Cloth masks vs. surgical masks in the community: which is better?

The debate of cloth masks vs. surgical masks has been going on since the start of Covid. While the difference between the these and more effective personal protection PPE such as N95 mask has been long established, public health isn’t just about best practice. How could clinical and public advice possibly be so different? Read on!

How we got here

When COVID-19 first struck in early 2020, mask advice came strong and early. There were public health campaigns that explained the importance of wearing masks, and wearing them properly. Instructions and patterns were circulated online so that creative folk could make their own.

PPE availability played a large part in the use of homemade or cloth masks for the general public. Shortages across the world meant that any clinical standard PPE had to be stockpiled for use in a clinical setting. Because of this, surgical masks, which have since become ubiquitous, were not generally available to the public.

Unfortunately, a less stringent standard generally results in lower quality across the board. Remember testing cloth masks by trying to blow a candle out while having the mask on? If not, you’re not alone. In an article by the OzSAGE Community Mask Working Group, “… the basic cloth and surgical masks which most Australians use, whilst somewhat effective at protecting others from an infected wearer (‘source control’), are varied in quality and are not effective at adequately protecting the wearer. The filtration effectiveness of cloth masks is generally lower than that of surgical masks, and surgical masks have poor fit.”

So while cloth masks are less effective than surgical masks, at a time where any mouth and nose covering was beneficial, it made sense to compromise.

Public health advice vs. clinical standards

As clinicians, you are no doubt aware that cloth and surgical masks and N95 masks are tools in different strategies. While cloth masks aim to reduce the amount of infectious material that the wearer is putting out into the air, N95 masks filter the air the wearer is breathing, which helps to protect them from breathing infectious material from other people. N95 masks are also more expensive and require a proper fitting process to ensure that they are effective.

Knowing then that N95s are the best masks for personal safety, but that most people won’t wear them, what should the community be wearing in 2022?

In a The Guardian article in January 2022, Dr Katrina Powers, an occupational health physician in Western Australia, said, “It’s very important that with Omicron – it’s just so transmissible – that people wear the best quality mask they can. Cloth masks are not enough: there are either not enough layers to filter out the viral particles or the weave is too loose.”

Hassan Vally, an associate professor in epidemiology at Deakin University, said studies on previous Covid variants show that an N95 mask is better than a surgical mask, which is better than a cloth mask: “If you’re in a higher risk situation, you want to be wearing the best mask you possibly can,” he said.

Prof Malcom Sim believes P2 class respirators are less useful for the general public than in specific workplace settings such as hospitals. “They’re not designed for general use out in the community,” he said. “You need to be trained in how to use them, they need to be fit tested for them to perform at their proper level of protection, and they’re not really designed for taking on…and off.”

Where do we go from here?

A 2021 technical report by the European Centre for Disease Prevention and Control stated, “The evidence regarding the effectiveness of medical face masks for the prevention of COVID-19 is limited, face masks should be considered as a non-pharmaceutical intervention in combination with other measures as part of efforts to control COVID-19 pandemic.” The conclusion from this study is that masks should be used in public settings but are an intervention that should be used in combination with other measures. It goes on to start that “when non-medical face masks are use, it is advisable that masks that comply with available guidelines for filtration efficacy and breathability are preferred.”

It is clear that P2/N95 respirators are not recommended for use in the community, but surprisingly the preference between cloth mask and surgical masks really boils down to personal choice. While surgical masks are more likely to be effective than cloth masks, what’s more important is appropriate construction of the mask, and proper usage. A surgical mask isn’t helping anyone if it’s under their nose! And, it needs to be said, that the use of face masks, whichever you choose to wear, should complement other preventive measures such as physical distancing, staying home when ill, working from home if possible, good respiratory etiquette, meticulous hand hygiene and no touching the face, eyes, nose or mouth.

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