Q&A: Thanks to COVID, Masks Are Here to Stay

Daniel Burnett, MD, MBA: “The aerosols, the things that are the true danger and that can hang in the air for hours, depending on their size, are still released around the edges and around the nose of cloth masks. A cloth mask does very little to protect you.”

The wearing of masks will probably become ingrained in the health care system of the United States because of coronavirus disease 2019 (COVID-19), says David Burnett, MD, MBA, the chief executive officer of JustMask, a company that makes multilayered electrostatic masks. Burnett tells Infection Control Today® that the COVID-19 variants might force the public to continue to wear masks, as well, and that “we’ll morph into a society where masks will be worn similar to the way they are in Asia.” Burnett also understands why Anthony Fauci, MD, the director of the National Institute of Allergy and Infectious Diseases, likes the idea of double-masking, particularly for health care professionals because the “real benefit of double-masking, particularly for the medical community, is you can have a cheaper surgical mask or other disposable mask on the outside of what is a more protective mask underneath.”

Infection Control Today®:Is it safe to assume that mask education should be geared to the general public and that health care professionals know all they need to know about mask use?

Daniel Burnett, MD, MBA: I think that’s becoming the case. It’s still evolving, amazingly enough, given that the pandemic technically came about a year ago to the US. But there was quite a bit of misinformation out there. I believe that there is the evidence around masks for both the lay public and for the medical profession.

ICT®: What do you think about double-masking which Doctor Anthony Fauci just came out in favor for?

Burnett: Double-masking has a couple of benefits. One is if you don’t have an effective sealer on the edge of the mouth and the nose and the chin, the second mask can help improve that seal. And that’s honestly the biggest benefit of double-masking. The other real benefit of double-masking, particularly for the medical community, is you can have a cheaper surgical mask or other disposable mask on the outside of what is a more protective mask underneath.

ICT®: As a society, do you see us having to wear a mask from here on out or will there be a point where we won’t have to wear a mask?

Burnett: I think that depends. I do believe frontline health care workers are going to have to wear masks indefinitely and assume that there is either a coronavirus patient that is asymptomatic or had some other infection for the foreseeable future. For the typical layperson, I believe once this pandemic is under control and vaccines have kicked in and—as you said—the three pillars of personal protection kick in and take their effect, that we we’ll morph into a society where masks will be worn similar to the way they are in Asia; in Japan in particular. They’re worn by the person that is symptomatic or suspects that they may be infectious, but not by those that are not.

ICT®: Is the technology concerning mask usage changing?

Burnett: Yes it is. It has not evolved for decades. But now it’s rapidly changing and for good reason. Not only materials. There are some synthetic membrane-based materials that are much better than typical cloth born materials they use for filtration previously which are less efficient and more susceptible to damage if you touch the materials. Those have improved greatly. The other big changes. I think there’s a lot more effort being put into not only the comfort of the mask, but the fit of the mask on the face. When we first started this, people felt that as long as you have something over the front of your face, you’re protected. But the channels around the nose and edges of the mask made them massively ineffective.

ICT®: A core of our audience comprises infection preventionists, many of whom, as you know, have a nursing background. And they’re often in charge of going around and making sure that infection prevention and control standards are being met. Is there some advice that you have for them to watch out for in terms of how their fellow health care professionals are using masks? Other than if you see someone without a mask, tell them to put a mask on?

Burnett: Yes. The standard now is you should have a professionally fit N95 by doing a fit test, which is obviously something they should be doing. The other big gotcha here is there are a lot of medical professionals—sometimes it’s out of necessity, sometimes it’s out of laziness—who are wearing the same N95 for prolonged periods of time. And, as I mentioned earlier, the double-masking can be used to protect that mask underneath. Now, these masks were meant to be disposable; used for a day or most, and nobody knows, over what time in the hospital setting, the electrostatic charge dissipates, and the mask is saturated by electrolytes in the air. But that definitely does happen, and it becomes much less effective. I think one of the things that we’re going to have to do as an industry—the medical industry—is figure out just how long those masks do retain their charge, and then insist on swapping them out when they no longer are able to hold that charge.

ICT®: Does COVID-19 present a challenge to the wearing masks or protection by masks that no other pathogen has ever presented?

Burnett: I’m not sure I would say no other pathogen because you can catch tuberculosis on the airplane if you’re within three rows of somebody that has an active infection. And that’s been known for a while. And the flu virus also travels in a similar aerosol droplet size and same respiratory droplet size as COVID-19. The infectiousness and the transmissibility of COVID is really unprecedented. It’s remarkably contagious. In that respect, I do think it is a new frontier for mask wearing. You have to be able to take into account aerosols. And I think that’s partially the reason why we are still seeing a decent infection rate, despite mask wearing, in the health care providers.

ICT®: The R-naught for COVID-19 is something like 5.7?

Burnett: Yes. It’s quite high, compared to other infectious diseases out there.

ICT®: How would that compare to something like flu or even tuberculosis that you mentioned?

Burnett: I’m not sure of the exact R-mode of tuberculosis but the flu is a fraction of it. It’s typically in the 1 to 2 range. Two would be a high, 1 is more like what you would see for the typical flu.

ICT®: What has impressed you the most about how masks were handled in this pandemic? Obviously, at least in the beginning, there weren’t enough of them. Do you think there are enough of them now?

Burnett: The cloth masks certainly, and that’s why the recommendations are for double-masking with cloth masks or using a multi-layer cloth mask because that’s still something that we can all get access to. The N95 and the more protective professional masks are still in shorter supply. The government is ramping up supply and worldwide we’re ramping up supply. My guess is we will have a larger store of these for the next pandemic. Hopefully our learnings will apply at that point in time in the future.

ICT®: The 3 low-tech pillars of infection prevention: hand hygiene, social distancing, wearing a mask. Some experts have told me that if you could only do one, then do hand hygiene. Do you agree with that?

Burnett: For coronavirus, I’m not sure. I don’t like to contradict other officials, but the contact mode of transmission for coronavirus in general is not as problematic as the aerosol transmission for coronavirus. I would argue that social distancing is probably the biggest factor. If you get into a room with 10 individuals in a house, and one of them has COVID-19 infection and is asymptomatic, you are all 10 profoundly exposed. I still think that isolating from others and social distancing is the biggest factor.

ICT®: You mentioned Japan earlier as a country with a culture where people are used to wearing masks. Do you see a country that does mask wearing the best that historically has not worn masks? And also, a country that historically did not do mask wearing well, but now is doing it really well?

Burnett: Japan is probably what I would consider to be a country that has done it well, historically. The travelers to Japan will frequently wonder why some people were wearing masks, and the answers they give would be allergy, which doesn’t make much sense because the masks they’re wearing are cloth masks, and those don’t really block allergens. They come in around the edges, and they’re small enough that [the masks] are minimally effective. But the other reason they give is they say that the person has a cold. They were respectful of the people around them and knew that they can at least reduce respiratory droplet transmission and to some degree aerosol transmission by wearing a mask and putting that in front of their face. That’s one culture where I feel they have respect for their fellow man and are desirous of not transmitting the virus to others. In terms of who’s done it well, I probably wouldn’t be as privy to that. I can say that America has not done it well. It’s probably our individualistic nature is my guess. In our culture of freedom, it’s the edges of the mask in the nose. That mask there does some good but not much good for aerosols, which are the respiratory droplets that are 1 micron in size or less. It does a decent job for the 1 to 5 and it does a good job for over 5 microns because it actually catches them in the mask itself. But the aerosols, the things that are the true danger and that can hang in the air for hours, depending on their size, are still released around the edges and around the nose of cloth masks. A cloth mask does very little to protect you from aerosols, because it’s the same thing. They come in around the edges.

ICT®: What is an electrostatic mask?

Burnett: We form an elastomeric seal around the face and then have a dense electrostatic filter along with an N95 mesh. We get the exclusive nature of N95 mesh, but also the particle trapping feature of the electrostatic felt in the mask and have no gaps around the edges. It solves some of the common problems of masks including the N95, where by having the elastomeric seal, it does not require a professional fit.

ICT®: What do you see as the main challenges going forward with the COVID variants and masking? Will that make any difference in how people go about masking? For the B.1.1.1.7 variant, for instance?

Burnett: The COVID variants in combination with what appears to be a rapidly diminishing immuno-protection from actual infection and potentially the vaccine, means that we’ll be wearing masks like we are for a little while. If we can demonstrate that the immuno-protection from the vaccine and actually getting COVID lasts more than the six months that they are now confident it does, ideally it would show that it lasts similar to the flu virus, so at least a year. Plus, then I think we can start to go to the masking regimen that I discussed earlier where only sick people will be masking. As the World Health Organization has mentioned, and most of the scientific professionals, they’re going to most likely result in this being something where every year we get a flu shot, and we get a COVID shot. And hopefully, the experts that are tracking the variants and the mutations around the world, get it right. And we will have a very mild flu or COVID season. And if they get it wrong, then it could be another rough season and [we’ll have to] institute more masking policies. Masks in some degree are here to stay.

\This interview has been edited for clarity and length.