As the governments reopen their economies and still try to maintain the social distancing norms while new infections continue to occur and while there is no vaccine or widely accessible or effective treatments in sight, there are many raging questions in the minds of people pertaining to the COVID pandemic. One of them is regarding the need to wear face masks.

Actually there has been a big debate on the need to wear face masks , as it is said to only prevent the people who are infected from viruses, and are asymptomatic, from unintentionally spreading the virus.

However, the reason why everyone is told to wear face masks is because, checking of coronavirus , and who really has it, is quite difficult. The testing of corona is impossible in the entire population, in countries with high population like China & India. There can be many people who are corona positive, but have no symptoms or haven’t got it tested. The government therefore can’t take a risk of allowing only selective people to wear face masks.

Acc. to US CDC , COVID-19 can be spread by people who do not have symptoms and do not know that they are infected. That’s why it’s important for everyone to wear face masks in public settings and practice social distancing.

WHO too initially had a strong stance that masks are not needed in public for those who don’t already have coronavirus. WHO also believed that, the widespread need to wear face masks might lead to a mask shortage for medical workers and create a false sense of security in the public. But then it eventually changed its stance on wearing masks.

People over 60 and people with underlying medical conditions should wear a medical-grade mask when they’re in public and cannot socially distance. The general public should wear a three-layer fabric mask in those situations.

The WHO also updated their advice for medical workers, saying all of them should always wear a medical mask while in clinical areas, not just people working with COVID-19 patients. WHO advised various governments to encourage the general public to wear face masks where there is widespread transmission and physical distancing is difficult, such as on public transport, in shops or in other confined or crowded environments.

Acc. to WHO , For children aged 5 years and under should not be required to wear face masks . This is based on the safety and overall interest of the child and the capacity to appropriately use a mask with minimal assistance. 

WHO and UNICEF advise that the decision to use masks for children aged 6-11 should be based on the following factors:

• Whether there is widespread transmission in the area where the child resides

• The ability of the child to safely and appropriately wear face masks

• Access to masks, as well as laundering and replacement of masks in certain settings (such as schools and childcare services) 

• Adequate adult supervision and instructions to the child on how to put on, take off and safely wear face masks

• Potential impact of wearing a mask on learning and psycho-social development, in consultation with teachers, parents/caregivers and/or medical providers

• Specific settings and interactions the child has with other people who are at high risk of developing serious illness, such as the elderly and those with other underlying health conditions 

WHO and UNICEF advise that children aged 12 and over should wear a mask under the same conditions as adults, in particular when they cannot guarantee at least a 1-metre distance from others and there is widespread transmission in the area.

Children should not wear face masks when playing sports or doing physical activities, such as running, jumping or playing on the playground, so that it doesn’t compromise their breathing.

Acc. to a 2020 study in the International Journal of Engineering Research and Technology, by a Korean research team, led by Zhixing Tian , N95 is designed to filter out at least 95% of the dust and mold in the air. It can filter particles above 0.3μm. They can block PM2.5 (<= 2.5μm) and virus-borne droplets (> 5μm). This is a reason that it is used by more people. However, they are so tightly sealed that prolonged use or exercise can easily cause brain hypoxia, dizziness, chest tightness and other symptoms. For example, N95 masks are dust masks for industrial use. According to German labour insurance regulations, workers should not wear N95 masks for more than half an hour at a time. Therefore, they are not suitable for long-term wear, especially for patients with cardiovascular disease, the elderly, and children.

First, when we put on a mask, a closed space is formed between the mask and the human face. Therefore, when a person inhales again, only after this part of the exhaust gas is inhaled into the human body can the external filtered air be taken in. As a result, the oxygen concentration will reduce in the inhaled air. First, low oxygen concentrations will cause the cells to be hypoxic cause physiological stress.

Second, because of the filtering effect and limited transmittance of the mask, breathing resistance is greater when wearing a mask, which makes us feel difficult to breathe. As a result, psychological stress caused by this negative external environment. The brain consumes a lot of oxygen in our body.

When there is insufficient oxygen in the air, the first organ to respond is the brain. Due to the lack of oxygen in the brain, it also damages our nervous system, causing adverse physiological reactions, such as dizziness, chest tightness, and psychological reactions about anxiety and depression. The longer the duration of wearing a mask, the more severe the situation of hypoxia, the more severe the body ’s response to hypoxia will be.

In a 2020 study in the journal Health Affairs, US researchers Wei Lyu & George L. Wehby, provided direct evidence on the effectiveness of widespread community use of face masks from a natural experiment that evaluated the effects of state government mandates in the US for face mask use in public on COVID-19 spread.

Fifteen states plus Washington, D.C., mandated face mask use between April 8 and May 15. The study found that mandating public use of face masks was associated with a reduction in the COVID-19 daily growth rate. Mandating face mask use in public is associated with a decline in the daily COVID-19 growth rate by 0.9, 1.1, 1.4, 1.7, and 2.0 percentage points in 1–5, 6–10, 11–15, 16–20, and 21 or more days. Estimates suggest that as a result of the implementation of these mandates, more than 200,000 COVID-19 cases were averted by May 22, 2020.

In a 2020 study by the US researchers from Texas A & M university , examined the chances of COVID-19 infection and how the virus is easily passed from person to person. From trends and mitigation procedures in China, Italy and New York City, the researchers found that using a face mask reduced the number of infections by more than 78,000 in Italy from April 6-May 9 and by over 66,000 in New York City from April 17-May 9.

By analyzing the pandemic trends without face-covering using the statistical method and by projecting the trend, researchers calculated that over 66,000 infections were prevented by using a face mask in little over a month in New York City. They concluded that wearing a face mask in public corresponds to the most effective means to prevent inter-human transmission. This inexpensive practice, in conjunction with social distancing and other procedures, is the most likely opportunity to stop the COVID-19 pandemic.

One of the researchers suggested that, “Our study establishes very clearly that using a face mask is not only useful to prevent infected coughing droplets from reaching uninfected persons, but is also crucial for these uninfected persons to avoid breathing the minute atmospheric particles (aerosols) that infected people emit when talking and that can remain in the atmosphere tens of minutes and can travel tens of feet.”

In a 2020 study in the journal Natural Medicine, a research team, led by Nancy H.L. Leung, identified seasonal human coronaviruses, influenza viruses and rhinoviruses in exhaled breath and coughs of children and adults with acute respiratory illness. The found that surgical face masks could prevent transmission of human coronaviruses and influenza viruses from symptomatic individuals.

In a 2020 study in the Journal of Medical Virology, a Chinese research team, led by Qing Xia Ma, found that instant hand wiping using a wet towel soaked in water containing 1.00% soap powder, 0.05% active chlorine, or 0.25% active chlorine from sodium hypochlorite removed 98.36%, 96.62%, and 99.98% of the virus from hands, respectively. N95 masks, medical masks, and homemade masks made of four-layer kitchen paper and one-layer cloth could block 99.98%, 97.14%, and 95.15% of the virus in aerosols. 

In a 2020 review study in the Annals of Internal Medicine, a US research team, led by Roger Chou, examined the effectiveness of N95, surgical, and cloth masks in community and health care settings for preventing respiratory virus infections, and effects of reuse or extended use of N95 masks. 39 studies with 33,867 participants were included. Community mask use was possibly associated with decreased risk for SARS-CoV-1 infection in studies. In high- or moderate-risk health care settings, studies found that risk for infection with SARS-CoV-1 and Middle East respiratory syndrome coronavirus probably decreased with mask use versus non-use and possibly decreased with N95 versus surgical mask use.

In a 2020 meta-analysis study in the journal The Lancet, a research team led by Derek Chu , researchers after reviewing hundreds of studies in over 16 countries and 6 continents, found that, transmission of viruses was lower with physical distancing of 1m or more, compared with a distance of less than 1m; protection was increased as distance was lengthened. Face mask use could result in a large reduction in risk of interaction infection, with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar. Eye protection also was associated with less infection.

In a 2020 study in The European Respiratory Journal, an Italian research team, led by Susanna Esposito , assessed the effect of community-wide mask usage to control coronavirus disease 2019 (COVID-19) in Hong Kong Special Administrative Region (HKSAR). Within first 100 days (31 December 2019 to 8 April 2020), 961 COVID-19 patients were diagnosed in HKSAR. The COVID-19 incidence in HKSAR was significantly lower than that of Spain, Italy, Germany, France, U.S., U.K., Singapore, and South Korea. The compliance of face mask usage by HKSAR general public was 96.6%. Researchers thus concluded that, community-wide mask wearing may contribute to the control of COVID-19 by reducing the amount of emission of infected saliva and respiratory droplets from individuals with subclinical or mild COVID-19.

In another 2020 systematic review study, a British research team, led by Julii S. Brainard, found that based on the studies, wearing facemasks can be very slightly protective against primary infection from casual community contact, and modestly protective against household infections when both infected and uninfected members wear face masks .

When both house-mates and an infected household member wore face masks the odds of further household members becoming ill may be modestly reduced by around 19%. The evidence is not sufficiently strong to support widespread use of face masks as a protective measure against COVID-19. However, there is enough evidence to support the use of facemasks for short periods of time by particularly vulnerable individuals when in transient higher risk situations.

In a 2020 meta-analysis study in the Journal of Education & Health Promotion, an Indian research team led by Suresh K. Sharma , tested the efficacy of cloth face masks in prevention of viral infection transmission. They found that, cloth face masks show minimum efficacy in source control than the medical grade mask. The efficacy of cloth face masks filtration varies and depends on the type of material used, number of layers, and degree of moisture in mask and fitting of mask on face. However, it may be used in closed, crowded indoor, and outdoor public spaces involving physical proximity to prevent spread of SARS-CoV-2 infection.

In a 2020 meta-analysis study in the International Journal of Infectious Diseases, a research team from Qatar led by Karima Chaabna , reviewed 12 studies on the effectiveness of medical facemask use to prevent influenza, influenza-like illness, SARS-CoV and SARS-CoV-2 transmission. The meta-analysis demonstrated that facemask use significantly reduces the risk of transmitting these respiratory infections. Respiratory infection incidence is lower with high medical facemask compliance, early use, and use in combination with intensive hand hygiene. Facemasks are effective in reducing SARS-CoV-2 transmission when used before those infected develop symptoms. 

In a 2020 study in the British Journal of Sports Medicine , suggested that, tough infection control remains an important consideration, but wearing a mask comes with issues of potential breathing restriction and discomfort in mind. Selecting an appropriate face-covering becomes an act of balancing benefits versus possible adverse events. Most people will be able to exercise safely wearing a face covering, but points to consider include:

• Viral transmission from infected but asymptomatic or pre-symptomatic individuals is possible. Due to the increased rate and force associated with breathing during exercise, the risk of spread of virus-containing droplets could theoretically be higher than when at rest.

• Reserve filtering facepiece respirators (FFRs) (e.g. N95/FFP1/FFP2) for specific work environments such as front-line healthcare workers. These should not be used by the public and also not for exercise purposes.

• Airflow-restricting masks can increase the rate of perceived exertion and decrease performance during resistance training. 

• While there is no evidence showing the effects of cloth masks or buffs, they could potentially increase the breathing effort and cause accumulation of CO2. Wearing a mask may, in fact, simulate the physiological effect of altitude training, albeit on a smaller scale. This is unlikely to be an issue for most people but could present a problem at higher intensities of exercise, particularly for those with underlying health concerns. It would be prudent for people with existing heart or lung conditions to exercise at a lower intensity than usual while wearing a mask, to prevent any adverse events. People must be cognisant of their breathing during exercise and somewhat slow down or take a break if they feel that their work rate is too high or if experiencing dizziness or light-headedness.

• A more breathable material will aid in comfort but may have the cost of less effective viral source control. Two layers of material are considered sufficient to balance efficacy and comfort. Not having a tight seal around the sides of your face also allows for better air movement, but will subsequently increase the risk of droplet spread.

• Due to the accumulation of moisture from our exhaled breath, cloth masks or buffs are likely to get wet during exercise. Breathing through dry cloth is easier as opposed to damp cloth. Hot and humid conditions can worsen the effect of strenuous breathing. Moisture-wicking material, such as polyester, is a good option but may cause skin irritation in sensitive individuals. Theoretically, wet material may facilitate viral transmission. However, cloth masks are recommended for source control and are likely insufficient to prevent transmission of viral particles to the wearer even when dry.

• Ensure that your face covering is comfortable and secure before leaving the house, to limit the need to readjust it and touch your face.

Wearing of masks has been shown to be quite detrimental to the health of pregnant women. In a 2015 study in the journal Antimicrobial Resistance and Infection Control, by a research team from Singapore, led by Pearl Shuang Ye Tong, studied healthy pregnant healthcare workers between 27 to 32 weeks gestation, whilst at rest and exercising, using the N95 masks. Breathing through N95 mask materials was shown to impede gaseous exchange and impose an additional workload on the metabolic system of pregnant healthcare workers. The results suggested that pregnant women may experience more fatigue and require more rest breaks from mask use. Scheduled work breaks should be considered for pregnant healthcare workers working in high risk areas which require prolonged use of N95 respirators. In face of the imminent threat of pandemic airborne respiratory diseases it should be emphasized that the benefit of using N95 mask to prevent serious emerging infectious diseases should be weighed against possible respiratory consequences associated with N95 mask usage.

SHOULD YOU WEAR FACE MASKS WHILE EXERCISING?

Acc. to WHO , “people should NOT wear face masks when exercising, as masks may reduce the ability to breathe comfortably. Sweat can make the mask become wet more quickly which makes it difficult to breathe and promotes the growth of microorganisms. The important preventive measure during exercise is to maintain physical distance of at least one meter from others.”

However, people also had a myth that if we wear masks for a prolonged period, it may lead to oxygen deficiency or CO2 intoxication. However, WHO states that, “The prolonged use of medical masks can be uncomfortable. However, it does not lead to CO2 intoxication nor oxygen deficiency. While wearing a medical mask, make sure it fits properly and that it is tight enough to allow you to breathe normally. Do not re-use a disposable mask and always change it as soon as it gets damp.”

In a 2020 study in the journal Medical Hypothesis, Indian researchers Bhaskaran Chandrasekaran & Shifra Fernandes, explored the answers to the debatable questions about the use of face masks during exercise: 1) Does the use of face-masks offer any benefit for ‘social exercisers’ during this pandemic; 2) Does exercising with facemasks alter normal physiological responses to exercise; 3) Does exercising with facemasks increase the risk of falling prey to Coronavirus; 4) How could “social exercisers” combat the physiological alteration?

Coronavirus is known to spread via droplets and causes upper respiratory tract infections with ARDS. Respirator facemasks (N95) serve as personal protective equipment that could filter fine airborne particles and prevent them from reaching the respiratory system as well as prevent inter-individual infections, especially influenza and coronaviruses.

Acc. to Chandrasekaran & Fernandes, The face mask forms a closed circuit for the inspired and expired air, though not completely airtight. Rebreathing of the expired air increases arterial CO2 concentrations and increases the intensity of acidity in the acidic environment. Thus individuals exercising with a mask would have physiological effects similar to a Chronic Obstructive Pulmonary Disease (COPD) person exercising such as discomfort, fatigue, dizziness, headache, shortness of breath, muscular weakness and drowsiness. The resistance offered to the inspiratory and expiratory flow, for prolonged periods (about 10 mins), could result in respiratory alkalosis, increased lactate levels and early fatigue. Because the O2 levels may fall at higher levels can lead to temporary fall in 02 levels leading to hypoxia type environment.

While compared to normal breathing, any kind of protective mask negatively effects the airflow to the lungs. Thicker the mask material, greater the airflow obstruction. Less oxygen in your lungs means less oxygen in your bloodstream and your working muscles, which is what makes training more difficult. With less air, your body has less available oxygen to utilize during exercise to convert glucose into energy (Click here to know more). That’s why it’s very difficult to perform continuously at the level you would without wearing a mask, even if you are competitive athlete.

Exercise is excellent for your immunity. The acidic environment created because of use of face masks and resulting increase in the CO2 environment, which reduces the mobility of hypoxic natural killer cells to the target cells, aggravating the chances of infection during the pandemic.

On the other hand, acc. to Chandrasekaran & Fernandes, the reduced availability of O2 and CO2 would increase the heart rate and blood pressure exponentially even at low workloads. This physiological alteration may increase aortic pressure and left ventricular pressures, leading to an upsurge of cardiac overload and coronary demand. These changes may be subtle in healthy individuals during exercise. Still, in persons with established chronic illness, these changes may aggravate the underlying pathophysiology, leading to hospitalization or increased use of medication.

There is another issue found with use of tight masks during high intensity workouts. The hypoxia reduces renal blood flow and glomerular filtration rate posing a risk of reduced renal functions. Thus, aciduria and resulting tubular damage may potentially aggravate the compromised renal functions in individuals with established chronic diseases.

Reduced oxygen to the brain, due to the hypoxic environment created can also lead to reduction in brain metabolism, and is overall detrimental to mental health. Elderly people, suffering from various respiratory diseases, are at even greater risk, when using masks during workouts.

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On the other hand, use of masks itself has been debatable and condemned by top experts. Perencevich et al. 2020, “The average healthy person shouldn’t be wearing masks as it creates a false sense of security and people tend to touch their face more often when compared to not wearing masks”. The surgical masks are debated to trap the droplets containing the virus inside, increasing rather than reducing the risk of infection.

Acc. to Chandrasekaran & Fernandes , even with the usage of a protective face mask, social distancing while exercising outdoors is essential. To avoid the adverse effects of exercising with a face mask, the individual should first be aware of their exercise limit. Low to moderate-intensity exercise would be beneficial and would help reduce the ill effects of mask breathing. When experiencing symptoms of dizziness, imbalance, excessive fatigue, and shortness of breath, it would be advisable to stop and take a break, until symptoms subside. Intermittent atmospheric breathing without the mask would be beneficial to restore the normalcy of breathing and reducing the stress on the cardiopulmonary system, in an area which is not densely occupied by people. Individuals with chronic diseases should avoid venturing outdoors to exercise. Home-based exercises, performed under the supervision of a health professional, would be preferred to avoid any adverse outcomes.

Lindsay Bottoms, deputy head for the Centre for Research in Psychology and Sports Science at the University of Hertfordshire in the UK, carried out a self-experiment with and without the use of mask. She ran on a treadmill at 10km/h for three minutes to reflect the intensity and duration of fencing. She did this with full fencing kit, with and without a cloth face mask under my fencing mask. She used a portable gas analyser and adapted it to measure the concentration of gases being breathed in and out.

She found that, the concentration of oxygen in the atmosphere is around 21% at sea level. When running on the treadmill with only the fencing mask, the concentration of oxygen was around 19.5%. This is equivalent to exercising at 600 meters above sea level. But wearing a face mask under the fencing mask reduced her oxygen level to around 17% — the equivalent of exercising at 1,500 meters. Any further decreases in oxygen concentration — by exercising longer or harder — would have a large effect on the physiological responses to exercise, causing altitude-sickness symptoms such as dizziness or headache.

She also found that, there are negligible levels of carbon dioxide in atmospheric air, and when exercising with only the fencing mask this remains below 1%. With the face mask on, it trebled to 3%. Bottoms found that, UK Health and Safety Executive — the government agency responsible for regulation and enforcement of workplace safety — advises that employees should not be exposed to 1.5% carbon dioxide for more than 15 minutes.

In an earlier 2015 study in the Asian Journal of Sports Medicine, an Italian research team, led by Desiderio Passali , investigated the presence of nasal obstruction in 40 fencers and the relationship with the use of mask. The study showed that wearing the mask causes increased breathing impairment in fencers, when compared with similar physical activity without the mask.

In a 2020 study in the journal Clinical Research in Cardiology, a German research team, led by Sven Fikenzer , studied the effects of wearing no mask, a surgical mask, and a FFP2/N95 mask in 12 healthy males. Researchers found that, ventilation, cardiopulmonary exercise capacity and comfort are reduced by surgical masks and highly impaired by FFP2/N95 face masks in healthy individuals. 

In a 2020 study in the Spanish journal Apunts Sports Medicine, researcher Fernando Pifarre & team , assessed the physiological impact of the hypercapnia hypoxia generated by the masks during aerobic sports practice in eight subjects. Researchers found that, the use of masks in athletes causes hypoxic and hypercapnic breathing, being more evident in effort. The use of masks during a short exercise with an intensity around 6-8 METS, decreases O2 by 3.7% and increases the CO2 concentration by 20%.

One odd study also supported the fact that there won’t be any issues during workout, if we wear a surgical mask. For e.g. in a 2020 study in the Journal of Human Sports & Exercise, a Japanese research team led by Atsuya Otsuka , determined in six men, whether cardiopulmonary function and anaerobic threshold vary while wearing surgical masks, during pedalling movement. Researchers found that, although the number of complaints of respiratory distress, was significantly higher while wearing a surgical mask. The exercise intensity achieved by each participant was equivalent, irrespective of whether they wore the surgical mask; therefore, wearing a surgical mask does not affect cardiopulmonary function during vigorous exercise.

In a 2016 study in the journal Sports, a Brazilian research team, led by Yuri Motoyama , compared the number of repetitions to volitional failure, the blood lactate concentration, and the perceived exertion to resistance training with and without an airflow-restricting mask. Eight participants were assigned to an airflow-restricting mask group (MASK) or a control group (CONT) and completed five sets of chest presses and parallel squats until failure at 75% one-repetition-maximum test (1RM) with 60s of rest between sets. Researchers found that an airflow-restricting mask in combination with resistance training increase perceptions of exertion and decrease muscular performance and lactate concentrations when compared to resistance training without this accessory. This evidence shows that the airflow-restricting mask may change the central nervous system and stop the exercise beforehand to prevent some biological damage.

Acc, to US CDC, Masks are recommended as a simple barrier to help prevent respiratory droplets from traveling into the air and onto other people when the person wearing the mask coughs, sneezes, talks, or raises their voice. This is called source control. This recommendation is based on what we know about the role respiratory droplets play in the spread of the virus that causes COVID-19, paired with new emerging evidence , from clinical and laboratory studies that shows masks reduce the spray of droplets when worn over the nose and mouth. COVID-19 spreads mainly among people who are in close contact with one another (within about 6 feet), so the use of masks is particularly important in settings where people are close to each other or where social distancing is difficult to maintain.

When it comes to physical activity, US CDC suggested that, people who are engaged in high intensity activities, like running, may not be able to wear a mask if it causes difficulty breathing. If unable to wear a mask, consider conducting the activity in a location with greater ventilation and air exchange (for instance, outdoors versus indoors) and where it is possible to maintain physical distance from others.