Association of American Physicians and Surgeons

https://aapsonline.org/mask-facts/

MASKS

Filter Efficiency and Fit

Data from a University of Illinois at Chicago review https://www.cidrap.umn.edu/news-

perspective/2020/04/commentary-masks-all-covid-19-not-based-sound-data

 HEPA (high efficiency particulate air) filters are 99.97 to 100% efficient. HEPA filters
are tested with particles that are 0.125 μm (the size of SARS-CoV-2).
 Masks and respirators work by collecting particles through several physical mechanisms,
including diffusion (small particles) and interception and impaction (large particles).
 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. They aren’t effective at blocking
particles smaller than 100 μm.
https://multimedia.3m.com/mws/media/957730O/respirators-and-surgical-masks-
contrast-technical-bulletin.pdf
o OSHA/CDC:  A surgical mask is not a respirator. It cannot be used to protect
workers who perform or assist with aerosol-generating procedures, which may
create very fine aerosol sprays. A surgical mask can only be used to protect
workers from contact with the large droplets made by patients when they
cough, sneeze, talk or breathe.
https://www.osha.gov/dts/guidance/flu/healthcare.html
o

Conclusions

The preponderance of scientific evidence supports that aerosols play a critical role in the
transmission of SARS-CoV-2.  Years of dose response studies indicate that if anything gets
through, you will become infected.

 Thus, any respiratory protection respirator or mask must provide a high level of filtration
and fit to be highly effective in preventing the transmission of SARS-CoV-2.  (Works for
Mycobacterium tuberculosis (3μm)
 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).
o The chance of catching COVID-19 from a passing interaction in a public space is
therefore minimal.
Laboratory Studies

 N95 filtering facepiece respirators (FFRs) are constructed from electret (a dielectric
material that has a quasi-permanent electric charge.) An electret generates internal and
external electric fields so the filter material has electrostatic attraction for additional
collection of all particle sizes. As flow increases, particles will be collected less
efficiently.

 A properly fitted N95 will block 95% of tiny air particles down to
0.3 μm from reaching the wearer’s face.
o https://www.honeywell.com/en-us/newsroom/news/2020/03/n95-masks-explained.
o Problem: no source control. An N95 does not filter exhaled air passing through
the exhaust/exhalation valve (for easier breathing and less moisture inside the
mask).

 Study measuring filter efficiency (2010)

o https://academic.oup.com/annweh/article/54/7/789/202744;
https://www.cidrap.umn.edu/news-perspective/2020/04/commentary-masks-all-
covid-19-not-based-sound-data;
https://academic.oup.com/annweh/article/54/7/789/202744
o Filter efficiency was measured across a wide range of small particle sizes (0.02 to
1 µm) at 33 and 99 L/min.
o All the cloth masks and materials had near zero efficiency at 0.3 µm, a particle
size that easily penetrates into the lung (SARS-CoV-2 is 0.125 µm)
o Efficiency for the entire range of particles
 T-shirts — 10%
 Scarves — 10% to 20%
 Cloth masks — 10% to 30%
 Sweatshirts — 20% to 40%
 Towels — 40%

 Study measuring filter efficiency (2014, Korea)

o https://aaqr.org/articles/aaqr-13-06-oa-0201
o Evaluated 44 masks, respirators, and other materials with similar methods and
small aerosols (0.08 and 0.22 µm)
 N95 FFR filter — >95% efficiency
 Medical masks — 55% efficiency
 General (cloth) masks — 38% efficiency
 Handkerchiefs — 2% (one layer) to 13% (four layers) efficiency.

 Conclusion: Wearing masks (other than N95) will not be effective at preventing SARS-
CoV-2 transmission, whether worn as source control or as PPE.
o N95s protect health care workers but are not recommended for source control
transmission.
 o Surgical masks are better than cloth but not very efficient at preventing emissions
from infected patients. Cloth masks must be 3 layers, plus adding static electricity
by rubbing with rubber glove.
o The cloth that serves as the filtration for the mask is meant to trap particles being
breathed in and out. But it also serves as a barrier to air movement because it
forces the air to take the path of least resistance, resulting in the aerosols going in
and out at the sides of the mask.
o An August 2020 UCSF study suggested that the mask would decrease the
absolute volume of the inoculum. (The concentrations of bacteria upstream and
downstream of the test devices were measured with an aerodynamic size
spectrometer) https://ucsf.app.box.com/s/blvolkp5z0mydzd82rjks4wyleagt036

Negative Effects of Masks

Air inside the mask is definitely stale.  In filtering particles, the mask makes it harder to breathe.

Decreased PaO2

 A 2004 observational study of end stage renal disease patients during dialysis for 4 hours
(2004, Taiwan).
o https://pubmed.ncbi.nlm.nih.gov/15340662/;
o https://www.researchgate.net/publication/8371248_The_physiological_impact_of
_wearing_an_N95_mask_during_hemodialysis_as_a_precaution_against_SARS_
in_patients_with_end-stage_renal_disease
o 39 patients, mean age, 57 years. 70% had decreased PaO2 (from 100 to 92); 19%
had hypoxemia (PaO2 <70); all patients had increased respiratory rate 16 to 18;
chest discomfort (3 baseline patients to 11 patients); respiratory distress (1
baseline patient to 17 patients)

 Stanford engineers estimated that N95 masks cause a 5% to 20% reduction in O2 intake.
This can cause dizziness and lightheadedness. This can be life-threatening for someone
with lung disease or with respiratory distress. 
o https://engineering.stanford.edu/magazine/article/covid-19-prompts-team-
engineers-rethink-humble-face-mask

 Study of surgeons in the OR (2008, Turkey).

o http://scielo.isciii.es/pdf/neuro/v19n2/3.pdf
o Scientists looked at O2 levels of surgeons wearing masks while performing
surgery. Found a decrease in the oxygen saturation of arterial pulsations
(peripheral capillary O2 saturation/SpO2) fell from 98% to 96% and a slight
increase in pulse rates compared to preoperative values in all surgeon groups.
Increased CO2

 This may be merely theoretical. Carbon dioxide molecules freely diffuse through the
masks, allowing normal gas exchange while breathing.

 CO2 is present in the atmosphere at a level of about 0.04% (400ppm). According to the
U.S. Department of Agriculture / OSHA, carbon dioxide becomes toxic at concentrations
above 4 percent (40,000ppm); symptoms at 5,000-10,000 ppm. 10,000 ppm has been
measured behind mask.

 Experiment (July 2020). 

o https://www.wthr.com/article/news/health/coronavirus/verify-do-face-masks-
reduce-oxygen-intake-carbon-dioxide-experiment-multiple-maskss/531-
c00c96cb-9273-4947-949c-0807f94454a7
o Pulse oximeter and exhaled CO2 (via tube in mask) No change with mask. (End-
tidal capnography or end-tidal CO2 (EtCO2) monitoring is a non-invasive
technique that measures the partial pressure or maximal concentration of carbon
dioxide (CO2) at the end of an exhaled breath. The normal values are 5-6% CO2,
which is equivalent to 35-45 mmHg.)

 Health care worker study (2005, Scandinavia)

o https://pubmed.ncbi.nlm.nih.gov/16441251/
o 37.3% reported face-mask-associated headaches, 32.9% reported headache
frequency >6 times per month. 7.6% had taken sick leave from March 2003 to
June 2004 (mean 2 days; range 1-4 days) and 59.5% required use of abortive
analgesics because of headache.

 Health care worker study (2009, Japan) with similar headache results as Scandinavian
study (above).
o https://pubmed.ncbi.nlm.nih.gov/19216002/

 While there are some articles reporting OSHA tests, it is not clear they were proper tests.

 Some people have mistakenly claimed that OSHA standards (e.g., the Respiratory
Protection standard, 29 CFR 1910.134; the Permit-Required Confined Space standard 29
CFR 1910.146; and the Air Contaminants standard, 29 CFR 1910.1000) apply to the
issue of oxygen or carbon dioxide levels resulting from the use of medical masks or cloth
face coverings in work settings with normal ambient air (e.g. healthcare settings, offices,
retail settings, construction). These standards do not apply to the wearing of medical
masks or cloth face coverings in work settings with normal ambient air). These standards
would only apply to work settings where there are known or suspected sources of
chemicals (e.g., manufacturing facilities) or workers are required to enter a potentially
dangerous location (e.g., a large tank or vessel). https://www.osha.gov/SLTC/covid-
19/covid-19-faq.html
  It is hard to tell if the headaches experienced by HCWs with N95s is CO2 or having a
strap around the head.

 But when asked should we be worried about CO2, mask proponents say, “No” because
you can exhale around the sides of the mask. This defeats the purpose. (2006)
https://pubmed.ncbi.nlm.nih.gov/16441251/

Moisture retention

 Reuse of cloth masks, frequency and effectiveness of cleaning, and poor filtration may
result in increased risk of infection.

 Observations during SARS suggested double-masking and other practices increased the
risk of infection because of moisture, liquid diffusion.
o https://bmjopen.bmj.com/content/5/4/e006577;
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420971/pdf/bmjopen-2014-
006577.pdf

 Recent study (in German) cultured 82 bacterial colonies & 4 mold (fungoid) colonies
from a child’s masks after 8 hours of wear.
o https://twitter.com/MMaccruiskeen/status/1307266527662669825?s=20

Self-contamination

 Contamination through repeated use and improper doffing is possible.  The virus may
survive on the surface of the mask.  The pathogen goes from mask to bare hands.

“Mask mouth”

 Reported by dentists.  https://nypost.com/2020/08/05/mask-mouth-is-a-seriously-stinky-

side-effect-of-wearing-masks/ 

 Wearing masks increases dryness, which leads to decrease in saliva. It is the saliva that
fights bacteria. Result is decaying teeth, receding gum lines and seriously sour breath.
Gum disease — or periodontal disease — will eventually lead to strokes and an increased
risk of heart attacks.”

World Health Organization (WHO), June 2020

 https://apps.who.int/iris/bitstream/handle/10665/332293/WHO-2019-nCov-IPC_Masks-
2020.4-eng.pdf?sequence=1&isAllowed=y
 “The likely disadvantages of the use of mask by healthy people in the general public
include:
o potential increased risk of self-contamination due to the manipulation of a face
mask and subsequently touching eyes with contaminated hands;
o potential self-contamination that can occur if non- medical masks are not changed
when wet or soiled. This can create favorable conditions for microorganism to
amplify;
o potential headache and/or breathing difficulties, depending on type of mask used;
o potential development of facial skin lesions, irritant dermatitis or worsening acne,
when used frequently for long hours;
o difficulty with communicating clearly;
o potential discomfort;
o a false sense of security, leading to potentially lower adherence to other critical
preventive measures such as physical distancing and hand hygiene;
o poor compliance with mask wearing, in particular by young children;
o waste management issues; improper mask disposal leading to increased litter in
public places, risk of contamination to street cleaners and environment hazard;
o difficulty communicating for deaf persons who rely on lip reading;
o disadvantages for or difficulty wearing them, especially for children,
developmentally challenged persons, those with mental illness, elderly persons
with cognitive impairment, those with asthma or chronic respiratory or breathing
problems, those who have had facial trauma or recent oral maxillofacial surgery,
and those living in hot and humid environments.