Everything You Need To Know About Wearing Masks—Until The CDC Tells Us More
As of Friday afternoon, April 4, the CDC has officially begun recommending more widespread mask-wearing, including by people who don’t show any symptoms of COVID-19. Specifically, the CDC “recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies) especially in areas of significant community-based transmission.”
The CDC guidelines are aimed at reducing transmission of COVID-19 from people who are infected but not yet showing symptoms; there is still not sufficient evidence to show that wearing a mask reduces the wearer’s likelihood of catching COVID-19.
The CDC also states it’s “critical to emphasize that maintaining 6-feet social distancing remains important to slowing the spread of the virus,” but its guidelines on wearing masks are incredibly vague. In fact, nowhere on the CDC pages about wearing or making cloth masks does the agency mention the most important aspect of wearing masks: that wearers wash their hands before and after putting on the mask and after every time they touch it.
The CDC should provide more guidance on safety and proper use about masks, according to Shanina Knighton, PhD, RN, a clinical nursing scientist and infection preventionist at Case Western Reserve University in Cleveland, Ohio. If people don’t receive continuing instruction and emphasis on the previous behaviors that reduce infections, she said, they tend to focus only on what’s new.
“When you tell someone to do something, if you do not give them clear instruction, it will become a safety issue,” Dr. Knighton said. “I can see someone literally bleach-coating—soaking a mask in bleach and letting it dry—and putting it on their face and thinking that because this is an EPA-approved product, I’m now protected against COVID. But now you have skin irritation and you’re inhaling bleach all day.” Shortly after the EPA announced that bleach products kill COVID-19, several bleach poisonings occurred around the country from people drinking bleach to try to kill the virus.
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Even the World Health Organization, whose stance on masks has continued to evolve, has emphasized the importance of proper use and disposal of masks and reinforced the behaviors with more solid evidence behind them.
“Mask or no mask, there are proven things all of us can do to protect ourselves and others – keep your distance, clean your hands, cough or sneeze into your elbow, and avoid touching your face," the WHO tweeted April 6. “Masks alone cannot stop the #COVID19 pandemic. Countries must continue to find, test, isolate and treat every case and trace every contact,” the WHO said.
People will make mistakes or assumptions if they have not been properly informed on how to wear and maintain masks, including concerns about skin irritation. The CDC page on making masks says nothing more about laundering than “A washing machine should suffice in properly washing a face covering.”
“You cannot tell the public this information without informing them how to launder it,” Dr. Knighton said. “You’re telling them to wear it out in public. What do I do when I start to eat my food? Where do I put my mask? Do I put down under my chin and proceed to eat? What happens when that person sets it down on the surface? What happens if someone sneezes on the outside of your mask? Do you immediately take it off? Do you leave it on your face? It’s just not clear, and it doesn’t share the things that people will commonly encounter.”
The CDC also neglected to mention the option of disposable homemade masks, such as ones made with paper towels, that may be more sanitary for those who cannot wash cloth masks frequently or thoroughly enough or who lack reliable, safe laundry resources. George Yang, MD, a plastic surgeon in New York, has created a YouTube video to show people how to make and wear paper towel masks for one-time use.
Whether people use DIY cloth or paper masks, however, they need to understand proper etiquette, including with coughing and sneezing.
“The masks to some people mean they can cough and sneeze without covering their mouth, thinking that the droplets aren’t going to travel through the mask,” Dr. Knighton said. “It is the CDC’s social responsibility to provide full instructions for masks including that people continue to wash their hands and to also make sure they are using proper cough and sneeze etiquette. These masks are going to help, but we still need you to cough and sneeze into your elbow.”
a black professional woman smiling at the camera and wearing a yellow shirt with pearls
Dr. Shanina Knighton is a clinical nursing scientist and infection preventionist at Case Western ... [+] PHOTO COURTESY OF SHANINA KNIGHTON, PHD
The WHO acknowledged the need for more research into mask use for the general public. To try to fill the gaps the CDC has left open with mask guidance, Dr. Knighton has answered common questions about wearing masks as much as is possible with the existing evidence.
What’s the most important thing to do when wearing masks?
There are actually three things. First, wash or sanitize your hands, clean your face with a warm damp face cloth, and allow your face to dry before applying your mask. Second, avoid touching your face. Third, always wash or sanitize your hands before and after applying and removing your mask. When you remove your mask, take it off only from the ear straps, as seen in this video from the WHO.
What should I use to make my mask?
Even though the goal of wearing a mask is to prevent droplets from you reaching other people, you have to be able to breathe. Use porous materials that have tiny holes or pores (like a sponge) that allow gas to pass through them, such as cotton. Avoid using waterproof materials, such as waterproof nylon and polyester, because they may not provide enough spacing between fabric for safe breathing.
The CDC provides three ways to make masks, including a sewn mask, a no-sew design from a T-shirt, and a design with a bandana. Other instructions include this one from Johns Hopkins, this one with a video from Kaiser Permanente, and this video using shop towels.
If you prefer not to use a cloth mask, you can use paper towels or coffee filters to make disposable mask, but avoid any plastic or other materials that could risk suffocation. According to Dr. Michael Klompas, an infectious disease physician at Brigham and Women's Hospital in Boston, a scarf may not work as well as a mask fitted to your face.
How do I manage using my cell phone while wearing my mask?
A 2018 survey shows people use their phones up to 52 times per day and that phones are 10 times dirtier than a public toilet—you don’t want to put the phone up against your mask. It will take a lot of effort to avoid reaching for your cell phone when it rings, so when you are out in public, such as visiting a grocery store, consider silencing your phone completely to avoid grabbing for it if it rings. You won’t be able to speak on it right away if your face is covered by the mask because it will sound muffled.
Be careful how you interact with your mask and your phone. Putting a contaminated phone up to your mask contaminates the mask. Pulling your mask down beneath your chin potentially contaminates your mask. Gently wiping down your phone with a 70% isopropyl alcohol or a disinfectant wipe is enough to remove the virus. Be careful not to set your phone down on surfaces and then apply it directly to your face.
Should I be wearing a mask everywhere, including my home?
While the CDC recommends wearing a mask while out in public, for your safety, DO NOT wear the mask while driving if it inhibits your sight. The CDC has not made recommendations about wearing masks at home if no one has symptoms of COVID-19. If someone has cold symptoms in your home, they should wear masks in combination with social distancing, hand hygiene, and cough and sneeze etiquette.
You do not need to sleep in your mask. Your mask should be removed by the ear straps only, never by the front of the mask. The CDC has not specified whether it’s necessary to wear masks while taking walks or in public parks where there are few people or you are much more than six feet away.
If I need to take my mask off in public, where do I put it until I can put it back on? What if I need to eat or drink something while wearing a mask?
There is limited research in this area, but think of your mask as a part of your face: Wash your hands before touching the mask and gently remove it only by the ear straps. For storing it, have a designated brown paper bag with you that you can place it in when not using it so you don’t set it down. If you are in public daily and will be wearing the mask for hours, change your brown paper bag daily.
When you use the bag, label one side “outside” for the outer side of the mask (the side that faces the public), and label the other “inside” for the inner part of the mask (the side near your mouth). Always put the mask in the bag with the inside part corresponding to the side marked “inside” so that you don’t contaminate it with what is on the outer-facing part of the mask.
My mask is getting wet from condensation from my breath. Do I need to change it out?
In healthcare, using disposable masks helps with this problem, but if you are using a cloth mask and find that this happens often, determine if the cloth you have is breathable or too thick. The CDC suggests using a T-shirt, likely cotton, for DIY masks. However, this NBC story notes a study finding other fabrics may work better—this is an example of an area where more research is essential.
Sweat absorbable or moisture-wicking fabrics similar to Dryfit have not been tested, but they may help absorb moisture from breathing. Avoid waterproof materials. If fluid can’t travel through them then it may be challenging to breathe through them. A study that looked at the effectiveness of cloth masks notes the moisture inside of the masks as an issue and risk for germ transmission.
How often do I wash my mask? Do I need more than one?
These questions deserve further scientific investigation and direction by the CDC, but until we have that guidance, these are my recommendations based on my experience and expertise. Ideally, masks should be changed after every wear, but this may not be possible for most people. Assuming no one in your home is sick, it depends on how many times you leave your home each day and each week how often you change it.
Try to have two masks for when the other is being laundered. How often you change it also depends on how long you’re wearing it and where you go in public. Everyone should be practicing social distancing, but in places like grocery stores, you might engage with people in closer proximity.
To avoid potential contamination from the mask, I suggest laundering it when you get home, especially if you don’t know the next time you’ll need it. This prevents you from having a potentially contaminated mask lingering around your home.
What detergents should I use to wash my mask?
This question also deserves CDC research and guidance, but until then, we can only rely on limited evidence from studies about irritation from contact dermatitis. Many detergents can cause rashes, and most detergents have fragrance and enzyme ingredients that can cause pore-clogging or breakouts, so the best option is to use detergents free of fragrance and enzymes.
If you launder your masks with the rest of your laundry, rinse it for extra time in plain water to ensure fragrances are removed. You can also spray it with a 5% bleach solution and let it dry, but test this first to be sure it doesn’t irritate your skin. Treat your mask as if it is your face with the same sensitivity as your skin.
Are there any chemicals, such as fabric softener or bleach, I shouldn’t use in sterilizing or washing my mask?
Again, treat your mask as if it has the same sensitivity as your skin since it will be up against your skin for long periods. It’s best to avoid fabric softeners, bleach, and any ingredients that might cause an allergic reaction, rashes or other symptoms, including fragrances that can cause headaches with long exposure. In addition, do not spray down masks with products such as Lysols and other disinfectants since their labels state that they may irritate the skin.
Should I dry my mask in the dryer or air-dry it?
You can dry your mask in the dryer, but avoid using dryer sheets. For air drying it, hang it on a coat hanger, clothing line, or laundry drying rack.