In Fighting COVID-19, If the Mask Fits … But, Often, It Doesn’t

March 16, 2020

As COVID-19 continues its logarithmic leaps from person to people, across borders and oceans, trailing jokey and terrifying viral memes, it has triggered an odd assortment of hoarding behaviors in the panicky public: toilet paper, hand sanitizer, soap … and surgical facemasks.

Early—and indeed, ongoing—lack of information about the virus’s etiology and pathology meant facemasks have become a precious commodity. In early March, health authorities from Washington State (which by that time had announced the first COVID-19–related death in the US) sent an urgent request to the federal Strategic National Stockpile for 233,000 respirators and 200,000 surgical masks.  

They received an answer—but not the one they hoped for. They would get less than half the amount they requested: 93,600 N95 respirators and 100,200 surgical masks.

Masks come in different shapes, with different features, intended for different purposes: flat-fold tie-on, duckbill with or without shield, cone shaped, flat-fold with shields … theoretically, there should be something for everyone. But they’re only effective when worn properly, and not everyone can—or does—wear them properly. Most guidelines suggest changing a surgical mask any time it becomes wet. A mask wet with exhaled moisture has increased resistance to airflow, is less efficient at filtering bacteria, and vents more. It’s not uncommon, though, says Dianne Rawson, RN, MA, in The Basics of Surgical Mask Selection, to see masks poorly fitted, placed below the nose, or wet with blood or body fluids

Even the correct mask can put clinicians at risk if not worn correctly: with nose and mouth completely covered to create a seal and prevent gaps. But fit can be an issue for anyone whose face doesn’t follow the median contours, or someone who has a beard or mustache. A 2000 study found that bacterial shedding from people with beards was increased (although an analysis of that study called it “an example of contamination being extrapolated to infection without measuring the endpoint of infection”).

One National Health Service hospital in England has responded to the coronavirus pandemic by asking staff to “consider” shaving their beards. “I recognize,” Derek Sandeman, MD, the medical director, said, “for some this is a big ask, that beards are so popular at present. However, I do believe it is the right thing to do.” He added that alternative types of respiratory equipment are available for people who have a good reason to keep their beards, including for religious reasons.

The CDC has helpfully published a visual aid for the kinds of facial hair that work, or don’t work, with mask use. Some styles, such as soul patches, pencil mustaches, and “the Zappa” made the cut. 

The current health emergency (like other epidemics) has also put a new spotlight on compliance, a complicated subject. Studies have demonstrated that healthcare workers are generally poorly compliant with respiratory guidelinesBut compliance studies often run into the Hawthorne effect: Knowing they’re being observed, staff tend to improve their adherence. 

Health authorities have a double-pronged problem to solve: the pandemic-driven urgency for enough protection and the daily-use desire for more comfortable protection. The CDC has come under fire for not planning for a shortfall during the current crisis, and for not acting quickly and forcefully enough when the crisis began to expand. The result? Workers are not sure from day to day whether they’ll have the supplies they need, leading to a breakdown in a crucial bond of trust. 


“…[I[f workers had more confidence in their employers’ commitment to worker health and safety,” Annalee Yassi, MSc, notes, “employees would have more confidence in the messages and directives they received during a crisis….”