed influenza. It suggests that N95 respirators should not be recommended for general public and nonhigh-risk medical staff those are not in close contact with influenza patients or suspected patients.
  • April 8, 2020, Rapid Expert Consultation on the Effectiveness of Fabric Masks for the COVID-19 Pandemic  https://www.nap.edu/catalog/25776/rapid-expert-consultation-on-the-effectiveness-of-fabric-masks-for-the-covid-19-pandemic-april-8-2020   https://www.nap.edu/read/25776/chapter/1#6There are no studies of individuals wearing homemade fabric masks in the course of their typical activities. Therefore, we have only limited, indirect evidence regarding the effectiveness of such masks for protecting others, when made and worn by the general public on a regular basis. That evidence comes primarily from laboratory studies testing the effectiveness of different materials at capturing particles of different sizes. The evidence from these laboratory filtration studies suggests that such fabric masks may reduce the transmission of larger respiratory droplets. There is little evidence regarding the transmission of small aerosolized particulates of the size potentially exhaled by asymptomatic or presymptomatic individuals with COVID-19. The extent of any protection will depend on how the masks are made and used. It will also depend on how mask use affects users’ other precautionary behaviors, including their use of better masks, when those become widely available. Those behavioral effects may undermine or enhance homemade fabric masks’ overall effect on public health. The current level of benefit, if any, is not possible to assess.
  • 6 Apr 2020:  Facemasks and similar barriers to prevent respiratory illness such as COVID-19: A rapid systematic review https://www.medrxiv.org/content/10.1101/2020.04.01.20049528v1Based on the RCTs we would conclude that wearing facemasks can be very slightly protective against primary infection from casual community contact, and modestly protective against household infections when both infected and uninfected members wear facemasks. However, the RCTs often suffered from poor compliance and controls using facemasks. The evidence is not sufficiently strong to support widespread use of facemasks as a protective measure against COVID-19.
  • 6 Apr 2020:  Physical interventions to interrupt or reduce the spread of respiratory viruses. Part 1 – Face masks, eye protection and person distancing: systematic review and meta-analysis https://www.medrxiv.org/content/10.1101/2020.03.30.20047217v2We included 15 randomised trials investigating the effect of masks (14 trials) in healthcare workers and the general population and of quarantine (1 trial). We found no trials testing eye protection. Compared to no masks there was no reduction of influenza-like illness (ILI) cases (Risk Ratio 0.93, 95%CI 0.83 to 1.05) or influenza (Risk Ratio 0.84, 95%CI 0.61-1.17) for masks in the general population, nor in healthcare workers (Risk Ratio 0.37, 95%CI 0.05 to 2.50). There was no difference between surgical masks and N95 respirators: for ILI (Risk Ratio 0.83, 95%CI 0.63 to 1.08), for influenza (Risk Ratio 1.02, 95%CI 0.73 to 1.43).
  • Apr 01, 2020, COMMENTARY: Masks-for-all for COVID-19 not based on sound data https://www.cidrap.umn.edu/news-perspective/2020/04/commentary-masks-all-covid-19-not-based-sound-data
    In summary, though we support mask wearing by the general public, we continue to conclude that cloth masks and face coverings are likely to have limited impact on lowering COVID-19 transmission, because they have minimal ability to prevent the emission of small particles, offer limited personal protection with respect to small particle inhalation, and should not be recommended as a replacement for physical distancing or reducing time in enclosed spaces with many potentially infectious people. We are very concerned about messaging that suggests cloth masks or face coverings can replace physical distancing. We also worry that the public doesn’t understand the limitations of cloth masks and face coverings when we observe how many people wear their mask under their nose or even under their mouth, remove their masks when talking to someone nearby, or fail to practice physical distancing when wearing a mask.
  • September 3, 2019,  N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial https://jamanetwork.com/journals/jama/fullarticle/2749214Among outpatient health care personnel, N95 respirators vs medical masks as worn by participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed influenza.
  • 2019 Sep 3 N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial https://pubmed.ncbi.nlm.nih.gov/31479137/Among outpatient health care personnel, N95 respirators vs medical masks as worn by participants in this trial resulted in no significant difference in the incidence of laboratory-confirmed influenza.
  • 2019 Jun 26 Optical microscopic study of surface morphology and filtering efficiency of face masks https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599448/The pore size of masks ranged from 80 to 500 μm, which was much bigger than particular matter having diameter of 2.5 μm or less (PM2.5) and 10 μm or less (PM10) size. The PM10 filtering efficiency of four of the selected masks ranged from 63% to 84%. The poor filtering efficiency may have arisen from larger and open pores present in the masks. Interestingly, we found that efficiency dropped by 20% after the 4th washing and drying cycle.
  • 1 December 2017 Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis  https://academic.oup.com/cid/article/65/11/1934/4068747We found no clear benefit of either medical masks or N95 respirators against pH1N1. However, current policies mandating standard and droplet precautions when performing routine care for influenza patients are reasonable.
  • 2017 Nov The efficacy of medical masks and respirators against respiratory infection in healthcare workers https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5705692/We could not demonstrate efficacy of medical masks against any outcome, but the non‐significant trend appeared to be towards protection. Medical masks may well have efficacy,5 but if so, the degree of efficacy was too small to detect in this study, and larger studies are needed, given the widespread use of these devices in health care.
  • 2017 Nov  Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis  https://pubmed.ncbi.nlm.nih.gov/29140516/Meta-analysis of observational studies provided evidence of a protective effect of masks (OR = 0.13; 95% CI: 0.03-0.62) and respirators (OR = 0.12; 95% CI: 0.06-0.26) against severe acute respiratory syndrome (SARS). This systematic review and meta-analysis supports the use of respiratory protection. However, the existing evidence is sparse and findings are inconsistent within and across studies.
  • October 18, 2016, Oral Health: Why Face Masks Don’t Work: A Revealing Review  https://archive.is/mK9db    
    The primary reason for mandating the wearing of face masks is to protect dental personnel from airborne pathogens. This review has established that face masks are incapable of providing such a level of protection. Unless the Centers for Disease Control and Prevention, national and provincial dental associations and regulatory agencies publically admit this fact, they will be guilty of perpetuating a myth which will be a disservice to the dental profession and its patients.
  • 2016 Jun 2. The Respiratory Protection Effectiveness Clinical Trial (ResPECT): a cluster-randomized comparison of respirator and medical mask effectiveness against respiratory infections in healthcare personnel https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890247/  
    While it may seem that N95 respirators should better protect HCPs than MM against airborne infections in the workplace, this notion has not been validated by objective clinical evidence.
  • 17 May 2016 Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis https://www.cmaj.ca/content/188/8/567Although N95 respirators appeared to have a protective advantage over surgical masks in laboratory settings, our meta-analysis showed that there were insufficient data to determine definitively whether N95 respirators are superior to surgical masks in protecting health care workers against transmissible acute respiratory infections in clinical settings.
  • 2015 Jul Respiratory Infections in the U.S. Military: Recent Experience and Control https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475643/Face masks by themselves have not been clearly proven to be efficacious in household or community settings (664,–668, 715). To emphasize this point, a recent systematic review of HH measures found that face masks may be beneficial in preventing laboratory-confirmed influenza infections in community settings but only if combined with HW and HH measures (644). Moreover, cloth masks have actually been found to increase the risk of ILI and influenza virus infection rates compared to face masks among health care workers in the first RCT conducted in Vietnam (716). Future studies are urgently needed in military trainee as well as in health care settings in order to assess the effectiveness of face masks and respirators (715).
  • 2015 Jun, Unmasking the surgeons: the evidence base behind the use of facemasks in surgery https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480558/However, overall there is a lack of substantial evidence to support claims that facemasks protect either patient or surgeon from infectious contamination. More rigorous contemporary research is needed to make a definitive comment on the effectiveness of surgical facemasks.
  • 2015 Apr 22 A cluster randomised trial of cloth masks compared with medical masks in healthcare workers https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420971/This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for HCWs, particularly in high-risk situations, and guidelines need to be updated.
  • 2015 A cluster randomised trial of cloth masks compared with medical masks in healthcare workers https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420971/This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for HCWs, particularly in high-risk situations, and guidelines need to be updated.
  • 2013.06 Comparison of Filtration Efficiency and Pressure Drop in Anti-Yellow Sand Masks, Quarantine Masks, Medical Masks, General Masks, and Handkerchiefs https://aaqr.org/articles/aaqr-13-06-oa-0201.pdfMedical masks, general masks, and handkerchiefs were found to provide little protection against respiratory aerosols.
  • 2013 May; Factors associated with the transmission of pandemic (H1N1) 2009 among hospital healthcare workers in Beijing, China https://pubmed.ncbi.nlm.nih.gov/23078163/
    A total of 51 cases identified via National Notifiable Infectious Disease Surveillance System participated in this study. Controls were matched to cases for a total of 255 individuals. About 19·6% (10/51) of cases and 26·0% (53/204) of controls recalled they had conducted a high-risk procedure on a patient with pandemic (H1N1) 2009. 72·5% (37/51) of cases and 71·6% (146/204) of controls stated they wore medical masks in ≥80% of working time. Only 5·9% (3/51) and 36·3% (74/204) of cases and controls, respectively, reported receiving pandemic vaccination. Participants receiving pandemic vaccination had a significantly lower risk of infection during the pandemic (OR = 0·150, 95% CI: 0·047-0·479, P = 0·001). The estimated vaccine effectiveness was 85·0%. Conclusions: We showed a high vaccine effectiveness of the pandemic vaccine and that vaccination was the only factor significantly associated with risk of infection in HCWs.
  • 2012 Jul  The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779801/In conclusion, there is a limited evidence base to support the use of masks and/or respirators in healthcare or community settings. Mask use is best undertaken as part of a package of personal protection, especially including hand hygiene in both home and healthcare settings. Early initiation and correct and consistent wearing of masks/respirators may improve their effectiveness. However, this remains a major challenge – both in the context of a formal study and in everyday practice.
  • 2011 Dec 21 The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5779801/… there is a limited evidence base to support the use of masks and/or respirators in healthcare or community settings. Mask use is best undertaken as part of a package of personal protection, especially including hand hygiene in both home and healthcare settings. Early initiation and correct and consistent wearing of masks/respirators may improve their effectiveness. However, this remains a major challenge – both in the context of a formal study and in everyday practice.
  • 2011 Feb 17 Findings from a household randomized controlled trial of hand washing and face masks to reduce influenza transmission in Bangkok, Thailand https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634545/Influenza transmission was not reduced by interventions to promote hand washing and face mask use. This may be attributable to transmission that occurred before the intervention, poor facemask compliance, little difference in hand‐washing frequency between study groups, and shared sleeping arrangements. A prospective study design and a careful analysis of sociocultural factors could improve future NPI studies.
  • October 2010, Simple Respiratory Protection—Evaluation of the Filtration Performance of Cloth Masks and Common Fabric Materials Against 20–1000 nm Size Particles https://academic.oup.com/annweh/article/54/7/789/202744Results obtained in the study show that common fabric materials may provide marginal protection against nanoparticles including those in the size ranges of virus-containing particles in exhaled breath… The penetration values obtained for common fabric materials indicate that only marginal respiratory protection can be expected for submicron particles taking into consideration face seal leakage.
  • 2010 Mar-Apr Impact of Non-Pharmaceutical Interventions on URIs and Influenza in Crowded, Urban Households https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821845/In this population, there was no detectable additional benefit of hand sanitizer or face masks over targeted education on overall rates of URIs, but mask wearing was associated with reduced secondary transmission and should be encouraged during outbreak situations.
  • 2010 Feb 15 Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial  https://pubmed.ncbi.nlm.nih.gov/20088690/We observed significant reductions in ILI during weeks 4-6 in the mask and hand hygiene group, compared with the control group, ranging from 35% (confidence interval [CI], 9%-53%) to 51% (CI, 13%-73%), after adjusting for vaccination and other covariates. Face mask use alone showed a similar reduction in ILI compared with the control group, but adjusted estimates were not statistically significant. Neither face mask use and hand hygiene nor face mask use alone was associated with a significant reduction in the rate of ILI cumulatively.
  • 2009 Feb 12 Use of surgical face masks to reduce the incidence of the common cold among health care workers in Japan: a randomized controlled trial  https://pubmed.ncbi.nlm.nih.gov/19216002/Face mask use in health care workers has not been demonstrated to provide benefit in terms of cold symptoms or getting colds. A larger study is needed to definitively establish noninferiority of no mask use.
  • 2009 Feb, Face Mask Use and Control of Respiratory Virus Transmission in Households  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2662657/Adherence to mask use was associated with a significantly reduced risk of ILI-associated infection. We concluded that household use of masks is associated with low adherence and is ineffective in controlling seasonal ILI. If adherence were greater, mask use might reduce transmission during a severe influenza pandemic.
  • 2004 Oct Factors associated with transmission of severe acute respiratory syndrome among health-care workers in Singapore  https://pubmed.ncbi.nlm.nih.gov/15473141/Multivariate analysis confirmed the strong role of contact with respiratory secretions (adjusted OR 21.8, 95 % CI 1.7 274.8, P=0.017). Both hand washing (adjusted OR 0.07, 95 % CI 0.008-0.66, P=0.02) and wearing of N95 masks (adjusted OR 0.1, 95% CI 0.02-0.86, P=0.04) remained strongly protective but gowns and gloves had no effect.
  • 2004 Jan Effectiveness of personal protective measures in prevention of nosocomial transmission of severe acute respiratory syndrome https://pubmed.ncbi.nlm.nih.gov/15061941/Univariate analysis showed that mask, gown, gloves, goggles, footwear, “hand-washing and disinfecting”, gargle, “membrane protection”, “taking shower and changing clothing after work”, “avoid from eating and drinking in ward”, oseltamivir phospha tall had protective effects (P < 0.05), but stepwise logistic regression showed significant differences for mask (OR = 0.78, 95% CI: 0.60 – 0.99), goggles (OR = 0.20, 95% CI: 0.10 – 0.41) and footwear (OR = 0.58, 95% CI: 0.39 – 0.86). Analysis for linear trend in proportions showed that dose response relationship existed in mask, gown, gloves, goggles, footwear, gargle, “membrane protection” and “taking shower and changing dree after work” (P < 0.01). The attack rate of HCWs who were rescuing severe SARS patients without any PPE was 61.5% (16/26). It seemed that the more the protective measures were used, the higher the protective effect was (P < 0.001), and could reach 100% if mask, gown, gloves, goggles, footwear, “hand-washing and disinfecting” were all used at the same time.
  • 2003 May 3 Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS) https://pubmed.ncbi.nlm.nih.gov/12737864/Fewer staff who wore masks (p=0.0001), gowns (p=0.006), and washed their hands (p=0.047) became infected compared with those who didn’t, but stepwise logistic regression was significant only for masks (p=0.011). Practice of droplets precaution and contact precaution is adequate in significantly reducing the risk of infection after exposures to patients with SARS. The protective role of the mask suggests that in hospitals, infection is transmitted by droplets.
  • July 01, 1991 Surgical face masks in modern operating rooms—a costly and unnecessary ritual? https://www.journalofhospitalinfection.com/article/0195-6701(91)90148-2/pdfFollowing the commissioning of a new suite of operating rooms air movement studies showed a flow of air away from the operating table towards the periphery of the room. Oral microbial flora dispersed by unmasked male and female volunteers standing one metre from the table failed to contaminate exposed settle plates placed on the table. The wearing of face masks by non-scrubbed staff working in an operating room with forced ventilation seems to be unnecessary.
  • May 1991 Postoperative wound infections and surgical face masks: A controlled study https://link.springer.com/article/10.1007/BF01658736It has never been shown that wearing surgical face masks decreases postoperative wound infections. On the contrary, a 50% decrease has been reported after omitting face masks. The present study was designed to reveal any 30% or greater difference in general surgery wound infection rates by using face masks or not… These results indicate that the use of face masks might be reconsidered. Masks may be used to protect the operating team from drops of infected blood and from airborne infections, but have not been proven to protect the patient operated by a healthy operating team.

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