Face Mask Use in the Community for Reducing the Spread of COVID-19: A Systematic Review

  1. Daniela Coclite
  2. Antonello Napoletano
  3. Silvia Gianola
  4. Andrea del Monaco
  5. Daniela D'Angelo
  6. Alice Fauci
  7. Laura Iacorossi
  8. Roberto Latina
  9. Giuseppe La Torre
  10. Claudio M. Mastroianni
  11. Cristina Renzi
  12. Greta Castellini
  13. Primiano Iannone

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Abstract

Background: Evidence is needed on the effectiveness of wearing face masks in the community to prevent SARS-CoV-2 transmission.

Methods: Systematic review and meta-analysis to investigate the efficacy and effectiveness of face mask use in a community setting and to predict the effectiveness of wearing a mask. We searched MEDLINE, EMBASE, SCISEARCH, The Cochrane Library, and pre-prints from inception to 22 April 2020 without restriction by language. We rated the certainty of evidence according to Cochrane and GRADE approach.

Findings: Our search identified 35 studies, including three randomized controlled trials (RCTs) (4,017 patients), 10 comparative studies (18,984 patients), 13 predictive models, nine laboratory experimental studies. For reducing infection rates, the estimates of cluster-RCTs were in favor of wearing face masks vs. no mask, but not at statistically significant levels (adjusted OR 0.90, 95% CI 0.78–1.05). Similar findings were reported in observational studies. Mathematical models indicated an important decrease in mortality when the population mask coverage is near-universal, regardless of mask efficacy. In the best-case scenario, when the mask efficacy is at 95%, the R0 can fall to 0.99 from an initial value of 16.90. Levels of mask filtration efficiency were heterogeneous, depending on the materials used (surgical mask: 45–97%). One laboratory study suggested a viral load reduction of 0.25 (95% CI 0.09–0.67) in favor of mask vs. no mask.

Interpretation: The findings of this systematic review and meta-analysis support the use of face masks in a community setting. Robust randomized trials on face mask effectiveness are needed to inform evidence-based policies.

PROSPERO registration: CRD42020184963.

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  1. ScreenIT

    SciScore for 10.1101/2020.08.25.20181651: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    RandomizationWe used the Cochrane risk of bias tool for randomized controlled trials (25); the Newcastle Ottawa scale for non-randomized studies (26).
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    , EMBASE, SCISEARCH and The Cochrane Library from inception to April 22
    EMBASE
    suggested: (EMBASE, RRID:SCR_001650)
    Cochrane Library
    suggested: (Cochrane Library, RRID:SCR_013000)
    Grey literature was interrogated in MedRxiv, Rxiv and bioRxiv databases.
    bioRxiv
    suggested: (bioRxiv, RRID:SCR_003933)
    The reviewers’ decisions and reasons for exclusion were recorded using appropriate reference management software such as EndNote.
    EndNote
    suggested: (EndNote, RRID:SCR_014001)
    Data analyses were performed using RevMan Software.
    RevMan
    suggested: (RevMan, RRID:SCR_003581)

    Results from OddPub: Thank you for sharing your data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strength and limitations: Our review included experimental laboratory research and mathematical modelling studies to complement observations studies and trials, for obtaining a more complete picture on mortality and viral load reduction, filtering capacity and population coverage which are important factors influencing the R0. We adopted full methodological rigor within a much shorter time-frame compared to traditional reviews, using enhanced processes. We also critically assessed the risk of bias of included studies (randomized controlled studies and observational studies) and infeasibility of mathematical modelling studies. Our systematic review has some limitations. We did not investigate the balance of pros and cons of wearing a mask. On one hand, the use of face masks may provide a false sense of security leading to suboptimal physical distancing, poor respiratory etiquette and hand hygiene – and possibly not staying at home when ill. There is a risk that improper removal of the face mask, handling of a contaminated face mask or an increased tendency to touch the face while wearing a mask by healthy persons might actually increase the risk of transmission (10). On the other hand, the fears related to the paradoxical increase of the infectious risk for their improper use are entirely theoretical, based on preconception without real foundation. Education campaigns should be encouraged for assuring proper use (10). We reported adjusted estimates from two out of three cluste...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • No funding statement was detected.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.3389/fmed.2020.594269
  3. Version published to 10.1101/2020.08.25.20181651v1 on medRxiv