As more-contagious variants of the coronavirus spread, the Centers for Disease Control and Prevention is urging people to wear better masks, or to double up on the ones they have. The Biden administration is reportedly considering sending masks to all Americans, reviving a proposal that the Trump administration quashed last year. Several members of Congress are pushing that option, too, and specifically calling for high-caliber masks that better protect against small virus-carrying particles not reliably captured by cloth masks.
This proposal echoes what we and others have been advocating over the past several months. Getting “hi-fi” masks — masks with both high-grade filtration and high-quality fit — to the general public to wear when indoors and among crowds is even more urgent now with the new, more transmissible variants. This is why a number of European countries have recently implemented programs to distribute medical-grade masks, and a few U.S. states, such as Washington, are doing the same.
With the federal government focused intensely on scaling up vaccination, a national initiative to distribute hi-fi masks could be seen as taking on too much. But the cost of sending masks out is outweighed by the benefit for two key reasons. The first is that keeping transmission down until enough people are vaccinated is crucial for preventing deaths. Second, masks will also serve as an important backstop in case some variants evade current vaccines and require future re-vaccination campaigns with booster shots.
A national mask initiative doesn’t have to be complicated, and the government could scale it up within a matter of weeks. A number of hi-fi masks already on the market are verified by the CDC to provide high-caliber protection, and their supply can be ramped up. The CDC’s recommendation that people “double-mask” was an acknowledgment of the need for better masks. But the CDC study supporting double-masking cautions that its results may not be generalizable, especially given that cloth masks vary widely in quality and fit. Accordingly, double-masking can end up doing harm if done incorrectly and people may think they are more protected than they really are. In contrast, the available hi-fi masks run into fewer of these issues — they’ve been tried and tested in actual use for years. Some experts worry that the more protective masks would be difficult to tolerate for long periods of time, but this probably would be a challenge for double-masking as well. While some people, such as essential workers and teachers, would need to wear masks for several hours a day, many would only need to do so for short durations — typically when they’re indoors or in crowded settings such as trips to the grocery store or in poorly ventilated public transit.
While double-masking can be used as a stopgap, there are four options for reliable, hi-fi masking that the Biden administration could pursue immediately.
One path is to boost the supply of N95 masks. These have been in short supply even for health workers, but they’re produced in the United States, and the available supply could be expanded, particularly with use of the Defense Production Act. The Association of the Nonwoven Fabrics Industry recently estimated that N95 production capacity is currently at 274 million masks per month. To get a regular and continuous supply of N95s to all American adults (about 255 million people), this number would need to be increased, though they should be initially prioritized for the roughly 100 million people who are over age 65 or front-line workers. There are also a number of manufacturers who are struggling to find buyers for their current stocks and could expand supply if the federal government were guaranteed to purchase their masks.
The downsides of N95s are that they come in multiple sizes and require “fit testing” to figure out the correct size for each person and train them on creating an effective seal without leakages. Scaling up fit testing for the general public may be needed for N95s to be used properly. This could, perhaps, be incorporated into primary-care visits and implemented in public venues, such as outside of grocery stores.
U.S. companies also produce elastomeric respirators that are sometimes worn on construction sites and chemical plants. These masks are reusable and made from elastic materials that readily form a seal around the face. Many elastomerics are already certified to provide N95-level protection with filters that need to be periodically replaced. The downside to these masks is that many people may find them bulky and awkward to wear. There would also need to be clear instructions on replacing the filters and a way to get replacements to people. For essential workers and first responders who need a more durable option to wear day in and day out, though, industrial-strength elastomeric masks could be a good option.
Another option is to source and distribute KF94 masks from South Korea, FFP2/FFP3 masks from Europe or KN95 masks from China that have already been tested and verified by the CDC to provide protection similar to U.S.-produced N95s. Michigan, for example, recently launched a program to distribute 3.5 million KN95s to residents. Just as with N95s, these are not necessarily one-size-fits-all. These masks are also produced overseas, making it difficult to ensure their supply and quality given some counterfeits.
A fourth option, and the one that may be the fastest and easiest to implement en masse, is to distribute “mask fitters” that are worn over surgical masks and enhance their seal to the face. Many three-ply surgical masks provide filtration just a notch below N95s. In practice, they’re less protective mainly because they do not fit snugly, allowing unfiltered air to flow around the edges. Fitters would address that issue and, in preliminary studies, they significantly improved protection, falling just short of what N95s do. Unlike double-masking — in which a second cloth mask may cause uncomfortable breathing resistance and may not always have a great fit — fitters improve the fit of a surgical mask without adding more layers and resistance. These fitters are made from materials that are readily available and could be scaled up relatively quickly.
Because surgical masks are available ubiquitously and widely used, sending fitters — which would be quick, easy and cheap to mass produce — with a package of three-ply surgical masks could happen urgently, allowing people to start wearing them now.
Any of these plans could be implemented relatively soon — even within a few weeks. If supply is initially insufficient for a universal rollout, just as with vaccines, hi-fi masks can first be targeted to the highest-risk groups based on age (as Austria and Germany are doing), employment as an essential worker, or living in communities with high rates of transmission. If all the different hi-fi masks were pursued together, it’s possible that there may already be enough supply right now.
The most direct way for the government to rapidly distribute masks to people is by mailing them to every home. There is no consensus on how long the same mask can be reused, which depends on a variety of factors, including the exact type of mask. For most people, one mask probably could be safely re-worn for at least a few days. One drawback to this approach is that it probably will be difficult to customize mask shipments, so some households may receive more or less than they need or masks of the wrong size.
Or we could borrow from Germany’s plan, and provide credits or vouchers that people can redeem in stores or online for predesignated masks. People could then select the ones they most prefer and also choose the best size with fit testing. This approach would also make it easier to tap into the aggregate supply of all hi-fi masks and prevent waste.
Whichever way they’re initially distributed, hi-fi masks should also be made ubiquitously available for purchase so people can also seek them out on their own.
We are in a race to vaccinate enough to get us to herd immunity before more-contagious and potentially resistant variants can spread widely. Better masks can help stop transmission now. Let’s get every American the masks they need to get the protection we all require.