Abstract
BackgroundEvidence for face-mask wearing in the community to protect against respiratory disease is unclear.AimTo assess effectiveness of wearing face masks in the community to prevent respiratory disease, and recommend improvements to this evidence base.MethodsWe systematically searched Scopus, Embase and MEDLINE for studies evaluating respiratory disease incidence after face-mask wearing (or not). Narrative synthesis and random-effects meta-analysis of attack rates for primary and secondary prevention were performed, subgrouped by design, setting, face barrier type, and who wore the mask. Preferred outcome was influenza-like illness. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) quality assessment was undertaken and evidence base deficits described.Results33 studies (12 randomised control trials (RCTs)) were included. Mask wearing reduced primary infection by 6% (odds ratio (OR): 0.94; 95% CI: 0.75–1.19 for RCTs) to 61% (OR: 0.85; 95% CI: 0.32–2.27; OR: 0.39; 95% CI: 0.18–0.84 and OR: 0.61; 95% CI: 0.45–0.85 for cohort, case–control and cross-sectional studies respectively). RCTs suggested lowest secondary attack rates when both well and ill household members wore masks (OR: 0.81; 95% CI: 0.48–1.37). While RCTs might underestimate effects due to poor compliance and controls wearing masks, observational studies likely overestimate effects, as mask wearing might be associated with other risk-averse behaviours. GRADE was low or very low quality.ConclusionWearing face masks may reduce primary respiratory infection risk, probably by 6–15%. It is important to balance evidence from RCTs and observational studies when their conclusions widely differ and both are at risk of significant bias. COVID-19-specific studies are required.
Highlights
On 30 January 2020 the World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC) in response to the emergence of a novel coronavirus in Wuhan, China [1]
Previous systematic reviews on the efficacy and effectiveness of using face masks in community settings assessed face masks combined with other personal protection measures [11,12,13] or mixed healthcare workers with non-healthcare workers [12,14,15,16]
GRADE assessment suggested that wearing a mask may slightly reduce the odds of primary infection with influenza-like illness (ILI) by around 6 to 15%
Summary
On 30 January 2020 the World Health Organization (WHO) declared a Public Health Emergency of International Concern (PHEIC) in response to the emergence of a novel coronavirus in Wuhan, China [1]. Previous systematic reviews on the efficacy and effectiveness of using face masks in community settings assessed face masks combined with other personal protection measures [11,12,13] or mixed healthcare workers with non-healthcare workers [12,14,15,16]. Those that examined community use had focused only on randomised control trials (RCTs) [17,18]. Aim: To assess effectiveness of wearing face masks in the community to prevent respiratory disease, and recommend improvements to this evidence base.
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