Face masks during the COVID-19 pandemic

During the COVID-19 pandemic, face masks have been employed as a public and personal health control measure against the spread of SARS-CoV-2. Their use is intended as personal protection to prevent infection and as source control to limit transmission of the virus in a community or healthcare setting. The use of masks has received varying recommendations from different public health agencies and governments. The World Health Organization and other public health organisations agree that masks can limit the spread of respiratory viral diseases such as COVID-19.[1][2][3] However, the topic has been a subject of debate,[4] with some public health agencies and governments initially disagreeing on a protocol for wearing face masks.

Tsai Ing-wen, President of the Republic of China, wearing a surgical mask.

Types of respirator by physical form

As of early May 2020, 88% of the world's population lives in countries that recommend or mandate the use of masks in public; more than 75 countries have mandated the use of masks.[5] Debates have emerged regarding whether masks should be worn even when social distancing at 2 meters (6 feet),[6][7][8] and whether they should be worn during exercise.[9] Additionally, public health agencies of some countries and territories have changed their recommendations regarding face masks over time.[10] Face masks have been a subject of shortages, and not all have been certified. Moreover, substandard masks were reported on the market with significantly reduced performance.[11]

There are different types of face masks including:

• cloth face masks
• medical or surgical masks
• filtering facepiece respirators such as N95 masks, N99 masks, and FFP masks

Face shields, medical goggles, and other types of personal protective equipment are sometimes used together with face masks.

Types of masks

Small particles zigzag due to Brownian motion, and are easily captured. Large particles get strained out, or have too much inertia to turn, and hit a fiber. Mid-size particles follow flowlines and are more likely to get through the filter; the hardest size to filter is 0.3 microns diameter.[12]

Cloth masks

French cloth face masks certified by AFNOR.

Face masks retain most of the respiratory droplets released from the wearer through talking, coughing, or sneezing, thus reducing the spread of pathogens.[13]

Main article: Cloth face mask

A cloth face mask is a mask made of a common textile, usually cotton, worn over the mouth and nose. Although they are less effective than medical-grade masks, many health authorities recommend that the general public use them because medical-grade masks are in short supply.[14][15]

There were calls for research into the effectiveness of improvised masks even before the emergence of COVID-19, motivated also by past epidemics and modelling of likely mask shortages. However, little research has been done. There are no studies of the use of cloth masks by the general public, one study on the use of cloth masks in hospitals (by healthcare workers, not patients), and many controlled-setting/lab studies of cloth masks' effects on aerosols as of May 2020.[16]

Cloth masks are low-cost and reusable. They vary widely in effectiveness depending on material, fit/seal, and number of layers, among other factors. Unlike disposable masks, there are no legal standards for cloth masks. Fit is important (as with disposable masks). Measures to improve fit, such as an outer layer made from sheer nylon stockings or sheer tights around the head, reduce leakage.[16]

Improvised cloth masks seem to be worse than standard commercial disposable masks, but better than nothing. There is, however, little good evidence on them. A single study gives evidence that an improvised mask was better than nothing, but not as good as soft electret-filter surgical mask, for protecting health care workers simulating treating a simulated infected patient, regardless of whether "patient" or carers wore the mask.[16] Another study had volunteers wear masks they made themselves, to a pattern like that of a standard surgical mask, but with ties rather than earloops,[17] from cotton T-shirts, and found that the number of microscopic particles that leaked inside the homemade masks was twice the number that leaked into the commercial masks, and that the homemade mask let three times as many microorganisms expelled by the wearer escape (median averages). There is limited evidence that cloth masks can significantly reduce droplet dispersal.[16]

Cloth masks are commonly made with one layer, two layers, or two layers with a pocket for a removable-filter interlayer[16] (disposable surgical masks also have three layers, with the filter layer midmost[18]). The CDC recommends more than one layer.[19] There is no research on the usefulness of a filter interlayer, as of May 2020. There were until recently no non-disposable materials designed for making masks (see end of paragraph). Common household fabrics which could be used (turned to a new use) as mask materials have been tested.[20][21][22][23] Cloth materials vary widely in filtration efficiency. Some cotton and polyester household fabrics have been found to compare with disposable surgical masks for dry particle filtering. Cotton T-shirt material, pillowcase material, and 70% cotton/30% polyester sweatshirt material are among the common materials that performed well in lab tests, with T-shirts preferred to pillowcases because it was thought that it would probably fit better. Teatowels and vacuum-cleaner bags were effective at filtering, but had a very high air resistance, so were not recommended. Scarves filtered poorly. Surgical sterilisation wrap, a polypropylene non-woven fabric made for wrapping sterilized things to keep them sterile, is designed to filter germs from the air. Using surgical sterilisation wrap to make masks, or as a filter interlayer in cloth masks, has been suggested. There are, however, no tests on using surgical sterilisation wrap for masks, as of May 2020.[16]

Other suggested materials for filter interlayers include air filter materials used in ventilation, heating, and air conditioning, some of which are similar to rigid electret masks in the size ranges of particles they filter. Electrostatic cotton and non-woven, meltblown fabric are the conventional materials used in disposible masks, but are not readily available during the COVID-19 epidemic. A new type of filter, a washable electrostatic cotton filter, has been reported since the start of the pandemic; it is said to withstand repeated washing and folding.[16] It is made of electrospun nanofibers; flanking insulating blocks lay these into quasi-aligned nonwoven sheets, which are layered criss-cross to make a meshlike multilayer mask.[24][25] There is a need for research comparing how well these materials work.[16][26]

Decontamination and re-use

There is no research on decontaminating and reusing cloth masks, as of May 2020.[16] The CDC recommends doffing the mask by handling only the ear loops or ties, placing it directly in a washing machine, and immediately washing one's hands in soap and water for at least 20 seconds. They also recommend washing one's hands before donning the mask and again immediately after one touches it.[27]

There is no information on reusing a interlayer filter, and disposing of it after a single use may be desirable.[16]

Surgical masks

Main article: Surgical mask

A surgical mask

A surgical mask is a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment. If worn properly, a surgical mask is meant to help block large-particle droplets, splashes, sprays, or splatter that may contain viruses and bacteria, keeping it from reaching the wearer's mouth and nose. Surgical masks may also help reduce exposure of the wearer's saliva and respiratory secretions to others.[28]

Certified medical masks are made of non-woven material. They are mostly multi-layer. Filter material may be made of microfibers with an electrostatic charge; that is, the fibers are electrets. An electret filter increases the chances that smaller particles will veer and hit a fiber, rather than going straight through (electrostatic capture).[12][29][30] While there is some development work on making electret filtering materials that can stand being washed and reused,[31] current commercially-produced electret filters are ruined by many forms of disinfection, including washing with soap and water or alcohol, which destroys the electric charge.[32] During the COVID-19 pandemic, public health authorities issued guidelines on how to save, disinfect and reuse electret-filter masks without damaging the filtration efficiency.[33][32] Standard disposible surgical masks are not designed to be washed.

A surgical mask, by design, does not filter or block very small particles in the air that may be transmitted by coughs, sneezes, or certain medical procedures. Surgical masks also do not provide complete protection from germs and other contaminants because of the loose fit between the surface of the face mask and the face.[28] However, in practice, with respect to some infections like influenza, surgical masks appear as effective as respirators (such as N95 or FFP masks).[34] Surgical masks may be labeled as surgical, isolation, dental, or medical procedure masks.[28] Surgical masks are made of a nonwoven fabric created using a melt blowing process.[35][36]

Surgical masks made to different standards in different parts of the world have different ranges of particles which they filter. For example, the People's Republic of China regulates two types of such masks: single-use medical masks (Chinese standard YY/T 0969) and surgical masks (YY 0469). The latter ones are required to filter bacteria-sized particles (BFE ≥ 95%) and some virus-sized particles (PFE ≥ 30%), while the former ones are required to only filter bacteria-sized particles.[37][38][39]

Disposable filtering facepiece respirators

An N95 mask.

Dust masks can be confused for medical respirators.

An N95 mask is a particulate-filtering facepiece respirator that meets the N95 air filtration rating of the US National Institute for Occupational Safety and Health, meaning that it filters at least 95 percent of airborne particles, while not resistant to oil like the P95. It is the most common particulate-filtering facepiece respirator.[40] It is an example of a mechanical filter respirator, which provides protection against particulates, but not gases or vapors.[41] Like the middle layer of[18] surgical masks, the N95 mask is made of four layers[16] of melt-blown nonwoven polypropylene fabric.[42][43] The corresponding face mask used in the European Union is the FFP2 respirator.[44][45]

Hard electret-filter masks like N95 and FFP masks must fit the face to provide full protection. Untrained users often get a reasonable fit, but fewer than one in four gets a perfect fit. Fit testing is thus standard. A line of vaseline on the edge of the mask[46] has been shown to reduce edge leakage[16] in lab tests using manikins that simulate breathing.[46]

In the COVID-19 pandemic, there were shortages of filtering facepiece respirators, so that they had to be used for extended periods, and/or disinfected and reused. During the COVID-19 pandemic, public health authorities issued guidelines on how to save, disinfect and reuse masks, as some disinfection methods damaged the filtration efficiency.[33][32] Some hospitals stockpiled used masks as a precaution,[47] and some had to reuse masks.

Elastomeric respirators

Main article: Elastomeric respirator

Elastomeric full-face masks

Elastomeric respirators are reusable devices with exchangeable cartridge filters that offer comparable protection to N95 masks.[48] They were used as a substitute for N95 masks among shortages during the COVID-19 pandemic.[49]

The filters must be replaced when soiled, contaminated, or clogged. These components may be hard to find amidst shortages; the filters may thus be sterilized, in a way that does not harm the filter, and re-used. In medical use, they must be cleaned and disinfected, as some germs can survive on them for weeks.[49]

Full-face versions of elastomeric respirators seal better and protect the eyes. If they have exhalation valves, then they are counterrecommended in settings where the unfiltered exhaled air might infect others (for instance, surgery). Fitting and inspection is essential to effectiveness.[49]

Powered air-purifying respirators (PAPRs)

A PAPR in a level-3 biosafety lab. Note waist pack and hose to blow air into headpiece.

Main article: Powered air-purifying respirator

PAPRs are expensive masks with a battery-powered blower that blows air through a filter to the wearer. Because they create positive pressure, they need not be tightly-fitted.[50] PAPRs typically do not filter exhaust from the wearer.[51] They are not generally designed for healthcare use, as of 2017.[52]

Novel face masks (research and development)

On 15 April 2020 scientists claimed to have developed a biodegradable material for face masks which is effective at removing particles smaller than 100 nanometres including viruses and has a high breathability.[53][54] Two Israeli companies reportedly have developed antiviral face masks – one of which is infused with antiviral copper oxide and zinc oxide nanoparticles, the other is made out of cotton embedded with accelerated copper oxide particles and a nanofiber textile.[55][56][57] Other Israeli researchers have developed a 3D-printed nanoscale fiber sticker coated with antiseptics which can be attached to a traditional mask for extra protection.[57] Other reseachers report that laser-induced graphene may be used to add self-cleaning and photothermal properties to face masks.[57] In March 2020, Huang Jiaxing became the first scientist to receive a $200,000 grant by the United States' National Science Foundation to develop a chemical which can be safely built into common face masks to make them protect against SARS-CoV-2 and self-sanitize passing droplets.[57][58]

Face shields

Person wearing a face shield and a surgical mask.

Main article: Face shield

Face shields protect against splash and splatter. Cough simulation experiments show that they protect[16] the wearer[59] against large droplets immediately after the cough, but are less effective against smaller aerosols, which can remain airborne for extended periods and can easily flow around a face shield to be inhaled.

Because they lack a peripheral seal, face shields are used with nose-mouth masks, and to protect nose-mouth masks, but use of face shields alone is not recommended for healthcare workers.[16]

Recommendations

The landmark Egyptian Theater in Boise, Idaho presents a wry "Now Playing" public health message

Surgical masks are recommended for those who may be infected,[60][61][62] as wearing a mask can limit the volume and travel distance of expiratory droplets dispersed when talking, sneezing, and coughing.[63] Masks have also been recommended for use by those who are taking care of someone who may have the disease.[62] The WHO has recommended the wearing of masks by healthy people only if they are at high risk, such as those who are caring for a person with COVID-19, though they also acknowledge that wearing masks may help people avoid touching their face.[62] Several countries have started to encourage the use of face masks by members of the public.[64]

As of May 2020, 88% of the world's population lived in countries where their government and leading disease experts recommended or mandated the use of masks in public places to limit the spread of COVID-19.[5]

World Health Organization

The World Health Organization (WHO), in its updated advice dated 5 June 2020, recommends that the general public should wear non-medical fabric masks where there is known or suspected widespread transmission and where physical distancing is not possible, and that vulnerable people (aged over 60 or with underlying health risks) and people with any symptoms suggestive of COVID-19 as well as caregivers and healthcare workers should wear medical masks.[65] The stated purpose of mask usage is to prevent the wearer transmitting the virus to others (source control) or to offer protection to healthy wearers against infection (prevention).[65]

The WHO advises that non-medical fabric masks should comprise a minimum of three layers,[66] suggesting an inner layer made of absorbent material (such as cotton), a middle layer made of non-woven material (such as polypropylene) which may enhance filtration or retain droplets, and an outer layer made of non-absorbent material (such as polyester or its blends) which may limit external contamination from penetration.[67]

Previously, early in the outbreak, the WHO had only recommended medical masks for people with suspected infection and respiratory symptoms, their caregivers and those sharing living space, and healthcare workers.[68][69] In a 6 April advice, the WHO recognized that wearing a medical mask can limit the spread of certain respiratory viral diseases including COVID-19, but believed that the use of a mask alone is not sufficient to provide an adequate level of protection and that other measures (such as hand hygiene) should be adopted.[70] In the scope of the community setting, the WHO stated that medical masks should be reserved for healthcare workers, except for people with symptoms, claiming that medical masks would create a false sense of security and neglect of other measures.[70] The WHO advice for people to wear masks only if they had symptoms was criticized, as experts and researchers have pointed out the asymptomatic transmission of the virus.[71][72] The WHO revised its mask guidance in June, with its officials acknowledging that studies have indicated asymptomatic or pre-symptomatic spread but that not much is known.[73]

The WHO had early suggested that mask usage possibly leads to neglect of other essential health measures such as hand hygiene practices, but, according to Marteau et al. (27 July 2020), available evidence does not support that masking adversely affects hand hygiene.[74] Dame Theresa Marteau, one of the researchers, remarked that "The concept of risk compensation, rather than risk compensation itself, seems the greater threat to public health through delaying potentially effective interventions that can help prevent the spread of disease."[75]

Regarding the use of non-medical fabric masks in the general population, the WHO has stated that high-quality evidence for its widespread use is limited, but advises governments to encourage its use as physical distancing may not be possible in some settings, there is some evidence for asymptomatic transmission, and masks could be helpful to provide a barrier to limit the spread of potentially infectious droplets.[76]

US Centers for Disease Control and Prevention

Main article: Face masks during the COVID-19 pandemic in the United States

Guidance from the US Centers for Disease Control and Prevention on using and making cloth masks during the COVID-19 pandemic[77]

The United States Centers for Disease Control and Prevention (CDC), since 3 April 2020, recommends persons wear a cloth face covering in public.[78] In its latest considerations (updated 16 July 2020), the "CDC recommends that people wear cloth face coverings in public settings and when around people who don't live in your household, especially when other social distancing measures are difficult to maintain. Cloth face coverings may help prevent people who have COVID-19 from spreading the virus to others. Cloth face coverings are most likely to reduce the spread of COVID-19 when they are widely used by people in public settings."[79]

The CDC states that healthcare personnel should wear a NIOSH-approved N95 (or equivalent or higher-level) respirator or a face mask (if a respirator is not available) with a face shield or goggles as part of their personal protective equipment, while patients with suspected or confirmed SARS-CoV-2 infection should wear a face mask or cloth face covering during transport.[80] As crisis strategy for known shortages of N95 respirators in healthcare settings, among other sequential measures, the CDC suggests use of respirators beyond the manufacturer-designated shelf life, use of respirators approved under standards used in other countries that are similar to NIOSH-approved respirators, limited re-use of respirators, use of additional respirators beyond the manufacturer-designated shelf life that have not been evaluated by NIOSH, and prioritizing the use of respirators and face masks by activity type.[81]

Early in the pandemic, the CDC said that it "[did] not currently recommend the use of face masks for the general public."[82][83] However, on 3 April 2020, the CDC changed its advice to recommend that people wear cloth face coverings "in public settings when around people outside their household, especially when social distancing measures are difficult to maintain."[84] In response to an inquiry by NPR, the CDC said that this change in guidelines was due to the increasing and widespread transmission of the virus, citing studies published in February and March showing presymptomatic and asymptomatic transmission.[85] In an interview with KRMG on 28 July 2020, the CDC director Robert R. Redfield explained that they assumed that the disease was a symptomatic illness when they originally looked at masks, not understanding at the time how much of the viral infection was asymptomatic or presymptomatic, but came to understand the critical role of face coverings for source control once they understood that.[86]

Larry Gostin, a professor of public health law, said that initial CDC and WHO guidance had given the public the wrong impression that mask do not work, even though scientific evidence to the contrary was already available.[85] The confusing changing advice from discouraging to recommending public masking has led to decreasing public trust in the CDC.[72][87] In June 2020 Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, admitted that the delay in recommending general mask use was motivated by a desire to conserve dwindling supplies for medical professionals.[88]

In an interview with JAMA on 14 July 2020, Redfield said that "The data is clearly there that masking works. [...] Masking is not a political issue. It is a public health issue. It really is a personal responsibility for all of us."[89] He and two other CDC officials explained in a JAMA editorial, published on the same day, that "Covering mouths and noses with filtering materials serves 2 purposes: personal protection against inhalation of harmful pathogens and particulates, and source control to prevent exposing others to infectious microbes that may be expelled during respiration. When asked to wear face coverings, many people think in terms of personal protection. But face coverings are also widely and routinely used as source control."[90] In regards to the changes in CDC recommendations towards universal masking, they clarified that "Early in the pandemic, the Centers for Disease Control and Prevention (CDC) recommended that anyone symptomatic for suspected coronavirus disease 2019 (COVID-19) should wear a face covering during transport to medical care and prior to isolation to reduce the spread of respiratory droplets. After emerging data documented transmission of SARS-CoV-2 from persons without symptoms, the recommendation was expanded to the general community [...] Now, there is ample evidence that persons without symptoms spread infection and may be the critical driver needed to maintain epidemic momentum."[90]

China and Asia

China has specifically recommended the use of disposable medical masks by the public, including its healthy members,[91][92] particularly when coming into close contact (1 metre (3 ft) or less) with other people.[93] Hong Kong recommends wearing a surgical mask when taking public transport or in crowded places.[94][95] Thailand's health officials are encouraging people to make cloth face masks at home and wash them daily.[96] The Republic of China (Taiwan), South Korean, and Japanese governments have also recommended the use of face masks in public.

In March 2020, when asked about the mistakes that other countries were making in the pandemic, the Chinese Center for Disease Control and Prevention director-general George Fu Gao said:

"The big mistake in the U.S. and Europe, in my opinion, is that people aren't wearing masks. This virus is transmitted by droplets and close contact. Droplets play a very important role − you've got to wear a mask, because when you speak, there are always droplets coming out of your mouth. Many people have asymptomatic or presymptomatic infections. If they are wearing face masks, it can prevent droplets that carry the virus from escaping and infecting others."[97]

Europe

Most countries in Europe have introduced mandatory face mask rules for public places,[98][99] but Nordic countries have been an exception to this.[99] Denmark (on 31 July 2020),[100][101] Finland (on 13 August 2020),[102] and Norway (on 14 August 2020)[99] eventually started recommending public masking, while Sweden maintains its position to not recommend masks at all.[99]

In the Nordic countries, the main reasoning against masks recommendations given by officials is that public masking is deemed an unnecessary precaution when infection levels remain low.[103] Earlier, in June 2020, the Norwegian Institute of Public Health said that the wearing of face masks by asymptomatic individuals was not to be recommended due to the low prevalence of COVID-19 in the country, but noted that it should be reconsidered if cases rise.[104] Similarly, on 30 July 2020, the Danish Health Authority director Soren Brostrom said that face covers did not make sense in the current situation with low infection levels, but that they needed to evaluate whether it could make sense in the long term.[100][105]

Rationale for wearing masks

Queue to buy face masks in Hong Kong, 30 January 2020. Everyone in the line is already wearing a disposable medical mask.

Shadowgraphs. Left, videos of the outer airflow during a sneeze, comparing different methods of covering one's mouth and nose (and none).[106] Right, conversation. Convection also shown.

The National Health Commission of China cited the following reasons for the wearing of masks by the public, including healthy individuals:

1. Asymptomatic transmission. Many people can be infected without symptoms or only with mild symptoms.[107]
2. Difficulty or impossibility of appropriate social distancing in many public places at all times.[107]
3. Cost-benefit mismatch. If only the infected individuals wear a mask, they would possibly have a negative incentive to do so. An infected individual might get nothing positive, but only bear the costs such as inconvenience, purchasing expenses, and even prejudice.[107]
4. There is no shortage of masks in China. The country has the production capacity to meet the demand on masks.[107]

Yuen Kwok-yung, a microbiologist from the University of Hong Kong, cites a high viral load in infected people and transmission by asymptomatic carriers as the reasons why even seemingly healthy individuals should wear a mask.[108][109]

Wang Linfa, an infectious disease expert who heads a joint Duke University and National University of Singapore research team, stated that masking is about "preventing the spread of disease rather than preventing getting the disease", remarking that the point is to cover the faces of people who are infected but do not know it, so it is imperative for everyone to wear one in public.[110] Cheng, Lam, and Leung (16 April 2020) in The Lancet said that a public health rationale for mass masking is source control to protect others from respiratory droplets and underscored the importance of this approach due to asymptomatic transmission.[111]

In a perspective, Gandhi, Beyrer, and Goosby (31 July 2020) posit that masking reduces the inoculum of the virus for the wearer and thus helps lower the severity of infection.[112]

According to Stephen Griffin, a virologist at the University of Leeds, "Wearing a mask can reduce the propensity for people to touch their faces, which is a major source of infection without proper hand hygiene."[113]

Greenhalgh et al. (27 April 2020) argue for the precautionary principle as a reason for policies to encourage the wearing of face masks in public.[114]

Efficacy studies for COVID-19

A WHO-funded systematic review by Chu et al. (27 June 2020) published in The Lancet found that the usage of face mask could result in a large risk reduction of infection with epidemic-causative betacoronaviruses, in which N95 or similar respirators accounted for a larger risk reduction than disposable surgical or other similar masks.[115] Masks were found to be protective for both healthcare workers and people in communities exposed to infection; evidence supports masking in both healthcare and non-healthcare settings, with no striking differences detected in the effectiveness of masks between the settings.[115] Eye protection (e.g., goggles and face shields) was also associated with a lower risk of infection.[115]

A study by Chan et al. (30 May 2020), using SARS-CoV-2-challenged Syrian hamster models and non-infected hamsters placed in closed units with unidirectional airflow to test the effect of surgical mask partitions, concluded that SARS-CoV-2 can be transmitted by respiratory droplets or airborne droplet nuclei and that such transmission could be reduced by usage of surgical masks, especially when worn by infected individuals.[116] Yuen Kwok-yung, one of the researchers, said that "The findings implied to the world and the public is that the effectiveness of mask-wearing against the coronavirus pandemic is huge,"[117][118][119] but cautioned that a risk of infection still remains.[117]

A study surveying families in Beijing, China concluded that the wearing of face masks by infected individuals at home before symptom onset was effective in reducing the risk of spreading the disease to family members, but that it did little to provide additional protection after symptoms start appearing.[120]

Primary research from countries such as Germany and Thailand have shown significant decreases in case rates with widespread mask compliance, without, however, controlling for other measures such as social distancing.[121][122]

A report from the United States Department of Health and Human Services found that 139 clients exposed to two symptomatic hair stylists with confirmed COVID-19—with both the clients and stylists wearing face coverings—resulted in no symptomatic cases reported among all clients and no positive tests among those who volunteered to be tested.[123] This case was highlighted when the CDC reiterated that Americans should wear masks.[124]

Shortages of face masks

See also: Shortages related to the COVID-19 pandemic

Early epidemic in mainland China

People in Wuhan lining up in front of a drug store to buy surgical masks.

A notice at a supermarket in Beijing, which says each person can only buy one pack of surgical masks and one bottle of 84% disinfectant liquid a day.

Chinese electronics manufacturers, such as BYD Electronic, began to produce surgical masks after the outbreak.

As the epidemic accelerated, the mainland market in China saw a shortage of face masks due to increased public demand.[125] In Shanghai, customers had to queue for nearly an hour to buy a pack of face masks; stocks were sold out in another in half an hour.[126] Hoarding and price gouging drove up prices, so the market regulator said it would crack down on such acts.[127][128] In January 2020, price controls were imposed on all face masks on Taobao and Tmall.[129] Other Chinese e-commerce platforms – JD.com,[130] Suning.com,[131] Pinduoduo[132] – did likewise; third-party vendors would be subject to price caps, with violators subject to sanctions.

By March, China had quadrupled its production capacity to 100 million masks per day.[107]

National stocks and shortages

At the beginning of the COVID-19 outbreak in the United States, the U.S.'s Strategic National Stockpile contained just 12 million N95 respirators, far fewer than estimates of the amount required.[133] Millions of N95s and other supplies were purchased from 2005 to 2007 using congressional supplemental funding, but 85 million N95s were distributed to combat the 2009 swine flu pandemic, and Congress did not make the necessary appropriations to replenish stocks.[133] The Stockpile's primary focus has also primarily been on biodefense (defense against a terrorist or weapon of mass destruction attack) and response to natural disaster, with infectious disease a secondary focus.[133] By 1 April 2020, the Stockpile was nearly emptied of protective gear.[134] In January and February 2020, U.S. manufacturers, with the encouragement of the Trump administration, shipped millions of face masks and other personal protective equipment to the PRC, a decision that subsequently prompted criticism given the mask shortage that the U.S. faced during the pandemic.[135]

In France, 2009 H1N1-related spending rose to €382 million, mainly on supplies and vaccines, which was later criticized.[136][137] It was decided in 2011 to not replenish its stocks and rely more on supply from China and just-in-time logistics.[136] In 2010, its stock included 1 billion surgical masks and 600 million FFP2 masks; in early 2020, it was 150 million and zero respectively.[136] While stocks were progressively reduced, a 2013 rationale stated the aim to reduce costs of acquisition and storage, now distributing this effort to all private enterprises as an optional best practice to ensure their workers' protection.[136] This was especially relevant to FFP2 masks, more costly to acquire and store.[136][138] As the COVID-19 pandemic in France took an increasing toll on medical supplies, masks and PPE supplies ran low, causing national outrage. France needs 40 millions masks per week, according to French president Emmanuel Macron.[139] France instructed its few remaining mask-producing factories to work 24/7 shifts, and to ramp up national production to 40 million masks per month.[139] French lawmakers opened an inquiry on the past management of these strategic stocks.[140] The mask shortage has been called a "scandal d'État" (State scandal).[141]

In late-March/early-April 2020, as Western countries were in turn dependent on China for supplies of masks and other equipment, China was seen as making soft-power play to influence world opinion.[142][143] However, a batch of masks purchased by the Netherlands was reportedly rejected as being sub-standard. The Dutch health ministry issued a recall of 600,000 face masks from a Chinese supplier on 21 March which did not fit properly and whose filters did not work as intended despite them having a quality certificate.[142][143] The Chinese Ministry of Foreign Affairs responded that the customer should "double-check the instructions to make sure that you ordered, paid for and distributed the right ones. Do not use non-surgical masks for surgical purposes".[143] Eight million of 11 million masks delivered to Canada in May also failed to meet standards.[144][145]

N95 and FFP masks

N95 and FFP masks were in short supply and high demand during the COVID-19 pandemic.[146][136] Production of N95 masks was limited due to constraints on the supply of nonwoven polypropylene fabric (which is used as the primary filter), as well as the cessation of exports from China.[42][147] China controls 50 percent of global production of masks, and facing its own coronavirus epidemic, dedicated all its production for domestic use, only allowing exports through government-allocated humanitarian assistance.[42]

In March 2020, US President Donald Trump applied the Defense Production Act against the American company 3M, which allows the Federal Emergency Management Agency to obtain N95 respirators from 3M.[148][149] White House trade adviser Peter Navarro stated that there were concerns that 3M products were not making their way to the US.[148] 3M replied that it has not changed the prices it charges, and was unable to control the prices its dealers or retailers charge.[148]

In early April 2020, Berlin politician Andreas Geisel alleged that a shipment of 200,000 N95 masks that it had ordered from American producer 3M's China facility were intercepted in Bangkok and diverted to the United States. Berlin Police president Barbara Slowik stated that she believed "this is related to the US government's export ban."[150] 3M said they had no knowledge of the shipment, stating "We know nothing of an order from the Berlin police for 3M masks that come from China," and the US government denied that any confiscation had taken place and said that they use appropriate channels for all their purchases.[150][151]

Berlin police later confirmed that the shipment was not seized by US authorities, but was said to have simply been bought at a better price, widely believed to be from a German dealer or China. This revelation outraged the Berlin opposition, whose CDU parliamentary group leader Burkard Dregger accused Geisel of "deliberately misleading Berliners" in order "to cover up its own inability to obtain protective equipment". FDP interior expert Marcel Luthe said "Big names in international politics like Berlin's senator Geisel are blaming others and telling US piracy to serve anti-American clichés."[152] Politico Europe reported that "the Berliners are taking a page straight out of the Trump playbook and not letting facts get in the way of a good story."[153] The Guardian also reported that "There is no solid proof Trump [nor any other American official] approved the [German] heist".[154]

Jared Moskowitz, head of the Florida Division of Emergency Management, accused 3M of selling N95 masks directly to foreign countries for cash, instead of the US. Moskowitz stated that 3M agreed to authorized distributors and brokers to represent they were selling the masks to Florida, but instead his team for the last several weeks "get to warehouses that are completely empty." He then said the 3M-authorized US distributors later told him the masks Florida contracted for never showed up because the company instead prioritized orders that came in later, for higher prices, from foreign countries (including Germany, Russia, and France). As a result, Moskowitz highlighted the issue on Twitter, saying he decided to "troll" 3M.[155][156][157] Forbes reported that "roughly 280 million masks from warehouses around the US had been purchased by foreign buyers [on March 30, 2020] and were earmarked to leave the country, according to the broker — and that was in one day", causing massive critical shortages of masks in the US.[158][159]

As more and more countries restricted the export of N95 masks, Novo Textiles in British Columbia announced plans to start producing N95 masks in Canada.[160] AMD Medicom in Quebec had long been the main Canadian company producing N95s, but China, France, the Republic of China (Taiwan) and the United States all banned exports of medical equipment, barring Medicom's factories there from exporting the masks to Canada. The Government of Canada subsequently awarded Medicom a 10-year contract to build a factory to produce masks in Montreal.[161]

The mask industry

Manufacturing

With population of 24 million, Taiwan has been producing 13 million masks per day since March.

As of 2019, mainland China manufactured half the world output of masks.[162] As COVID-19 spread, enterprises in several countries quickly started or increased the production of face masks.[163] Cottage industries and volunteer groups also emerged, manufacturing cloth masks for localized use. They used various patterns, including some with a bend-to-fit nosepiece inserts. Individual hospitals developed and requested a library of specific patterns.[164][165][166][167]

In the first five months of 2020, 70802 new companies registered in China to make or trade face masks, a 1256% increase compared to 2019, and 7296 new companies registered to make or trade meltblown fabric, a key component of face masks, a 2277% rise from 2019.[168]

In April, however, the Chinese government stepped in with tighter regulations. 867 producers of the meltblown fabric were shut down in Yangzhong city alone. Many speculative manufacturers have been forced to quit due to changing export rules and tighter licensing requirements in China and weaker demand for lower quality products globally.[168]

Distribution

Some clinical stockpiles have proved inadequate in scale, and markets have expanded as non-medical consumers started obeying mandated mask-wearing or determined that masks might help or encourage them. Worldwide demand for face masks has resulted in masks shipping around the globe as a result of commercial transactions or of donations.[169]

Society and culture

Attitudes

Slovakia was one of the first countries in the world to introduce universal masking in public places.[170]

A sign language interpreter (on the right) is wearing a transparent mask to allow lip reading.

In East Asian societies, a primary reason for mask-wearing is to protect others from oneself.[171][172] The broad assumption behind the act is that anyone, including seemingly healthy people, can be a carrier of the coronavirus.[172] The usage of masks is seen as a collective responsibility to reduce the transmission of the virus.[173] A face mask is thus seen as a symbol of solidarity in Eastern countries.[173] Elsewhere, the need for mask-wearing is still often seen in an individual's perspective where masks only serve to protect oneself.[171] However, a cultural shift towards the message of solidarity has gradually taken place as the pandemic continued.[174] Masking is shifting to become a new social norm.[175][176]

Existing cultural norms and social pressure may impede mask-wearing in public, which explains why masking has been avoided in the West.[177] According to Joseph Tsang, a Hong Kong doctor and infectious disease expert, the promotion of universal masking may resolve perceptions against mask-wearing, because mask-wearing is intimidating if few people wear masks due to cultural barriers, but if all people wear masks it shows a message that people are in this together.[110] In Barceló and Sheen (6 May 2020), empirical evidence shows that an individual's likelihood of voluntarily wearing a mask is positively correlated with the proportion of uptake in the surrounding area.[178]

In the Western world, the public usage of masks still often carries a large stigma,[171][173][179] as it is seen as a sign of sickness.[179] This stigmatization is a large obstacle to overcome, because people may feel too ashamed to wear a mask in public and therefore opt to not wear one.[180] However, there is also a divide within the Western world, as seen in the Czech Republic and Slovakia where mass mobilization has occurred to reinforce the solidarity in mask-wearing since March 2020.[171]

Masking has been subjected to racial politics in Western countries.[181] For instance, it has been heavily racialized as an Asian phenomenon.[173] This has been reinforced in a lot of media discourses, where imagery of Asian people in masks often accompany unrelated stories about the pandemic.[181][182] The focus on race has brought hostility towards Asians who are confronted with the choice to mask as precaution while they face discrimination for it.[181][183] Huang Yinxiang, a sociologist from the University of Manchester, described maskaphobia—negative prejudice, fear or hatred against people wearing face masks—as making Asians in Western countries into targets for racists who want to normalize and justify xenophobia during the COVID-19 outbreak.[184] Likewise, people from certain groups such as Black Americans may not feel comfortable wearing masks, especially those that are not clearly medical but homemade masks, due to concerns of racial profiling.[185][186][187]

Gender plays a role in the willingness to wear masks during the pandemic; men are overall less inclined to mask in public than women.[188][189] There are indications that men are more likely to feel negative emotions (such as shame) and stigma for wearing masks.[188][189] It is suggested that this male behavior is driven by a sense of masculinity, where the act of masking is possibly perceived to run counter to it, which leads to an increase in men not wearing masks during the pandemic.[190][191]

Mask-wearing has been called a prosocial behavior in which one protects others within their community.[192][193] On social media, there has been an effort with the #masks4all campaign to encourage people to use masks.[194] Nevertheless, there have many occurrences of violence and hostility by people who became aggressive after they were requested to wear a mask or saw people in masks in places related to the service industry.[195][196][197][198] This has led to concerns about worker safety, with employees discouraged to actively enforce masking policies due to the potential of hostile situations, while enforcement by official authorities is severely lacking.[199]

There have also been concerns that the wearing of masks may also further isolate disadvantaged communities. Concerns had been expressed that those who are deaf or hard-of-hearing would be unable to communicate while wearing a face mask. This led to wider distributions of transparent masks, which allow for lip reading.[200][201] Similar concerns over difficulty in communicating have been expressed by those who may depend on dogs for theraputic or social reasons.[202] Convervsely, people who are exempt from wearing masks on medical grounds or due to a disability, fear they will be subjected to abuse for not wearing a mask, even if they are legally exempt from doing so. In the United Kingdom, charity Disability Rights UK has reported a significant increase in reports of people being confronted on trains and buses.[203]

Trends

Among the European countries surveyed by YouGov, the likelihood for people to mask has been split: In Northern Europe (e.g., Finland, Sweden, Norway, and Denmark), people are very unlikely to wear a mask.[204] In Western Europe (e.g., Italy, Spain, France, and Germany), people were initially unlikely to use a mask, but mask wearing greatly changed from low levels in March to higher levels in May.[204] An exception was the United Kingdom where mask usage only grew gradually during this time,[204] but it rose very quickly after official policy changes in July mandated masking in stores.[205]

Politics

The U.S. Surgeon General urged people to wear face masks and acknowledged that it's difficult to correct earlier messaging that masks do not work for the general public.[206]

The heads of state and government of Portugal and Spain wearing face masks during an official ceremony in July 2020

Although authorities in especially Asia have been recommending people to wear face masks in public, in many other parts of the world, conflicting advice have caused a lot of confusion among the general population.[207] Several governments and institutions, such as in the United States, have initially dismissed the use of face masks by the general population, often with misleading or incomplete information about the usefulness of masks.[208][209][210] Commentators have attributed the anti-mask messaging to efforts to manage the mask shortages, as governments did not act quickly enough, remarking that the claims go beyond the science or were simply lies.[210][211][212][213] On 12 June 2020, Anthony Fauci, a key member of the White House coronavirus task force, confirmed that the American public were not told to wear masks from the beginning due to the shortages of masks and explained that masks do actually work.[214][215][216][217][218]

In the United States, public masking has become a political issue, as opponents argue that it inhibits personal freedom and proponents emphasize the importance of masks for public health.[219] Some people may see it as a political statement.[220] Party affiliation partly determined how likely people were to embrace the wearing of masks in public.[220][221] Democrats were more likely to wear masks than Republicans.[220][221] Masks have become an aspect of the culture war that has emerged over the course of the pandemic.[219][220][221] Commentators argue that the resistance against masks partly stems from the confusing and mixed messaging about masking.[219][222][223]

Tom Jefferson and Carl Heneghan from the Centre for Evidence-Based Medicine suggest that issues in the value placed on evidence and the lack of clear answers to guide decision-makers have resulted in polarizing and politicized views influencing global interventions.[224]

Despite widespread implementation of masking policies globally, in some countries, large rallies have taken place in protest against masking mandates.[225][226][227] In Canada, the anti-mask crowd has hailed their protests as the so-called "March to Unmask."[227][228] In the United Kingdom, new protests came in the wake of the official announcement that masking will be compulsory in shops.[225]

In April 2020, health officials from Taiwan's Central Epidemic Command Center (CECC) pushed back on school bullying of young boys in pink face masks. At a press conference breaking gender norm barriers, the health officials wore pink masks, as various government agencies demonstrated solidarity by changing the colors on their Facebook pages to pink. One of the officials participating in the press conference later tweeted, "Pink is for everyone and no color is exclusive for girls or boys. Gender equality lies at the heart of Taiwan values." The press conference was held amid reports that male students were too embarrassed to wear their pink face masks, jeopardizing their safety and the safety of others in the face of COVID-19.[229]

Religion

Christian clergy from the Lutheran, Catholic, Presbyterian, Anglican, Baptist and Mormon traditions, as well as those from the Jewish, Buddhist and Unitarian religions have implored people to wear masks.[230]

James Martin, a Jesuit Catholic priest, who affirmed a belief in a consistent life ethic, specifically stating that a "reverence for life includes a desire to care for the unborn child in the womb, the elderly person in danger of euthanasia, the refugee starving on the border, the L.G.B.T. youth tempted to suicide and the inmate being readied for execution on death row".[231] Martin stated that to that list, sacred lives also include "the woman standing in line at the grocery store checkout counter, the elderly man seated in a church pew or the office worker who has just stepped aboard public transportation."[231] Because masks prevent of contagion, the act of wearing a mask, in Martin's view, is being pro-life.[231]

Fashion

Face masks have had an impact on fashion, with the masks themselves becoming fashion statements, haute couture brands having pivoted to address both public health and aesthetic needs.[232][233][234][235] As public usage of fabric masks have become more commonplace, people have started to consider the aesthetical design of it.[236]

The Walt Disney Company introduced uniformed face masks for their employees at Disney World and Disneyland domestically.[237][238]

Mask use and policies by country and territory

See also: COVID-19 pandemic by country and territory and National responses to the COVID-19 pandemic

% of population wearing face masks in public, by country/territory (as of 9 August)[239]

Country/territory	%
Singapore	92
Spain	90
Thailand	88
Hong Kong	86
Japan	86
Malaysia	85
Indonesia	85
Philippines	84
France	83
India	82
Italy	81
China	80
Taiwan	80
Vietnam	79
United Arab Emirates	79
United States	75
Canada	74
Saudi Arabia	71
United Kingdom	69
Mexico	67
Germany	65
Australia	41
Finland	7
Sweden	6
Norway	5
Denmark	4

• Argentina: After appearance of three asymptomatic cases, the capital Buenos Aires introduced compulsory masking since 14 April. Wearing a mask was made obligatory for everyone on public transit and everyone who contacts with the public in their position. Violators can face a fine. Authorities also prohibited the sale of N95 face masks to non-medical workers, suggesting the general public to use home-made masks instead.[240]
• Australia: The federal Department of Health does not recommend the wearing of face masks by the general public, but in regions where there is community transmission people may consider using a mask. In places where there is community transmission and it is difficult to keep a distance, masks are recognized as an important protective measure, but only if used properly.[241] In the state of Victoria, face coverings became compulsory on 22 July in the metropolitan Melbourne or Mitchell Shire areas when outside of your home.[242]
• Austria: Everyone entering a supermarket, a grocery store, or a drug store or using public transportation must wear a face mask, mandatory since 14 April.[243][244][245]
• Bahamas: On 19 April, the prime minister announced that wearing a mask or covering one's face with clothing is mandatory in public. Employers must provide their employees who are serving the general public with masks.[246]
• Bahrain: The Kingdom made wearing face masks in public areas compulsory for citizens and residents as well as shop workers.[247]
• Benin: From 8 April, Benin's authorities began enforcing the mandatory wearing of face masks to halt the coronavirus.[248]
• Bosnia and Herzegovina: Wearing a face mask is compulsory.[249][250]
• Bulgaria: Bulgaria's government passed an order imposing an obligation to wear face masks on 30 March. The order was cancelled the next day and changed into a recommendation, due to legal complaints.[251]
• Cambodia: Many Cambodians started wearing face masks soon after the outbreak began in Wuhan. Businesses started to require customers to wear masks.[252]
• Cameroon: On 6 April, mayor of Douala announced that wearing a mask will be mandatory to slow the spread of coronavirus.[253]
• Canada: Since 6 April, health officials recommend wearing non-medical masks in situations where physical distancing from others is difficult (like buying groceries, or public transit).[14] The use of face coverings in indoor, publicly accessible settings became mandatory in Toronto on July 7, 2020.[254]
• Chile: From 8 April, Chilean Health Minister announced wearing a mask is mandatory in public transit.[255]
• China: Healthy individuals are advised to wear disposable medical masks in public places.[91][93] Some local governments require wearing masks when going outside. Shanghai makes wearing masks mandatory in public places.[256]
  • Hong Kong: Members of the public are recommended to wear a surgical mask when taking public transport or staying in crowded places.[94]
• Colombia: In response to recommendations from the WHO, Colombia changed its policy on the use of masks and made it mandatory throughout the country for the use of public transport during the coronavirus emergency.[257]
• Croatia: Since 8 July, everyone entering any enclosed place, like shops and other buildings, must wear a face mask.[258]
• Cuba: On 11 March, the government urged citizens to make their own masks, while the textile industry was drafted to fabricate them. People were advised to carry several cloth masks with them, depending on how many hours they plan to spend in public areas.[259] Later, wearing a mask was made mandatory.[260]
• Czech Republic: It was forbidden to go out in public without wearing a mask, or covering one's nose and mouth until 25 May.[261]
• Dominican Republic: Since 16 April, the use of face masks is mandatory in all public spaces and in the workplace.[262]
• DR Congo: Since 20 April, wearing masks in the capital of Kinshasa is mandatory.[263]
• Denmark: The Danish Health Authority generally does not recommend the wearing of face masks in public places by healthy residents, but does recommend that masks should be worn by anyone who is forced to break self-isolation (for example, if someone who suspects he/she might be infected leaves self-isolation to get tested), has returned from a visit to a high-risk country (until fully home and able to isolate in the recommended period), or if the person takes care of an at-risk relative/loved one where distancing rules are impossible to follow.[264][265] Since 15 June 2020, face masks have been mandatory in all airports.[266] If a mask is worn, the authorities have emphasised on doing it correctly (arguing that if done incorrectly, a mask can do more harm than good) and that general isolation, distancing and hygiene guidelines should still be followed as closely as possible.[264][265] It is recommended that masks should be CE marked and have Danish labelling; homemade masks are advised against.[267][268][269] Levels of the virus in Denmark are low, but if there is an increase of transmission, the authorities will review the guidelines again.[270]
• Ecuador: On 8 April, the Emergency Operations Committee (COE) decided to make face masks obligatory in public spaces.[271]
• Egypt: On 30 May 2020, the wearing of face masks in public places and on public transportation became mandatory; failure to comply can result in fines of up to EGP4,000 (US$247).[272]
• Ethiopia: The Council of Ministers approved a regulation that outlaws handshakes, and obligates the use of face masks in public places.[273]
• Finland: The Government has not recommended that masks should be used by the general public, but has said that they can be used in situations where it is not possible to keep a distance. If someone choses to wear a mask, the Finnish Institute for Health and Welfare notes that it is important that it is used correctly, and that general distancing and hygiene guidelines should still be followed.[274]
• France: On 3 March, the government issued a degree announcing requisition of stocks of FFP2 and anti-splash masks until 31 May 2020.[275] On 8 May 2020, the government announced that 200 million masks per week will be available starting on 11 May: 100 million for medical workers and 100 million for the general public.[276]From July, France makes it compulsory for people to wear masks in shops and other enclosed public spaces.[277]
• Gabon: On 10 April, the Gabonese government announced individuals in all parts of the country are required to wear masks in public to limit the spread of COVID-19.[278]
• Germany: On 31 March, city-county Jena, Thuringia, was the first large German city to introduce an obligation to wear masks, or makeshift masks including scarves, in supermarkets, public transport, and buildings with public traffic, from 6 April. On 2 April, the Robert Koch Institute, the federal epidemic authority, changed its previous recommendation that only people with symptoms should wear masks to also include people without symptoms.[279][280] Later in April, Germany made the wearing of cloth face masks mandatory on public transport, as well as for shopping in most German states.[281] Some German states expanded the regulations to include outdoor markets. [282]
• Ghana: Use of face masks would be made mandatory in public spaces including public transport. However, surveys show about 22% of public transport vehicles would have fewer than 3 people without masks, with the vast majority having only partial or non-compliance to the policy on face masks.[283]
• Guatemala: From 8 April, Guatemalan president Alejandro Giammattei makes it mandatory to wear a face mask in public.[284]
• Guinea: Guinean President Alpha Conde decided to make wearing masks compulsory.[285]
• Honduras: From 7 April, Honduras President announced all citizens will now be required to cover their mouths when they are outside.[286]
• Iceland: Masks are not widely worn and are not recommended by the authorities.[287]
• India: On 3 April, the Office of the Principal Scientific Adviser to the Government of India issued an advisory and manual, asking healthy people to wear handmade reusable face covers when stepping out of their homes, especially for those in densely populated areas.[288][289] Some individual states, like Odisha, West Bengal, Maharashtra and Uttar Pradesh made wearing of masks compulsory in public places.[290][291][292]
• Indonesia: Citizens were ordered to wear face masks when they leave the house.[293]
• Ireland: From 18 May, the use of cloth face covering is recommend in enclosed public spaces where it's difficult to maintain social distance.[294][295]
• Israel: All residents are asked to wear face masks when in public.[296]
• Italy: Regions of Lombardy and Tuscany made wearing a face mask compulsory before going out in early April.[297]
• Ivory Coast: From April, 26 masks have become compulsory to enter shopping malls or supermarkets in the Southern suburb of Abidjan, Marcory.[298]
• Japan: Masks have been widely used by healthy individuals despite absence of official advice to do so.[299] On 1 March, prime minister Shinzo Abe enacted a policy in Hokkaido instructing manufacturers to sell face masks directly to the government, which would then deliver them to residents.[300]
• Kenya: Wearing a face mask is compulsory since 4 April. The government has Kenyans to strictly observe social distancing, which has been proved to one of the most efficient ways of preventing infection risks.[301]
• Liberia: From 21 April, it is now compulsory to wear a face mask or covering in public.[302]
• Lithuania: Wearing a face mask or any other means of covering one's nose and mouth in public places is compulsory since 10 April 2020.
• Luxembourg: From 20 April, wearing a mask is mandatory in places where it is not possible to keep enough distance to others such as supermarkets or on public transport.[303]
• Malaysia: Masks have been widely used by healthy individuals despite absence of official advice to do so.[304] On 17 March, Malaysia banned exports of medical and surgical masks, to meet local demand.[305] In April, the government was set to distribute 24.62 million masks, four for each household, while advising people to only use them if they have symptoms.[293] On 23 July, the government announced that the wearing of face masks (including homemade cloth masks) in public transportation and "crowded" public areas will be mandatory from 1 August, adding that those who did not comply could be slapped with a RM1,000 (USD235) fine under the nation's Prevention and Control of Infectious Diseases Act.[306][307][308]
  • Selangor: On 22 July, in an interview with Astro Awani, head of the Selangor COVID-19 task force and former Minister of Health Dr. Dzulkefly Ahmad stressed that face coverings should be worn at all public places, except in one's own residence or car.[309]
• Mexico: From 17 April, all Mexico City Metro passengers must wear masks while inside stations and on trains, Mayor Claudia Sheinbaum announced on 15 April.[310]
• Mongolia: Wearing a mask is now mandatory while riding public transportation in Ulaanbaatar. Public officials and news broadcasters had even adopted to wearing masks through press conferences and news broadcasts.[311]
• Morocco: Wearing a face mask is compulsory.[312]
• Mozambique: The Mozambican government announced on 8 April that wearing face masks is now compulsory on all forms of passenger transport, and wherever groups of people are gathered.[313]

• Netherlands: Facemasks became mandatory in Dutch public transport on June 1[314] and in parts of the busy inner cities of Amsterdam and Rotterdam on August 5.[315] In other places face masks are not mandatory.

• New Zealand: The Ministry of Health does not recommend the wearing of face masks by the general public. Levels of the virus in New Zealand are low to none, but if there is an increase of virus transmission, the guidelines may change.[316]
• North Macedonia: As of 22 April, citizens of Kumanovo, Tetovo, and Prilep must wear protective masks and gloves outside their homes, at public places, outdoor and indoor areas, markets, and shops announced the government.[317]
• Norway: The Norwegian Institute of Public Health does not recommend the wearing of face masks by the general public. Levels of the virus in Norway are low, but if there is an increase in virus transmission, the authorities will review the guidelines again.[318]
• Pakistan: The Balochistan government on 18 April told citizens to wear face masks when going outside. According to provincial government spokesperson Liaquat Shahwani, citizens have been urged to wear masks or to cover their faces with any cloth in the wake of the COVID-19 outbreak.[319]
• Panama: Panama has made it obligatory to wear a face mask whenever going outside, while also recommending the manufacture of a homemade cloth face mask to those who cannot purchase face masks.[320]
• Peru: From 7 April, the Peruvian government started distributing free masks after decreeing their mandatory use in the streets to chase away the new coronavirus, said President Martin Vizcarra.[321]
• Philippines: From 2 April, the government required all those living in areas under enhanced community quarantine to wear face masks.[322]
• Poland: Since 16 April, covering lips and nose is compulsory before leaving one's house (e.g., by a disposable mask, cloth mask, or scarf).[323]
• Russia: Khabarovsk has made the wearing of face masks obligatory to fight the spike in respiratory diseases and prevent the spread of the coronavirus.[324]
• Rwanda: On 20 April, Cabinet Minister of Health Daniel Ngamije said the latest guidelines require everyone to wear a mask in public, and at home during the lockdown and thereafter.[263]
• Serbia: Wearing face masks has been required since June 29 in public indoor places, including public transportation.[325]
• Singapore: Masks have been widely used by healthy individuals despite initial absence of official advice to do so.[326] General mask-wearing was no longer discouraged from 3 April,[327] and made mandatory outside of one's residence from 14 April.[328]
• Spain: Wearing masks has been required since 4 May while on public transportation, which includes taxis, trains and buses. The government is providing masks to the majority of people riding public transportation, regardless of if they have a mask on.[329][330] On 9 June, the Spanish Ministry of Health and the Ministry of Transport maintains the mandatory nature of masks on public roads, in open air spaces, and in closed spaces for public use[331]
• Slovakia: Face masks were compulsory in public transport and shops since 15 March.[332] On 25 March, it became forbidden to go out in public without wearing a mask or covering one's nose and mouth.[333] Since 20 May, face masks are no longer mandatory when distance between people is at least 5 meters.[334]
• Slovenia: From 29 March, wearing a face mask, even one made at home, or equivalents such as scarves that cover the mouth and nose is mandatory along with protective gloves; the decree stipulates that masks and gloves need to be worn in indoor public spaces.[335]
• South Africa: On 10 April, Minister of Health recommended that the general public use cloth face masks when going out in public (in addition to hand-washing and social distancing).[336] After 1 May, covering one's nose and mouth will be mandatory in public (with a cloth mask, scarf, T-shirt, etc.).[337]
• South Korea: Masks have been widely used by healthy individuals despite absence of official advice to do so.[338] The government implemented a policy of centralized procurement and rationing of face masks, purchasing 80 percent of national production since early March.[339] On 25 May, the Korean government / Central Disaster and Safety Countermeasure Headquarters required passengers on buses, taxis, subways, and flights to wear masks.[340]
• Sweden: Sweden's Public Health Agency states that the scientific evidence does not support public use of face masks, and that public use of face masks would undermine Sweden's COVID-19 response. The government has also warned that wearing them might create a false sense of security, and that public use of masks could do more harm than good.[341][342]
• Taiwan: On 21 January, the government announced a temporary ban on the export of face masks.[343] On 6 February, the government instituted a mask rationing system.[344] The ROC has been producing ten million masks per day since mid-March.[345] On 1 April, passengers on trains and intercity buses were required to wear face masks,[346] unmasked riders facing a fine.[347]
• Turkey: Residents will be required to wear masks at markets, as Turkish president announced.[348]
• Ukraine: Since 6 April, wearing a face mask is required by the government in public places. In Kyiv, public places were clarified to include parks and streets.[349]
• United Kingdom Health is a devolved policy in the United Kingdom, resulting in different policies across the four nations:
  • England: From 15 June, face coverings were made compulsory on public transport in England and from 24 July, they were also compulsory in shops and other public buildings such as shopping centres and banks in England.[350][351] From the 8th of August the number of places where face coverings will be complulsary will be expanded to other indoor venues where customers are not eating or drinking on the premises. [352]
  • Northern Ireland: The wearing of face masks on public transport was compulsory from 10 July.[353] While the wearing of face masks in retail stores is currently voluntary, Deputy First Minister Michelle O'Neill has advised this may become mandatory, if sufficient number of people were not wearing them by 20 August.[354]
  • Scotland: On 28 April, the First Minister for Scotland Nicola Sturgeon advised the voluntary use of cloth face masks in enclosed spaces such as shops and public transport (but not generally in public), while noting their limitation.[355] As of 10 July, face coverings were made compulsory on public transport and in shops in Scotland.[356]
  • Wales: Face masks became compulsory on public transport on Wales on 27 July.[357] While face masks are not compulsory in shops, First Minister Mark Drakeford has warned people may be turned away from healthcare settings if they refuse to wear a mask when asked.[358]
• United States: In March 2020, the CDC recommended that if neither respirators nor surgical masks are available, as a last resort, it may be necessary for healthcare workers to use masks that have never been evaluated or approved by NIOSH or homemade masks, though caution should be exercised when considering this option.[359] On 6 April, the CDC recommended the wearing of non-medical cloth face coverings when in public places.[360][361] As of 4 August 34 states and the District of Columbia have implemented health orders requiring the wearing of face coverings in most public spaces.[362][363][364]
• Uzbekistan: Officials made protective masks mandatory in all major cities to prevent the spread of coronavirus. Officials on 22 March said citizens not wearing masks in public in major cities would be fined $22 for the first offense and $67 for repeat offenses.[365]
• Venezuela: The government ordered the country's citizens to wear face masks in public in response to the arrival of the novel coronavirus.[366]
• Vietnam: Since 16 March, everyone must wear a face mask when going to public places (such as grocery stores, transportation hubs, and public transport).[367]
• Zambia: The government made it mandatory to wear face masks to minimise the spread in the country.[368]

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