Passengers arrive at Beijing railway station to board trains before Spring Festival. Beijing, China. 23 January 2020. Photo: Kevin Frayer/Getty Images.

Hong Kongers are obsessed with face masks. Since the outbreak of SARS in 2002-2003, which killed 299 people in Hong Kong and 349 people in China, it is not uncommon to see people wearing surgical masks in the streets, in shopping malls, or at work. Although omnipresent since the outbreak of novel coronavirus (2019-nCoV), its folkloric value is inversely proportional to its capacity to prevent anyone from being infected with… well, pretty much any infectious disease.

And yet… In Hong Kong, people believe that surgical masks will protect them from the flu, or even from 2019-nCoV. Walk around the streets of Hong Kong without a mask in times of an epidemic like SARS or 2019-nCoV, and traffic on the sidewalk will open up in front of you like the Red See in front of Moses. You will be treated as if you had the plague.

Paradoxically, though, you’ll be as likely to catch any infectious disease -flu, coronavirus, or other- as anyone else on the street who is wearing a surgical mask. Better, you’ll probably be less likely to be infected with the virus, in fact, since people –i.e. potential virus carriers- will walk away from you.

Now, if you paid attention to the words I used so far, you’ll have noticed that I’m only mentioning surgical masks. You know, those cheap masks, usually blue or green, that you see everywhere in Hong Kong. Well, those masks are useless against 2019-nCoV. And for three reasons.

Surgical mask

First off, surgical masks are loose-fitting. Try as you might, you will never obtain a perfect seal around your mouth and nose with a surgical mask. This allows smaller airborne droplets, which may -or may not- carry viruses, to find their way through gaps between the mask and you skin, and into your respiratory system, hence infecting you even though you are wearing a surgical mask.

As a matter of fact, the Centers for Disease Control and Prevention (CDC) indicates that the surgical mask “(d)oes NOT provide the wearer with a reliable level of protection from inhaling smaller airborne particles and is not considered respiratory protection”[1].

One could argue, though, that surgical masks may be useful in case an infected person coughs directly in your face. Although incredibly rude, it happens (this is Hong Kong, after all). And in such case, a surgical mask may offer some protection against splashes of fluids and larger droplets.

However, one must bear in mind the mode of transmission of coronaviruses. And 2019-nCoV, as most human coronaviruses, spreads from an infected person to another through the air (coughing or sneezing), through fecal contamination (albeit rarely), or through contact (direct or indirect) between a contaminated surface and your mouth, nose, or eyes. Yes, you could also get infected with 2019-nCoV through the eyes.

Now, let’s bring back that infected person coughing directly in your face. In such a scenario, wearing a surgical mask would help prevent contamination directly through the respiratory system. It wouldn’t protect you from a contamination through the eyes, though.

But why would you listen to me? What are my credentials? And you’d be right to call my words into question. As you should have with the information you read so far concerning… well, everything concerning 2019-nCoV. Anyway, let’s see what a specialist in infectious diseases has to say about the surgical mask:

“Surgical masks are just a physical barrier that will protect you against “a visible splash or spray of fluid or large droplets,” explains Raina MacIntyre, an infectious disease researcher and professor of global biosecurity at the University of New South Wales in Sydney who has studied the efficacy of face masks. These masks fit loosely on the face around the edges, so they don’t completely keep out germs, and small airborne particles can still get through.”[2]

And if those two reasons regarding the uselessness of wearing a surgical mask were not enough, let’s hit the nail in the coffin. And that nail is none other than… you. Yes, you, the person wearing a surgical mask. You’re using your mask improperly. So improperly, in fact, that in the event wearing a surgical mask would be useful, your misuse of said mask would render it ineffective and, in some cases, even more dangerous. Let’s give a look at a few very common examples of misuse of surgical masks.

And we’ll start at the beginning: your hands. Ask yourself the following simple question. Do you wash your hands before handling the mask you’re about to put on your face? No? Well, there you have it, thousands -if not millions- of potentially dangerous bacteria being transferred from your hands to the mask that you’re going to breathe through for a couple of hours. Right from the get-go, you’ve contaminated your mask.

And when you remove your mask, do you wash your hands immediately afterward? No? And there you have it again! All the bacteria the outer part of your mask has been collecting while you were wearing it have now transferred onto your hands. Make sure you don’t touch your face before you’ve washed your hands.

In the same vein, you’ll often see people at the restaurant lowering their mask while eating. They’ll be handling cutlery, chopsticks, plates, glasses, and other objects bacteria often transit on; as well as touch the table that has been haphazardly cleaned with a dirty piece of cloth. Once done with their meal, they’ll put their mask back on their face, even before they took the time to wash their hands.

Better still, people lowering their masks to smoke a cigarette. Every time they’ll take a drag on their cigarette, their hands -common vectors of bacteria- will come in contact with their mouth, increasing the chances for viruses to penetrate their respiratory system. But, don’t worry, they’ll put their mask back on as soon as they are done smoking.

The most disturbing misuse of surgical masks probably comes at the hands of children. And it is their very parents and teachers who teach them this terrifyingly disgusting, and dangerous habit. I have stopped counting the number of times I have seen parents tell their children to put their mask in their pocket before taking a picture, or before mealtime. And put it back on their faces afterward (without washing their hands, obviously).

In their pocket! Seriously? One of the nastiest breeding grounds for bacteria of all sorts one can imagine. Think about all the things you put in your pockets. Now think about all the things you used to put in your pockets when you were a child. And imagine all the bacteria that transit through children’s pockets and eventually end up on their masks. Parents -and teachers- couldn’t help viruses infect their children better; the very children they wanted to protect with those masks in the first place.

Now, if you still believe wearing a surgical mask may help prevent the transmission of infectious diseases, using your mask properly would be the least you could do. In Hong Kong, the Centre for Health Protection published a guide on how to use your surgical mask properly. You will find the English version of the guide here and the Chinese version here.

You will note that the document starts by stating that “(p)eople should wear a surgical mask when they have respiratory infection; when taking care of patient with respiratory infection; or when visiting clinics or hospitals during pandemic or peak season for influenza in order to reduce the spread of infection.”[3] Nowhere does it mention that healthy people should wear a surgical mask outside of hospitals. Just saying.

In fact, and it may sound counterintuitive, the only people who should wear a surgical mask are the people who are already infected. Whatever the disease they are infected with. And they should wear a mask to avoid spreading germs around them; because they are the very people who could prevent the further spreading of viruses.

Anyway. So far, we have established that surgical masks were useless -for healthy people- in case of an epidemic or pandemic. Or in any other case, really. How about other types of masks? Since the outbreak of 2019-nCoV, we often hear/read about the N95 respirator (also known as FFP2 in Europe) in the news. Does it offer any better protection against 2019-nCoV than the surgical mask?

N95 respirator

First and foremost, to understand what we are talking about, it is necessary to understand the differences between the surgical mask, on the one hand, and the N95 respirator, on the other hand. And it so happens that CDC made a comparison between both types of masks, which is available here.

As opposed to the surgical mask, the N95 respirator is a tight-fitting mask; fitting around your nose, mouth, and part of your chin. To be legally allowed to bear the mention N95 (in the United States), a respirator must be tested and approved by the National Institute for Occupational Safety and Health (NIOSH). And the mention 95 indicates that it “(f)ilters out at least 95% of airborne particles including large and small particles”[4].

This means that, as opposed to the surgical mask, the N95 respirator will prevent you from inhaling the majority of smaller airborne droplets. Similarly to the surgical mask, though, the N95 will not be of any help against airborne viruses that may land in your eyes.

Again, however, to be effective, the N95 respirator must be used properly. CDC’s recommendations on how to use the N95 respirator in case of a pandemic can be found here. And, although nearly identical (obviously), Hong Kong’s Centre for Health Protection also published its recommendations on the proper use of the N95 respirator, which can be found here (English) or here (Chinese).

Now, as we saw, the surgical mask is completely useless against 2019-nCoV, and the efficiency of the N95 respirator is rather limited -even though not inexistent. And this means that people wearing a mask are, paradoxically, extra dangerous. Indeed, contrary to people who do not wear a mask, people wearing masks may feel protected when, in fact, they are not. And this means they may be -and are- more careless.

Observe people wearing a mask in the street, and you will notice that they touch things with their hands, then touch their mask or face without washing their hands. They remove their masks on a whim, then put them back on, very often without washing their hands. Each one of those -seemingly- insignificant actions increases the possibility of an infection; be it 2019-nCoV, influenza, or any other virus.

So, what to do if masks are useless? How to prevent infection? Well, simply follow the specialists’ advice. Do what you should have done before paranoia struck Hong Kong: find reliable information. No, no, no, not on Facebook, you idiot! You’ll end up believing face masks are enough to prevent infections. Oh, wait, you did that already.

Joking aside, get reliable information about 2019-nCoV where reliable information about the disease resides. You can start locally with the Centre for Health Protection (CHP; Hong Kong) or the National Centre for Infectious Diseases (NCID; Singapore). Or, you can get your information from one of the most reliable sources in the world, the Centers for Disease Control and Prevention (CDC; United States). If you’re from the North, you’ll find information on the website of the Public Health Agency of Canada (PHAC; Canada). Or perhaps you prefer a European take on the situation? Well, you can always visit the European Centre for Disease Prevention and Control (ECDC; Europe). British? No problem, visit the National Health Service (NHS; United Kingdom). Tu ne comprends pas l’anglais? Alors visite le site de la Santé publique France (SfP; France) ou de l’Agence de la santé publique du Canada (ASPC; Canada). And if it’s international information you’re after, why not visit the website of the World Health Organisation (WHO, Global).

See, there is no shortage in reliable information sources. And, reading the information provided by the disease control agencies from around the world, you’ll notice one striking similarity between each and every one of those websites: the face mask. None of those organisations recommend the use of face masks other than for infected people or people who work in hospitals. Yet, in Hong Kong, and in many other parts of the world, you’ll be considered a madman if you dare leave your house without that piece of tissue in front of your mouth. Ah, lemmings sheep sheople intelligent people…

[1] https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf. Last retrieved on 30 January 2020.

[2] https://www.npr.org/sections/goatsandsoda/2020/01/29/800531753/face-masks-what-doctors-say-about-their-role-in-containing-coronavirus. Last retrieved on 31 January 2020.

[3] https://www.chp.gov.hk/files/pdf/use_mask_properly.pdf, p.1. Last retrieved on 31 January 2020.

[4] https://www.cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf. Last retrieved on 30 January 2020.