Face masks during the COVID-19 pandemic


During the COVID-19 pandemic, face masks have been employed as a public and personal health control measure against the spread of SARS-CoV-2. Its use is intended as personal protection to prevent infection and as source control to limit transmission of the virus in a community or healthcare setting. The use of masks has received varying recommendations from different public health agencies and governments. The World Health Organization and other public health organisations agree that masks can limit the spread of respiratory viral diseases such as COVID-19. However, the topic has been a subject of debate, with some public health agencies and governments initially disagreeing on a protocol for wearing face masks.
, 88% of the world's population lives in countries that recommend or mandate the use of masks in public; more than 75 countries have mandated the use of masks. Debates have emerged regarding whether masks should be worn even when social distancing at 2 meters, and whether they should be worn during exercise. Additionally, public health agencies of some countries and territories have changed their recommendations regarding face masks over time. Face masks have been a subject of shortages, and not all have been certified. Moreover, substandard masks were reported on the market with significantly reduced performance.
There are different types of face masks including:
Face shields, medical goggles, and other types of personal protective equipment are sometimes used together with face masks.

Types of masks

Cloth masks

A cloth face mask is a mask made of a common textile, usually cotton, worn over the mouth and nose. Although they are less effective than medical-grade masks, many health authorities recommend that the general public use them because medical-grade masks are in short supply.
There were calls for research into the effectiveness of improvised masks even before the emergence of COVID-19, motivated also by past epidemics and modelling of likely mask shortages. However, little research has been done. There are no studies of the use of cloth masks by the general public, one study on the use of cloth masks in hospitals, and many controlled-setting/lab studies of cloth masks' effects on aerosols as of 2020.
Cloth masks are low-cost and reusable. They vary widely in effectiveness depending on material, fit/seal, and number of layers, among other factors. Unlike disposable masks, there are no legal standards for cloth masks. Fit is important. Measures to improve fit, such as an outer layer made from sheer nylon stockings or sheer tights around the head, reduce leakage.
Improvised cloth masks seem to be worse than standard commercial disposable masks, but better than nothing. There is, however, little good evidence on them. A single study gives evidence that an improvised mask was better than nothing, but not as good as soft electret-filter surgical mask, for protecting health care workers simulating treating a simulated infected patient, regardless of whether "patient" or carers wore the mask. Another study had volunteers wear masks they made themselves, to a pattern like that of a standard surgical mask, but with ties rather than earloops, from cotton T-shirts, and found that the number of microscopic particles that leaked inside the homemade masks was twice the number that leaked into the commercial masks, and that the homemade mask let three times as many microorganisms expelled by the wearer escape. There is limited evidence that cloth masks can significantly reduce droplet dispersal.
Cloth masks are commonly made with one layer, two layers, or two layers with a pocket for a removable-filter interlayer. The CDC recommends more than one layer. There is no research on the usefulness of a filter interlayer, as of 2020. There were until recently no non-disposable materials designed for making masks. Common household fabrics which could be used as mask materials have been tested. Cloth materials vary widely in filtration efficiency. Some cotton and polyester household fabrics have been found to compare with disposable surgical masks for dry particle filtering. Cotton T-shirt material, pillowcase material, and 70% cotton/30% polyester sweatshirt material are among the common materials that performed well in lab tests, with T-shirts preferred to pillowcases because it was thought that it would probably fit better. Teatowels and vacuum-cleaner bags were effective at filtering, but had a very high air resistance, so were not recommended. Scarves filtered poorly. Surgical sterilisation wrap, a polypropylene non-woven fabric made for wrapping sterilized things to keep them sterile, is designed to filter germs from the air. Using surgical sterilisation wrap to make masks, or as a filter interlayer in cloth masks, has been suggested. There are, however, no tests on using surgical sterilisation wrap for masks, as of 2020.
Other suggested materials for filter interlayers include air filter materials used in ventilation, heating, and air conditioning, some of which are similar to rigid electret masks in the size ranges of particles they filter. Electrostatic cotton and non-woven, meltblown fabric are the conventional materials used in disposible masks, but are not readily available during the COVID-19 epidemic. A new type of filter, a washable electrostatic cotton filter, has been reported since the start of the pandemic; it is said to withstand repeated washing and folding. It is made of electrospun nanofibers; flanking insulating blocks lay these into quasi-aligned nonwoven sheets, which are layered criss-cross to make a meshlike multilayer mask. There is a need for research comparing how well these materials work.

Decontamination and re-use

There is no research on decontaminating and reusing cloth masks, as of 2020. The CDC recommends doffing the mask by handling only the ear loops or ties, placing it directly in a washing machine, and immediately washing one's hands in soap and water for at least 20 seconds. They also recommend washing one's hands before donning the mask and again immediately after one touches it.
There is no information on reusing a interlayer filter, and disposing of it after a single use may be desirable.

Surgical masks

A surgical mask is a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. If worn properly, a surgical mask is meant to help block large-particle droplets, splashes, sprays, or splatter that may contain viruses and bacteria, keeping it from reaching the wearer's mouth and nose. Surgical masks may also help reduce exposure of the wearer's saliva and respiratory secretions to others.
Certified medical masks are made of non-woven material. They are mostly multi-layer. Filter material may be made of microfibers with an electrostatic charge; that is, the fibers are electrets. An electret filter increases the chances that smaller particles will veer and hit a fiber, rather than going straight through. Typically, efficiency of the filtering materials decreases when washed or used multiple times.
A surgical mask, by design, does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures. Surgical masks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and the face. However, in practice, with respect to some infections like influenza, surgical masks appear as effective as respirators. Surgical masks may be labeled as surgical, isolation, dental, or medical procedure masks. Surgical masks are made of a nonwoven fabric created using a melt blowing process.
Surgical masks made to different standards in different parts of the world have different ranges of particles which they filter. For example, the People's Republic of China regulates two types of such masks: single-use medical masks and surgical masks. The latter ones are required to filter bacteria-sized particles and some virus-sized particles, while the former ones are required to only filter bacteria-sized particles.

Disposable filtering respirators

An N95 mask is a particulate-filtering facepiece respirator that meets the N95 air filtration rating of the US National Institute for Occupational Safety and Health, meaning that it filters at least 95 percent of airborne particles, while not resistant to oil like the P95. It is the most common particulate-filtering facepiece respirator. It is an example of a mechanical filter respirator, which provides protection against particulates, but not gases or vapors. Like the middle layer of surgical masks, the N95 mask is made of four layers of melt-blown nonwoven polypropylene fabric. The corresponding face mask used in the European Union is the FFP2 respirator.
Hard electret-filter masks like N95 and FFP masks must fit the face to provide full protection. Untrained users often get a reasonable fit, but fewer than one in four gets a perfect fit. Fit testing is thus standard. A line of vaseline on the edge of the mask has been shown to reduce edge leakage
in lab tests using manikins that simulate breathing.

Disinfecting and re-use

Hard electret-filter masks are designed to be disposable, for 8 hours of continuous or intermittent use. One laboratory found that there was a decrease in fit quality after five consecutive donnings.
Hard electret-filter masks are often reused, especially during pandemics when there are shortages. Infectious particles could survive on the masks for up to 24 hours after the end of use, according to studies using models of SARS-CoV-2; In the COVID-19 epidemic, the US CDC recommended that if masks run short, each health care worker should be issued with five masks, one to be used per day, such that each mask spends at least five days stored in a paper bag between each use. If there are not enough masks to do this, they recommend sterilizing the masks between uses. Some hospitals have been stockpiling used masks as a precaution. The US CDC issued guidelines on stretching N95 supplies, recommending extended use over re-use. They highlighted the risk of infection from touching the contaminated outer surface of the mask, which even professionals frequently unintentionally do, and recommended washing hands every time before touching the mask. To reduce mask surface contamination, they recommended face shields, and asking patients to wear masks too.
Apart from time, other methods of disinfection have been tested. Physical damage to the masks has been observed when microwaving them, microwaving them in a steam bag, letting them sit in moist heat, and hitting them with excessively high doses of ultraviolet germicidal irradiation. Chlorine-based methods, such as chlorine bleach, may cause residual smell, offgassing of chlorine when the mask becomes moist, and in one study, physical breakdown of the nosepads, causing increased leakage. Fit and comfort do not seem to be harmed by UVGI, moist heat incubation, and microwave-generated steam.
Some methods may not visibly damage the mask, but they ruin the mask's ability to filter. This has been seen in attempts to sterilize by soaking in soap and water, heating dry to 160 °C, and treating with 70% isopropyl alcohol, and hydrogen peroxide gas plasma. The static electrical charge on the microfibers is destroyed by some cleaning methods. UVGI, boiling water vapour, and dry oven heating do not seem to reduce the filter efficiency, and these methods successfully decontaminate masks.
UVGI, ethylene oxide, dry oven heating and vaporized hydrogen peroxide are currently the most-favoured methods in use in hospitals, but none have been properly tested. Where enough masks are available, cycling them and reusing a mask only after letting it sit unused for 5 days is preferred.

Elastomeric respirators

Elastomeric respirators are reusable devices with exchangeable cartridge filters that offer comparable protection to N95 masks. They were used as a substitute for N95 masks among shortages during the COVID-19 pandemic.
The filters must be replaced when soiled, contaminated, or clogged. These components may be hard to find amidst shortages; the filters may thus be sterilized, in a way that does not harm the filter, and re-used. In medical use, they must be cleaned and disinfected, as some germs can survive on them for weeks.
Full-face versions of elastomeric respirators seal better and protect the eyes. If they have exhalation valves, then they are counterrecommended in settings where the unfiltered exhaled air might infect others. Fitting and inspection is essential to effectiveness.

Powered air-purifying respirators (PAPRs)

are expensive masks with a battery-powered blower that blows air through a filter to the wearer. Because they create positive pressure, they need not be tightly-fitted. PAPRs typically do not filter exhaust from the wearer. They are not generally designed for healthcare use, as of 2017.

Novel face masks (research and development)

On 15 April 2020 scientists claimed to have developed a biodegradable material for face masks which is effective at removing particles smaller than 100 nanometres including viruses and has a high breathability. Two Israeli companies reportedly have developed antiviral face masks – one of which is infused with antiviral copper oxide and zinc oxide nanoparticles, the other is made out of cotton embedded with accelerated copper oxide particles and a nanofiber textile. Other Israeli researchers have developed a 3D-printed nanoscale fiber sticker coated with antiseptics which can be attached to a traditional mask for extra protection. Other reseachers report that laser-induced graphene may be used to add self-cleaning and photothermal properties to face masks. In March 2020, Huang Jiaxing became the first scientist to receive a $200,000 grant by the United States' National Science Foundation to develop a chemical which can be safely built into common face masks to make them protect against SARS-CoV-2 and self-sanitize passing droplets.

Face shields

s protect against splash and splatter. Cough simulation experiments show that they protect the wearer against large droplets immediately after the cough, but are less effective against smaller aerosols, which can remain airborne for extended periods and can easily flow around a face shield to be inhaled.
Because they lack a peripheral seal, face shields are used with nose-mouth masks, and to protect nose-mouth masks, but use of face shields alone is not recommended for healthcare workers.

Recommendations

Surgical masks are recommended for those who may be infected, as wearing a mask can limit the volume and travel distance of expiratory droplets dispersed when talking, sneezing, and coughing.
Masks have also been recommended for use by those who are taking care of someone who may have the disease. The WHO has recommended the wearing of masks by healthy people only if they are at high risk, such as those who are caring for a person with COVID-19, though they also acknowledge that wearing masks may help people avoid touching their face. Several countries have started to encourage the use of face masks by members of the public.
As of May 2020, 88% of the world's population lived in countries where their government and leading disease experts recommended or mandated the use of masks in public places to limit the spread of COVID-19.

World Health Organization

The World Health Organization, in its updated advice dated 5 June 2020, recommends that the general public should wear non-medical fabric masks where there is known or suspected widespread transmission and where physical distancing is not possible, and that vulnerable people and people with any symptoms suggestive of COVID-19 as well as caregivers and healthcare workers should wear medical masks. The stated purpose of mask usage is to prevent the wearer transmitting the virus to others or to offer protection to healthy wearers against infection.
The WHO suggests a minimum of three layers for non-medical fabric masks: an inner layer made of absorbent material, a middle layer made of non-woven material which may enhance filtration or retain droplets, and an outer layer made of non-absorbent material which may limit external contamination from penetration.
Previously, early in the outbreak, the WHO had only recommended medical masks for people with suspected infection and respiratory symptoms, their caregivers and those sharing living space, and healthcare workers. In a 6 April advice, the WHO recognized that wearing a medical mask can limit the spread of certain respiratory viral diseases including COVID-19, but believed that the use of a mask alone is not sufficient to provide an adequate level of protection and that other measures should be adopted. In the scope of the community setting, the WHO stated that medical masks should be reserved for healthcare workers, except for people with symptoms, claiming that medical masks would create a false sense of security and neglect of other measures. The WHO advice for people to wear masks only if they had symptoms was criticized, as experts and researchers have pointed out the asymptomatic transmission of the virus. The WHO revised its mask guidance in June, with its officials acknowledging that studies have indicated asymptomatic or pre-symptomatic spread but that not much is known.
The WHO had early suggested that mask usage possibly leads to neglect of other essential health measures such as hand hygiene practices, but available evidence does not support that masking adversely affects hand hygiene. Dame Theresa Marteau, one of the researchers, remarked that "The concept of risk compensation, rather than risk compensation itself, seems the greater threat to public health through delaying potentially effective interventions that can help prevent the spread of disease."
Regarding the use of non-medical fabric masks in the general population, the WHO has stated that high-quality evidence for its widespread use is limited, but advises governments to encourage its use as physical distancing may not be possible in some settings and masks could be helpful to provide a barrier to limit the spread of potentially infectious droplets.

US Centers for Disease Control and Prevention

The United States Centers for Disease Control and Prevention, since 3 April 2020, recommends persons wear a cloth face covering in public. In its latest considerations, the "CDC recommends that people wear cloth face coverings in public settings and when around people who don't live in your household, especially when other social distancing measures are difficult to maintain. Cloth face coverings may help prevent people who have COVID-19 from spreading the virus to others. Cloth face coverings are most likely to reduce the spread of COVID-19 when they are widely used by people in public settings."
The CDC states that healthcare personnel should wear a NIOSH-approved N95 respirator or a face mask with a face shield or goggles as part of their PPE gear, while patients with suspected or confirmed SARS-CoV-2 infection should wear a face mask or cloth face covering during transport. As crisis strategy for known shortages of N95 respirators in healthcare settings, among other sequential measures, the CDC suggests use of respirators beyond the manufacturer-designated shelf life, use of respirators approved under standards used in other countries that are similar to NIOSH-approved respirators, limited re-use of respirators, use of additional respirators beyond the manufacturer-designated shelf life that have not been evaluated by NIOSH, and prioritizing the use of respirators and face masks by activity type.
Early in the pandemic, the CDC said that it "does not currently recommend the use of face masks for the general public." However, on 3 April 2020, the CDC changed its advice to recommend that people wear cloth face coverings "in public settings when around people outside their household, especially when social distancing measures are difficult to maintain." In response to an inquiry by NPR, the CDC said that this change in guidelines was due to the increasing and widespread transmission of the virus, citing studies published in February and March showing presymptomatic and asymptomatic transmission. In an interview with KRMG on 28 July 2020, the CDC director Robert R. Redfield explained that they assumed that the disease was a symptomatic illness when they originally looked at masks, not understanding at the time how much of the viral infection was asymptomatic or presymptomatic, but came to understand the critical role of face coverings for source control once they understood that.
Larry Gostin, a professor of public health law, said that initial CDC and WHO guidance had given the public the wrong impression that mask do not work, even though scientific evidence to the contrary was already available. The confusing changing advice from discouraging to recommending public masking has led to decreasing public trust in the CDC. In June 2020 Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, admitted that the delay in recommending general mask use was motivated by a desire to conserve dwindling supplies for medical professionals.
In an interview with JAMA on 14 July 2020, Redfield said that "The data is clearly there that masking works. Masking is not a political issue. It is a public health issue. It really is a personal responsibility for all of us." He and two other CDC officials explained in a JAMA editorial, published on the same day, that "Covering mouths and noses with filtering materials serves 2 purposes: personal protection against inhalation of harmful pathogens and particulates, and source control to prevent exposing others to infectious microbes that may be expelled during respiration. When asked to wear face coverings, many people think in terms of personal protection. But face coverings are also widely and routinely used as source control." In regards to the changes in CDC recommendations towards universal masking, they clarified that "Early in the pandemic, the Centers for Disease Control and Prevention recommended that anyone symptomatic for suspected coronavirus disease 2019 should wear a face covering during transport to medical care and prior to isolation to reduce the spread of respiratory droplets. After emerging data documented transmission of SARS-CoV-2 from persons without symptoms, the recommendation was expanded to the general community Now, there is ample evidence that persons without symptoms spread infection and may be the critical driver needed to maintain epidemic momentum."

China and Asia

has specifically recommended the use of disposable medical masks by the public, including its healthy members, particularly when coming into close contact with other people. Hong Kong recommends wearing a surgical mask when taking public transport or in crowded places. Thailand's health officials are encouraging people to make cloth face masks at home and wash them daily. The Republic of China, South Korean, and Japanese governments have also recommended the use of face masks in public.
In March 2020, when asked about the mistakes that other countries were making in the pandemic, the Chinese Center for Disease Control and Prevention director-general George Fu Gao said:
"The big mistake in the U.S. and Europe, in my opinion, is that people aren't wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role − you've got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others."

Europe

The Norwegian Institute of Public Health said that the wearing of face masks by asymptomatic individuals was not to be recommended due to the low prevalence of COVID-19 in the country, but noted that it should be reconsidered if cases rise.

Rationale for wearing masks

The National Health Commission of China cited the following reasons for the wearing of masks by the public, including healthy individuals:
  1. Asymptomatic transmission. Many people can be infected without symptoms or only with mild symptoms.
  2. Difficulty or impossibility of appropriate social distancing in many public places at all times.
  3. Cost-benefit mismatch. If only the infected individuals wear a mask, they would possibly have a negative incentive to do so. An infected individual might get nothing positive, but only bear the costs such as inconvenience, purchasing expenses, and even prejudice.
  4. There is no shortage of masks in China, which has been producing 100 million masks per day since early March.
Yuen Kwok-yung, a microbiologist from the University of Hong Kong, cites a large viral load in sputum or saliva of an infected person and asymptomatic cases as the reasons why even healthy individuals should wear a mask.
Wang Linfa, an infectious disease expert who heads a joint Duke University and National University of Singapore research team, stated that masking is about "preventing the spread of disease rather than preventing getting the disease", remarking that the point is to cover the faces of people who are infected but do not know it, so it is imperative for everyone to wear one in public.
According to Stephen Griffin, a virologist at the University of Leeds, "Wearing a mask can reduce the propensity people to touch their faces, which is a major source of infection without proper hand hygiene."
Greenhalgh et al. argue for the precautionary principle as a reason for policies to encourage the wearing of face masks in public.

Efficacy studies for COVID-19

A WHO-funded systematic review by Chu et al. published in The Lancet found that the usage of face mask could result in a large risk reduction of infection with epidemic-causative betacoronaviruses, in which N95 or similar respirators accounted for a larger risk reduction than disposable surgical or other similar masks. Masks were found to be protective for both healthcare workers and people in communities exposed to infection; evidence supports masking in both healthcare and non-healthcare settings, with no striking differences detected in the effectiveness of masks between the settings. Eye protection was also associated with a lower risk of infection.
A study by Chan et al., using SARS-CoV-2-challenged Syrian hamster models and non-infected hamsters placed in closed units with unidirectional airflow to test the effect of surgical mask partitions, concluded that SARS-CoV-2 can be transmitted by respiratory droplets or airborne droplet nuclei and that such transmission could be reduced by usage of surgical masks, especially when worn by infected individuals.
A study surveying families in Beijing, China concluded that the wearing of face masks by infected individuals at home before symptom onset was effective in reducing the risk of spreading the disease to family members, but that it did little to provide additional protection after symptoms start appearing.
Primary research from countries such as Germany and Thailand have shown significant decreases in case rates with widespread mask compliance, without, however, controlling for other measures such as social distancing.
A report from the United States Department of Health and Human Services found that 139 clients exposed to two symptomatic hair stylists with confirmed COVID-19—with both the clients and stylists wearing face coverings—resulted in no symptomatic cases reported among all clients and no positive tests among those who volunteered to be tested. This case was highlighted when the CDC reiterated that Americans should wear masks.

Shortages of face masks

Early epidemic in mainland China

As the epidemic accelerated, the mainland market in China saw a shortage of face masks due to increased public demand. In Shanghai, customers had to queue for nearly an hour to buy a pack of face masks; stocks were sold out in another in half an hour. Hoarding and price gouging drove up prices, so the market regulator said it would crack down on such acts. In January 2020, price controls were imposed on all face masks on Taobao and Tmall. Other Chinese e-commerce platforms – JD.com, Suning.com, Pinduoduo – did likewise; third-party vendors would be subject to price caps, with violators subject to sanctions.
By March, the PRC had quadrupled its production capacity to 100 million masks per day.

National stocks and shortages

At the beginning of the COVID-19 outbreak in the United States, the U.S.'s Strategic National Stockpile contained just 12 million N95 respirators, far fewer than estimates of the amount required. Millions of N95s and other supplies were purchased from 2005 to 2007 using congressional supplemental funding, but 85 million N95s were distributed to combat the 2009 swine flu pandemic, and Congress did not make the necessary appropriations to replenish stocks. The Stockpile's primary focus has also primarily been on biodefense and response to natural disaster, with infectious disease a secondary focus. By 1 April 2020, the Stockpile was nearly emptied of protective gear. In January and February 2020, U.S. manufacturers, with the encouragement of the Trump administration, shipped millions of face masks and other personal protective equipment to the PRC, a decision that subsequently prompted criticism given the mask shortage that the U.S. faced during the pandemic.
In France, 2009 H1N1-related spending rose to €382 million, mainly on supplies and vaccines, which was later criticized. It was decided in 2011 to not replenish its stocks and rely more on supply from China and just-in-time logistics. In 2010, its stock included 1 billion surgical masks and 600 million FFP2 masks; in early 2020, it was 150 million and zero respectively. While stocks were progressively reduced, a 2013 rationale stated the aim to reduce costs of acquisition and storage, now distributing this effort to all private enterprises as an optional best practice to ensure their workers' protection. This was especially relevant to FFP2 masks, more costly to acquire and store. As the COVID-19 pandemic in France took an increasing toll on medical supplies, masks and PPE supplies ran low, causing national outrage. France needs 40 millions masks per week, according to French president Emmanuel Macron. France instructed its few remaining mask-producing factories to work 24/7 shifts, and to ramp up national production to 40 million masks per month. French lawmakers opened an inquiry on the past management of these strategic stocks. The mask shortage has been called a "scandal d'État".
In late-March/early-April 2020, as Western countries were in turn dependent on China for supplies of masks and other equipment, China was seen as making soft-power play to influence world opinion. However, a batch of masks purchased by the Netherlands was reportedly rejected as being sub-standard. The Dutch health ministry issued a recall of 600,000 face masks from a Chinese supplier on 21 March which did not fit properly and whose filters did not work as intended despite them having a quality certificate. The Chinese Ministry of Foreign Affairs responded that the customer should "double-check the instructions to make sure that you ordered, paid for and distributed the right ones. Do not use non-surgical masks for surgical purposes". Eight million of 11 million masks delivered to Canada in May also failed to meet standards.

N95 and FFP masks

N95 and FFP masks were in short supply and high demand during the COVID-19 pandemic. Production of N95 masks was limited due to constraints on the supply of nonwoven polypropylene fabric, as well as the cessation of exports from China. China controls 50percent of global production of masks, and facing its own coronavirus epidemic, dedicated all its production for domestic use, only allowing exports through government-allocated humanitarian assistance.
In March 2020, US President Donald Trump applied the Defense Production Act against the American company 3M, which allows the Federal Emergency Management Agency to obtain N95 respirators from 3M. White House trade adviser Peter Navarro stated that there were concerns that 3M products were not making their way to the US. 3M replied that it has not changed the prices it charges, and was unable to control the prices its dealers or retailers charge.
In early April 2020, Berlin politician Andreas Geisel alleged that a shipment of 200,000 N95 masks that it had ordered from American producer 3M's China facility were intercepted in Bangkok and diverted to the United States. Berlin Police president :de:Barbara Slowik|Barbara Slowik stated that she believed "this is related to the US government's export ban." 3M said they had no knowledge of the shipment, stating "We know nothing of an order from the Berlin police for 3M masks that come from China," and the US government denied that any confiscation had taken place and said that they use appropriate channels for all their purchases.
Berlin police later confirmed that the shipment was not seized by US authorities, but was said to have simply been bought at a better price, widely believed to be from a German dealer or China. This revelation outraged the Berlin opposition, whose CDU parliamentary group leader Burkard Dregger accused Geisel of "deliberately misleading Berliners" in order "to cover up its own inability to obtain protective equipment". FDP interior expert Marcel Luthe said "Big names in international politics like Berlin's senator Geisel are blaming others and telling US piracy to serve anti-American clichés." Politico Europe reported that "the Berliners are taking a page straight out of the Trump playbook and not letting facts get in the way of a good story." The Guardian also reported that "There is no solid proof Trump approved the heist".
Jared Moskowitz, head of the Florida Division of Emergency Management, accused 3M of selling N95 masks directly to foreign countries for cash, instead of the US. Moskowitz stated that 3M agreed to authorized distributors and brokers to represent they were selling the masks to Florida, but instead his team for the last several weeks "get to warehouses that are completely empty." He then said the 3M-authorized US distributors later told him the masks Florida contracted for never showed up because the company instead prioritized orders that came in later, for higher prices, from foreign countries. As a result, Moskowitz highlighted the issue on Twitter, saying he decided to "troll" 3M. Forbes reported that "roughly 280 million masks from warehouses around the US had been purchased by foreign buyers and were earmarked to leave the country, according to the broker — and that was in one day", causing massive critical shortages of masks in the US.
As more and more countries restricted the export of N95 masks, Novo Textiles in British Columbia announced plans to start producing N95 masks in Canada. AMD Medicom in Quebec had long been the main Canadian company producing N95s, but China, France, the Republic of China and the United States all banned exports of medical equipment, barring Medicom's factories there from exporting the masks to Canada. The Government of Canada subsequently awarded Medicom a 10-year contract to build a factory to produce masks in Montreal.

The mask industry

Manufacturing

As of 2019, mainland China manufactured half the world output of masks.
As Covid-19 spread, enterprises in several countries quickly started or increased the production of face masks.
Cottage industries and volunteer groups also emerged, manufacturing cloth masks for localized use. They used various patterns, including some with a bend-to-fit nosepiece inserts. Individual hospitals developed and requested a library of specific patterns.
In the first five months of 2020, 70802 new companies registered in China to make or trade face masks, a 1256% increase compared to 2019, and 7296 new companies registered to make or trade meltblown fabric, a key component of face masks, a 2277% rise from 2019.
In April, however, the Chinese government stepped in with tighter regulations. 867 producers of the meltblown fabric were shut down in Yangzhong city alone. Many speculative manufacturers have been forced to quit due to changing export rules and tighter licensing requirements in China and weaker demand for lower quality products globally.

Distribution

Some clinical stockpiles have proved inadequate in scale, and markets have expanded as non-medical consumers started obeying mandated mask-wearing or determined that masks might help or encourage them. Worldwide demand for face masks has resulted in masks shipping around the globe as a result of commercial transactions or of donations.

Society and culture

Attitudes

In East Asian societies, a primary reason for mask-wearing is to protect others from oneself. The broad assumption behind the act is that anyone, including seemingly healthy people, can be a carrier of the virus. The usage of masks is seen as a collective responsibility to reduce the transmission of the coronavirus. A face mask is thus seen as a symbol of solidarity in Eastern countries. Elsewhere, the need for mask-wearing is still often seen in an individual's perspective where masks only serve to protect oneself. However, a cultural shift towards the message of solidarity has gradually taken place as the pandemic continued.
Cultural norms and social pressure may impede mask-wearing in public, which explains why masking has been avoided in the West. According to Joseph Tsang, a Hong Kong doctor and infectious disease expert, the promotion of universal masking may resolve perceptions against mask-wearing, because mask-wearing is intimidating if few people wear masks due to cultural barriers, but if all people wear masks it shows a message that people are in this together. Consistent with this intuition, empirical evidence shows that an individual's likelihood of voluntarily wearing a mask is positively correlated with the proportion of uptake in the surrounding area.
In the Western world, the public usage of masks still often carries a large stigma, as it is seen as a sign of sickness. This stigmatization is a large obstacle to overcome, because people may feel too ashamed to wear a mask in public and therefore opt to not wear one. However, there is also a divide within the Western world, as seen in the Czech Republic and Slovakia where mass mobilization has occurred to reinforce the solidarity in mask-wearing since March 2020.
Among the European countries surveyed by YouGov, the likelihood for people to mask has been split: In Northern Europe, people are very unlikely to wear a mask. In Western Europe, people were initially unlikely to use a mask, but mask wearing greatly changed from low levels in March to higher levels in May. An exception was the United Kingdom where mask usage only grew gradually during this time, but it rose very quickly after official policy changes in July mandated masking in stores.
Masking has been subjected to racial politics in Western countries. For instance, it has been heavily racialized as an Asian phenomenon. This has been reinforced in a lot of media discourses, where unrelated stories about the pandemic are often accompanied by imagery of Asian people in masks. The focus on race has brought hostility towards Asians who are confronted with the choice to mask as precaution while they face discrimination for it. Huang Yinxiang, a sociologist from the University of Manchester, described maskaphobia—negative prejudice, fear or hatred against people wearing face masks—as making Asians in Western countries into targets for racists who want to normalize and justify xenophobia during the COVID-19 outbreak. Likewise, people from certain groups such as Black Americans may not feel comfortable wearing masks, especially those that are not clearly medical but homemade masks, due to concerns of racial profiling.
Gender plays a role in the willingness to wear masks during the pandemic; men are overall less inclined to mask in public than women. There are indications that men are more likely to feel negative emotions and stigma for wearing masks. It is suggested that this male behavior is driven by a sense of masculinity, where the act of masking is possibly perceived to run counter to it, which leads to an increase in men not wearing masks during the pandemic.
Mask-wearing has been called a prosocial behavior in which one protects others within their community. On social media, there has been an effort with the #masks4all campaign to encourage people to use masks. Nevertheless, there have been hostility and violence by people who became aggressive after they were requested to wear a mask or saw people in masks in places related to the service industry. This has led to concerns about worker safety, with employees discouraged to actively enforce masking policies due to the potential of hostile situations, while enforcement by official authorities is severely lacking.
There have also been concerns that the wearing of masks may also further isolate disadvantaged communities. Concerns had been expressed that those who are deaf or hard-of-hearing would be unable to communicate while wearing a face mask. This led to wider distributions of transparent masks, which allow for lip reading. Similar concerns over difficulty in communicating have been expressed by those who may depend on dogs for theraputic or social reasons. Convervsely, people who are exempt from wearing masks on medical grounds or due to a disability, fear they will be subjected to abuse for not wearing a mask, even if they are legally exempt from doing so. In the United Kingdom, charity Disability Rights UK has reported a significant increase in reports of people being confronted on trains and buses.

Politics

Although authorities in especially Asia have been recommending people to wear face masks in public, in many other parts of the world, conflicting advice have caused a lot of confusion among the general population. Several governments and institutions, such as in the United States, have initially dismissed the use of face masks by the general population, often with misleading or incomplete information about the usefulness of masks. Commentators have attributed the anti-mask messaging to efforts to manage the mask shortages, as governments did not act quickly enough, remarking that the claims go beyond the science or were simply lies. On 12 June 2020, Anthony Fauci, a key member of the White House coronavirus task force, confirmed that the American public were not told to wear masks from the beginning due to the shortages of masks and explained that masks do actually work.
In the United States, public masking has become a political issue, as opponents argue that it inhibits personal freedom and proponents emphasize the importance of masks for public health. Some people may see it as a political statement. Party affiliation partly determined how likely people were to embrace the wearing of masks in public. Democrats were more likely to wear masks than Republicans. The issue is seen as a part of a culture war. Commentators argue that the resistance against masks partly stems from the confusing and mixed messaging about masking.
Tom Jefferson and Carl Heneghan from the Centre for Evidence-Based Medicine suggest that issues in the value placed on evidence and the lack of clear answers to guide decision-makers have resulted in polarizing and politicized views influencing global interventions.
Despite widespread implementation of masking policies globally, in some countries, large rallies have taken place in protest against masking mandates. In Canada, the anti-mask crowd has hailed their protests as the so-called "March to Unmask." In the United Kingdom, new protests came in the wake of the official announcement that masking will be compulsory in shops.
In April 2020, health officials from Taiwan's Central Epidemic Command Center pushed back on school bullying of young boys in pink face masks. At a press conference breaking gender norm barriers, the health officials wore pink masks, as various government agencies demonstrated solidarity by changing the colors on their Facebook pages to pink. One of the officials participating in the press conference later tweeted, "Pink is for everyone and no color is exclusive for girls or boys. Gender equality lies at the heart of Taiwan values." The press conference was held amid reports that male students were too embarrassed to wear their pink face masks, jeopardizing their safety and the safety of others in the face of COVID-19.

Fashion

Face masks have had an impact on fashion, with the masks themselves becoming fashion statements, haute couture brands having pivoted to address both public health and aesthetic needs. As public usage of fabric masks have become more commonplace, people have started to consider the aesthetical design of it.

Mask use and policies by country and territory

Country/territory%
Hong Kong90
Singapore90
China88
Italy87
Taiwan87
Thailand87
Japan86
Vietnam86
Malaysia85
Indonesia84
Philippines84
India82
United Arab Emirates78
Spain72
Mexico67
United States63
Germany62
France56
Saudi Arabia56
Canada41
Australia25
United Kingdom13
Finland7
Norway7
Denmark5
Sweden2