This will be a quick update to implore nurses to not use cloth masks and not call for the creation of more cloth masks. The evidence shows that they are ineffective, do not create a barrier for transmission, and may in some ways increase transmission.
We all learned in nursing school that once the mask becomes damp it’s not effective. Cloth masks will become damp within minutes and we have no evidence around if adding in a filter or other materials sandwiched between layers of cloth will help. Add to this that one then has a wet, potentially contaminated cloth mask that should likely be disposed of, but at the very least needs laundering, and it becomes clear that cloth masks are not the answer. They may indeed be harmful.
In my humble opinion: The CDC stating that bandanas, scarfs and cloth masks could be helpful when they are actually potentially harmful is reprehensible.
Please review the BMJ Open article entitled:
While the ANA has called out the CDC on their call for non-evidence based protocols and statements and addressed the white house, nurses are going to have to act locally.
At the very least please contact your representatives and demand access to proper PPE, increases in manufacturing, the federal government taking more responsibility for ensuring our safety.
How can we organize ourselves around advocating for proper PPE?
NurseManifest 
Tragedy upon tragedy. Thank you Carey for this very important update.
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Carey,
I am going to have to disagree here, but not because these alternatives don’t suck and aren’t what is needed. While these alternatives are certainly not what is needed, anything at all is going to be more effective than nothing at all. Talking to a patient who suddenly coughs, will, in the absence of any barrier at all, result in far more viruses entering your mouth than will pass through even the most permeable cloth barrier.
Also, touching our faces is something we do without any awareness. Even inadequate cloth barriers will hopefully reduce the number of touches around the mouth, nose and eyes just on the basis of altering ones’s perception of personal space.
People should change/clean these alternative cloth masks frequently, like between patients, and the less contact needed to remove them the better. Compared to storing N95 masks in a paper bag, using one N95 mask throughout a shift, having no barrier at all, cloth masks will, I suspect, prove to have been a better strategy.
We are all going to have to be very creative going forward because the health care system failed to be prepared.
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We can disagree and I am not sure any barrier will protect better than no barrier outside of the extreme as you mention sputum or particles going directly in the mouth. Sputum being coughed directly onto a damp scarf or bandana is also going to contaminate the person. As per the article, as soon as the cloth is damp 97% of effectiveness was lost in the RCT. Is 3% effectiveness worth it to feel somehow protected? The article also states that washing properly was likely an issue. I stand by the evidence that states to not use cloth masks, though I also recognize that these issues are complex.
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Carey,
Yes, we are definitely going to disagree on this one. Purely as a statistician I could go on forever about the flaws in this study. I won’t. I apologize if the below post feels harsh, but this could cost people their lives.
Let’s focus on the most glaring problems with this study.
The study is NOT a study of mask vs no mask. It IS a study of efficacy between two different types of masks, which everyone already knew differed in efficacy, which is why “richer” countries use N95 masks and “poorer” countries use less effective cloth masks.
The null hypothesis of no difference between mask types is ridiculous at the very outset, and guaranteed to be rejected, because we already know, from decades of research, that N95 masks work better than cloth masks. It looks like a study designed by a desperate researcher looking for a significant outcome so they can publish a paper, any paper at all.
Extrapolating from differences between lowered efficacy in known, less effective cloth masks, to lack of efficacy for cloth masks vs no masks at all is a leap too far, and dangerous for workers who might choose such an interpretation and not use cloth masks when no N95 masks are available. This study is irrelevant to the issue of cloth mask vs no mask.
“Participants wore the mask on every shift for four consecutive weeks. Participants in the medical mask arm were supplied with two masks daily for each 8 h shift, while participants in the cloth mask arm were provided with five masks in total for the study duration, which they were asked to wash and rotate over the study period.”
Well, what might we expect in a situation where one arm is given two sterile masks a day, and another group is using the same 5 masks for the entire 4 week length of the study? We should expect that the re-used masks will prove less effective. But the differences in efficacy for the cloth masks and the N95 masks would be far smaller if the subjects were given two sterile cloth masks a day for the entire 4 weeks.
“Penetration of cloth masks by particles was almost 97% and medical masks 44%.”
Let’s rephrase this: Non-penetration was 3% vs 56% . Not quite as dramatic is it? And remember that none of the N95 masks was used for much longer than half a shift on average, compared to 4 weeks for the 5 cloth masks. As well, just washing the masks would likely transfer some of the test material to the inside, but this would also happen if people were given 5 N95 masks for the duration of the study and told to wash them.
This is a very, very poorly designed, poorly controlled, poorly analysed, and poorly written article.
As I said above, any barrier at all is preferable to no barrier and this study certainly does not provide any evidence that this isn’t true.
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This is a better study and note the last line in the quoted summary below:
https://www.researchgate.net/publication/258525804_Testing_the_Efficacy_of_Homemade_Masks_Would_They_Protect_in_an_Influenza_Pandemic?fbclid=IwAR2Zf9w3AqY5eiCgoyTMGdYswi-Trog1AVWNlov4KMaJq4d2D4x85X1gua0
“This study examined homemade masks as an alternative to commercial face masks. Several household materials were evaluated for the capacity to block bacterial and viral aerosols. Twenty-one healthy volunteers made their own face masks from cotton t-shirts; the masks were then tested for fit. The number of microorganisms isolated from coughs of healthy volunteers wearing their homemade mask, a surgical mask, or no mask was compared using several air-sampling techniques. The median-fit factor of the homemade masks was one-half that of the surgical masks. Both masks significantly reduced the number of microorganisms expelled by volunteers, although the surgical mask was 3 times more effective in blocking transmission than the homemade mask. Our findings suggest that a homemade mask should only be considered as a last resort to prevent droplet transmission from infected individuals, but it would be better than no protection. (Disaster Med Public Health Preparedness. 2013;0:1-6)”
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Thomas, a study of 21 is probably not very valuable, we both know that’s a super low n. And the other study I mentioned above, with a much larger n, actually does say it is better than nothing…by about 3%, but both of these studies do not consider the aftermath transmission issues of contaminated masks.
Regardless, as Dr. Marks says in her comments, we need to unite and demand proper PPE that meets appropriate standards. Otherwise, we will end up in a situation where there are very few healthy enough and skilled enough to properly care for those who need it.
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A study of death rates when rolling over a human being with a steam roller with an N of 1 provides all the information needed, and no additional subjects will alter the conclusion.
A small, well-designed and appropriately analyzed, and humbly reported study beats the hell out of an unduly large, poorly conceptualized, poorly designed, poorly implemented, poorly analyzed, and poorly reported study.
Don’t judge any study by sample size. You can get any study wrong regardless of how large you make the sample size, and get it right despite a very small sample size. Careful conceptualization and design are key.
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The study you cited was also on patients’ use of cloth, not providers, and is likely not generalizable. Regardless of the findings of either this study or the study I cited, nurses and other providers deserve to have appropriate guidelines and access to PPE.
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I think many studies are poorly designed, only 25%of all studies are replicable, but this made it to BMJ Open. Regardless, the use of cloth masks goes against what the general evidence says, and the message to keep making them, to go ahead and use them instead of taking other actions it what bothers me.
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There is a substantial, and obvious question of bias, if you look at the sponsorship for this research:
“Funding Funding to conduct this study was received from the Australian Research Council (ARC) (grant number LP0990749).
Competing interests CRM has held an Australian Research Council Linkage Grant with 3M as the industry partner, for investigator-driven research. 3M has also contributed masks and respirators for investigator-driven clinical trials. CRM has received research grants and laboratory testing as in-kind support from Pfizer, GSK and Bio-CSL for investigator-driven research. HS had a NHMRC Australian-based Public Health Training Fellowship at the time of the study (1012631). She has also received funding from vaccine manufacturers GSK, bio-CSL and Sanofi Pasteur for investigator-driven research and presentations. AAC used filtration testing of masks for his PhD thesis conducted by 3M Australia.”
Generally speaking, reputable journals do not publish articles that conclude that a sponsor’s products are superior to alternatives.
BMJ Open is essentially a vanity press, pay to publish, journal. Any statistician who would have reviewed the article would have rejected it for the reasons I outlined above, as well as dozens of other issues, including obvious bias, although no reputable statistician would have spent much time reviewing it before concluding that it was not worthy of publication.
Nobody, certainly not me, is advocating using cloth masks as preferable to N95 masks, or as the only response to the current situation. I have already said I think a job action is appropriate, and could easily be done in a few minutes by off-shift nurses, to get the attention of the public and the idiot in the wh.
Everyone I know who is working in affected settings is scrambling to come up with anything that will protect them better than nothing, which is what so many of them have at the moment. We are not talking about people with options to use N95 masks, we are talking about people who may be working without adequate access to gloves, gowns, masks, and face shields.
Please reconsider your recommendation.
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Bottom line is we need proper PPE.
These products need to be made and distributed ASAP! That’s where our lobbying and advocating needs to be! Talking to Trump who is a pathological liar will not help. Grassroots, get to the manufacturers and distributors!!!!
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There are some alternatives here. Hospitals, or nurses, if their hospitals/nursing homes/home health agencies/ALFs won’t step up, can order masks and other PPEs directly. If you go to alibaba,com and search for n95 masks or other items, you will see links for producers. Most will be in China of course since that is where a lot of our pharmaceuticals, gloves, medical devices, and gowns are manufactured already. Many of them have minimums on the order of 1 – 2,000 items so it isn’t a great resource for individual nurses, but if a dozen or more nurses pool resources they could order the equipment they need.
You are correct that trump is too much of a sociopath to rely on him to come through and most hospitals are far better experienced at saying NO than saying YES in response to nurses. Fortunately, there are still a few people in FEMA and other agencies that are going around worst potus ever. They just have to do it cautiously lest trump hear about it on fox news.
The Incident Command System seems beyond the comprehension of republican potuses for reasons I just can’t understand, because it is really a simple disaster response guide.
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Thank you for the article and commentaries.
In my opinion” non-penetration of 3% vs 56%” IS quite dramatic.
As a nurse who will be providing outpatient urgent care services througout this pandemic, I want full PPE. I do not want to be using a cloth mask. Nurses need to get angry and speak up and speak out and not settle for anything but the highest level of protection. If nurses agree to cloth masks then this deflects the attentiion away from the problem-unpreparedness, and a exposes the gross inadeqacies of this health care system where nurses are too often treated as a commodity. As Dr. Clark’s original post discussed, there are many ethical challenges ahead. As always, nurses are valiently stepping up to care for sick patients all over the country, but at what cost?
“How can we organize ourselves around advocating for proper PPE?” as Dr. Clark asks above.
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Valiantly
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